Brian F. Hoffman

Risk Assessments for Acute Violence to Third Parties: A Review of the Literature

Objectives: To provide an overview of risk assessments for acute violence to third parties by combining a clinical and research focus and to offer guidelines to physicians conducting clinical assessments. Method: A computerized literature search of the MEDLINE and PSYCHINFO data bases from 1967 to 1996 was completed using the key words violence, aggression, dangerous behaviour, risk, risk assessment, risk factors, and practice guidelines. The search yielded 116 relevant references, 26 of which were original research articles on risk factor identification. A secondary search, based on the citations from the primary search, yielded an additional 8 general discussion articles. Results: Risk assessments may be conducted using different methods, although all methods should be systematic and comprehensive. Research shows that risk assessments do have validity for use in short-term prediction and that it is possible to develop clinical guidelines in this area. A combined clinical and research approach holds the most promise for improving the accuracy of probability estimates, and most published guides and tools rely on such a combination. Conclusions: Risk assessments are an important and necessary part of the clinical examination. Because this field has sufficiently evolved, there is abundant literature to refer to when determining what constitutes an acceptable assessment for risk of violence to third parties and when it is appropriate to conduct such an examination.

Gas sniffing as a form of substance abuse.

The authors review the existing literature on inhalation of gasoline fumes, highlighting the acute and chronic physical and psychological effects. The clinical picture of gas sniffing includes visual hallucinations, changes in consciousness, euphoria, nystagmus, dizziness, weakness and tremors. There is the possibility of rapid recovery, sudden death or brain damage with chronic abuse. When leaded gasoline is abused then blood and urine lead levels and erythrocytic delta-aminolevulinic acid dehydrase (ALAD) levels may be helpful. Although the treatment of acute and chronic gas sniffing syndromes is often supportive and non-specific, when lead levels are high chelated therapy is indicated including British anti-lewisite, calcium disodium versenate or D-penicillamine. We also report our findings on an isolated native Indian population where intentional gas sniffing has reached epidemic proportions. Ten percent of the total population and 25% of the children between 5 and 15 years of age had been identified as gasoline inhalation abusers. In this population, the most important etiological factors included environmental, family and cultural components. The authors emphasize the need to correct the family and social deficiencies in such communities if the incidence of gas sniffing is to be decreased.

Two new cases of XYY chromosome complement: and a review of the literature.

Two cases with XYY chromosome complement are presented and compared with 153 cases described in the literature. Some patients with abnormalities of personality development and manifest psychopathology may have sex chromosome abnormalities and should be studied further for the interaction of genetic and environmental factors in personality development. In particular, tall, schizoid impulsive men with a history of criminality, arson or sexual offences should be screened for this particular genetic configuration. Because of the biased manner by which most of the cases are found, it is not yet known whether an XYY genotype results in a characteristic phenotype. What is needed is a genetic study of a normal population and a prospective study of newborns with various genotypes which would, unfortunately, create complex research and ethical problems.

Neurosyphilis in a young man.

New cases of neurosyphilis are comparatively rare. The epidemiology and clinical presentation of neurosyphilis are described. The article describes the presentation of general paresis in a 34 year old man, 10 years after he had been ineffectively treated with penicillin for secondary syphilis. The various laboratory tests for syphilis are reviewed. The Venereal Disease Research Laboratories (VDRL) is currently the best screening test and the Fluorescent Treponema Antibody-Absorption Test (FTA-ABS) is the current recommended specific test for syphilis. Central nervous system involvement is confirmed in the laboratory by a positive VDRL on the cerebrospinal fluid. Physicians should be on the alert for this cause of dementia which may, once again, be increasing in frequency.

Courts and Torts: The Psychiatrist Preparing for Trial

Objective: To outline how a psychiatric expert can do an impartial assessment and medicolegal report and then give an effective presentation in court that can sustain cross-examination. Methods: The legal principles of litigating emotional trauma are reviewed, including proving causation, characterizing emotional suffering, assessing disability, and determining a realistic prognosis. Results: Psychiatrists must understand the interplay of legal and psychiatric principles when they are asked to assess litigants who are suing for monetary compensation for a widening range of emotional injuries resulting from motor vehicle accidents, slips and falls, incest and sexual abuse of children, discrimination, unlawful dismissal, malpractice, human-made disasters, product liability, and intentional torts, to name a few. Conclusion: The psychiatrist can prepare his or her attitude, knowledge, and skills to give a presentation in court that will be credible, trustworthy, and dynamic. With adequate preparation, the psychiatric expert can bring an informed psychiatric perspective to the court that will have a significant impact on the outcome of the judicial deliberations.

Looking at legislative and judicial views of psychic trauma--fluctuating recognition and discrimination.

Objective To describe how Canadian courts and legislation have viewed psychic or emotional trauma in the past century and the principles that are used. Methods The author reviews major trends in legislation and judicial findings pertaining to emotional trauma and gives examples of the fluctuating and ambivalent recognition by the courts. Results The courts have progressed from refusing to acknowledge emotional trauma, to accepting emotional trauma when accompanied by physical trauma, and finally acknowledging emotional trauma even in the absence of physical injury and the “indirect” emotional trauma suffered by the relatives of victims. However, from time to time, the courts or legislation may appear to deny the distress, dysfunction or the rights of a person who suffers significant emotional symptoms after an injury. This occurred recently in Ontario where injured persons in motor vehicle accidents who suffered emotional trauma were not allowed to sue for compensation from June 1990 to January 1994. Combined efforts by a coalition of mental health professionals with victims of trauma at least partially reversed the discriminatory laws. Conclusions Psychiatrists must continue to play a vital role in the education of the courts, politicians and the public about the realities of emotional trauma and mental illness and their long-term impact so that fair compensation can be assessed by the courts and discriminatory legislation reversed.

A survey of interdisciplinary differences in attitudes and morale within a psychiatric hospital

SummaryThis survey has examined a number of jobrelated attitudes. Staff members in a traditional, hierarchically organized psychiatric hospital were the respondents. Differences between disciplines may be greater in this type of organization. It would be of interest to compare our sample with samples from hospitals structured along less traditional lines, such as in hospitals experimenting with program rather than discipline budgeting. These organizations, while creating unique problems of their own, might eliminate some of the differences found between disciplines in our survey.