Thomas B. Mackenzie

Suicide in the Medical Patient

According to the statistical abstract of the United States for 1982–1983, there were 1,913,800 deaths in the United States in 1979 [1]. Twenty-seven thousand, or 1.4 percent of those deaths were by suicide, yielding a suicide rate of 11.9/100,000/year. The rate was highest (39.2/100,000) for white males sixty-five years and over and lowest (0.1/100,000) for black females between five and fourteen years. It is generally accepted that physical illness is a risk factor for suicide. If this is true, then in caring for persons with significant physical illness, physicians are dealing with a population at increased risk of suicide. In its opening section, this article will review the evidence that points to a positive correlation between suicide and physical illness. Next the association between specific illnesses, such as peptic ulcer and cancer, and suicide will be examined. Third, risk factors associated with the occurrence of suicide in medical-surgical hospitals will be reviewed. Fourth, the occurrence of suicide in relationship to medical procedures will be discussed. Fifth, the evaluation and management of suicidal patients in medical settings will be briefly considered. This review will not consider the relationship between physical illness and attempted suicide.

Memory and awareness in a patient with multiple personality disorder.

We studied an individual with multiple personality disorder in whom each of several personalities claimed to have no direct awareness of the others and to be unable to consciously remember the experiences of other personalities. A broad selection of implicit and explicit memory tests was used to determine the extent to which one personality had access to knowledge acquired by another and the circumstances in which that knowledge would be expressed. The implicit assessment of memory was a necessary but not sufficient condition for demonstrating interpersonality access. The degree of compartmentalization of knowledge in this patient depended largely on whether the interpretation of presented information was likely to differ across personalities.

Adult Men and Women With Trichotilomania: A Comparison of Male and Female Characteristics

Trichotillomania (hair pulling) has been considered a disorder that primarily affects women. It is rarely reported in men. Such rarity may reflect distinct clinical features in men that call for different treatment strategies. To investigate potential gender differences in trichotillomania, the authors systematically assessed the descriptive and phenomenological characteristics as well as psychiatric comorbidity of 14 male hair pullers and compared them to 128 female hair pullers who had been similarly assessed. Although a few gender differences existed, male trichotillomania was very similar to that seen in women. These results suggest that gender-specific treatment is not justified at this time; however, a more thorough psychiatric screening should be done with men because they may have additional psychiatric comorbidity.

Lifetime prevalence of psychiatric disorders in women with perimenstrual difficulties

Fifty-eight women age 30-40 years, blind to the purpose of the study were segregated according to whether they reported none-mild or moderate-severe perimenstrual difficulties on screening interview. Lifetime prevalence of major psychiatric disorders was ascertained using the Diagnostic Interview Schedule. Women in the moderate-severe group (n = 29) showed a significantly greater lifetime prevalence of affective disorders and drug abuse. No cases of somatization disorder were detected in either group.

Identification of cues associated with compulsive, bulimic, and hair-pulling symptoms

Subjects with obsessive compulsive disorder, bulimia nervosa, or trichotillomania selected cues which elicited or worsened their symptoms from a 339 item list. Principal components analysis suggested a four-component solution. Each disorder was significantly associated with one of these components. Diagnostic assignment based on component scores yielded 85% correct classification. The diagnostic groups did not differ on a negative feeling state component. The results indicate that both disorder-specific and generic components exist. This approach has potential for defining clinical subtypes, studying the interaction of feeling states and environmental cues in evoking symptoms, and designing treatment strategies.

Cues to obsessive-compulsive symptoms: Relationships with other patient characteristics

The waxing and waning of symptoms in obsessive-compulsive disorder (OCD) suggests that environmental cues may impact on exacerbations of this disorder. Eighty-one Ss with OCD completed the Cues Checklist (CCL; Mackenzie, Ristvedt, Christenson, Lebow & Mitchell, 1992), a 339-item checklist of rationally-derived cues and circumstances that might be expected to elicit or worsen symptoms. Principal components analysis revealed four components: household order and organization, contamination and cleaning, negative affect, and prevention of harm and checking. Total number of cues endorsed and component scores were correlated with other characteristics of the disorder, and with the presence of other Axis I and II disorders. Patterns of cue endorsement related to standard measures of obsessive-compulsive content but not to symptom severity. Early-onset Ss endorsed a greater number of cues. History of depression, anxiety disorders and Axis II pathology related most strongly to scores on the negative affect component. The values and limitations of this approach are discussed.

Effects of caffeine withdrawal on isoproterenol-stimuiated cyclic adenosine monophosphate

The effect of short‐term caffeine withdrawal on lymphocyte beta‐adrenoceptor sensitivity was studied in seven men who had been drinking coffee daily for at least 3 mo before the study. The ratio of cyclic adenosine monophosphate production after in vitro incubation with isoproterenol and a blank was used to assess receptor sensitivity. There was a reduction in sensitivity to isoproterenol but not to prostaglandin E1 3 days after caffeine withdrawal. The mechanism of this effect is not clear, but may represent a biochemical correlate of caffeine‐withdrawal syndrome

The Manipulative Patient: An Interactional Approach

The words manipulative or manipulation are used in the contemporary psychiatric literature to describe certain persons and their habitual modes of behavior. The terms represent an attempt to describe some essential quality of the patients style of relating to others. In the following discussion, we will attempt to shift this perspective to a more interpersonal one, seeing the attribution of this label as part of a sequence of communication, mutual perception, and struggle between caretaker and patient. The accusation that a patient is manipulative signals the disruption of the helping process.

Alcohol effects on the facial expressions of anxiety patients undergoing a panic provocation.

Using subjects with panic disorder, we investigated the effect of alcohol on expressive-emotional facial reactions to a well-known laboratory panic provocation procedure (inhalation of 35% carbon dioxide). Subjects consuming alcohol (vs. a placebo) displayed lower levels of emotional masking and fear/distress facial responses; however, differences were significant only for emotional masking. A composite variable combining the masking and fear/distress scores was also significantly lower in the group consuming alcohol. To the extent that masking behavior is a valid proxy for fear/distress responding, then the latter finding supports the conclusion that alcohol reduced negative affectivity associated with the inhalation. However, we also note the possibility that alcohol reduced masking directly without affecting fear/distress. We make parallel recommendations for future research that treats masking behavior as a nuisance variable on the one hand, or a dependent variable of potential importance on the other. We conclude that expressive-behavioral measures appear to be both feasible and potentially informative in alcohol research.

Obsessive-compulsive disorder exacerbated during pregnancy: a case report.

An established obsessive compulsive disorder (OCD) in a twenty-six-year-old woman, characterized by obsessional fear of rat germs and ritualistic cleansing, was observed to worsen during pregnancy. The patients OCD had followed a fluctuating course for three years but she had not previously experienced a decompensation of such duration and severity. During her pregnancy she became depressed and suicidal, was unable to care for her family and spent the majority of her confinement in the hospital. Several mechanisms are discussed which might explain the exacerbation.