Individual predictors of traumatic reactions in firefighters.

Increasingly, theorists and researchers in the area of trauma are pointing to the importance of individual differences in resilience and vulnerability as key determinants of the intensity and duration of trauma-related symptoms. Determining the relative influence of individual predictors is important for the further development of theoretical models for understanding trauma responses and for the subsequent development of intervention strategies that are sensitive to individual differences. This study explores the influence of individual factors and social support on traumatic reactions in firefighters exposed to tragic events in the line of duty. A total of 164 Australian firefighters completed questionnaires targeting locus of control, self-efficacy, patterns of interpersonal relating, social support and level of emotional distress. Results indicate that individuals with feelings of insecurity, lack of personal control, and alienation from others were more likely to experience higher levels of depression and posttraumatic stress symptoms subsequent to exposure to traumatic events on the job.

The duty to warn and protect--impact on practice.

OBJECTIVE: To discuss the concepts of the duty to protect and the associated threat to confidentiality and their impact on practice for Canadian psychiatrists. METHOD: We review these concepts and provide a synthesis of legal cases impacting psychiatric practice. CONCLUSION: The onus is on the psychiatrist to make him or herself aware of the current state of the legal obligation with respect to duty to protect. The evolving concept of duty to protect has and will continue to have significant impact on the practice of psychiatry.

Physicians who commit sexual offences: are they different from other sex offenders?

OBJECTIVE: To determine if physician sex offenders differ significantly from other sex offenders by using a control group and assessing both groups with reliable and valid instruments. METHOD: Nineteen male physician sex offenders were compared with 19 male sex offender control subjects, matched on offence type, age, education, and marital status. Both groups were compared with a general sample of sex offenders (n = 2125). The 3 groups were compared on sexual history and preference, substance abuse, mental illness, personality, history of crime and violence, neuropsychological impairment, and endocrine abnormalities. RESULTS: Physicians in this study were highly educated and older, forming a statistically significant subgroup of sex offenders. The majority of physician sex offenders suffered from a sexual disorder (68.4%), as did the other 2 groups. Physicians showed more neuropsychological impairment and endocrine abnormalities and less antisocial behaviour than did the general sample of sex offenders but did not differ from the matched control group. Physician offenders who sexually assaulted their patients did not differ from those who had nonpatient victims. CONCLUSIONS: Despite differences in age, education, and occupation between physician sex offenders and sex offenders in general, the same assessment procedures can be recommended for examining both groups. Although the sample size is small, results suggest that physicians who commit sexual offences should be scrutinized by phallometric assessment of sexual deviance and especially for neurological and endocrine abnormalities.

Canadian landmark case: Regina v. Swain: translating M'Naughton into twentieth century Canadian.

Since their adoption in 1892, the insanity laws in the Criminal Code of Canada have utilized a modified M'Naughton rule. The Department of Justice began work in the 1970s to update these laws. In 1983, soon after the Canadian Charter of Rights and Freedoms was proclaimed, the case of Regina v. Swain provided the impetus for this change. In 1990 the Supreme Court of Canada struck down the old law, giving parliament a specific time to pass new legislation. Bill C-30 modernized the language of the Criminal Code and introduced a number of procedural safeguards to protect the rights of the accused.

Confidentiality in crisis: Part I--The duty to inform.

OBJECTIVE: To discuss the ethical and legal imperatives to protect third parties from harm in circumstances often believed to be protected by doctor-patient confidentiality. METHOD: A review of recent legislative changes and legal decisions pertaining to a psychiatrist's duty to warn. CONCLUSION: The current legislative and legal climate presents many risks to the concept of doctor-patient confidentiality. Psychiatrists must carefully consider any guarantees of confidentiality made to patients and must discuss the limits of confidentiality when obtaining consent for treatment.

Confidentiality in crisis: Part II--Confidentiality of treatment records.

OBJECTIVE: To discuss the implications of recent legislative changes and court decisions in Canada that have placed the privacy of psychiatric records information at risk. New areas of exposure include client access to clinical information provided by family members, parental access to children's records, and court access to clinical records in civil, criminal, and family law matters. METHOD: A review of recent legislative changes and court decisions pertaining to access to psychiatric records. CONCLUSION: At present, psychiatric records can no longer be regarded as confidential. Recent changes in the concept of privilege of treatment records necessitates several changes in psychiatric practice regarding informed consent to treatment, content of clinical records, and responses to demands for information.

Report from the Committee on Sex Offenders: the Abel Assessment for Sexual Interest--a brief description.

This article briefly reviews objective methods of assessing sexual interest and/or arousal and mentions some of the disadvantages of penile plethysmography. Literature that supports the use of viewing time as a measurement of sexual interest is reviewed. A detailed description of a new system of assessing sexual interest, called the Abel Assessment, which has both subjective and objective components, is presented. A critique of this assessment system is then offered.

Consent to electroconvulsive therapy: investigation of the validity of a competency questionnaire.

A valid consent is a necessary precondition to the administration of electroconvulsive therapy (ECT). However, the assessment of mental competence to consent may be both complicated and controversial because neither case law nor statutes provide a clear description of the necessary mental abilities. The closest approximation in the literature is that derived from judicial commentary on the relevant case law and summarized into four standards. We designed a 15-item questionnaire to define and test the content or essential elements of each of these standards, and surveyed lawyers and health care professionals with known expertise or interest in the field to investigate the content validity of the questionnaire. Of the 15 items, 12 were rated important or essential to the assessment of competence to consent to ECT by > or = 67% of the lawyers and 11 were so rated by > or = 67% of the health professionals. Ten items were rated as important or essential by > or = 67% of both groups. Only two items were not so endorsed by > or = 67% of one of the groups. We conclude that the questionnaire has a satisfactory content validity and may be considered a general guideline for assessing competence to consent to ECT.

The forensic psychiatric aspects of schizophrenia.

This review of the literature does seem to reveal an association between schizophrenia and a variety of antisocial behaviors that include violent crime, and even homicide, especially in North America. The literature consistently shows that since the 1950s, schizophrenics have been involved in crime and arrested more frequently than the general population, they are overrepresented in correctional settings, and they represent the majority of those found not guilty by reason of insanity. Many authors cite changes in mental health policies, particularly de-institutionalization, as one of the major causes of these phenomena. It is important to note that a history of prior arrests and of being male, poor, unskilled, uneducated, and unmarried are perhaps the best predictors of antisocial behaviors in the mentally ill and in the general population alike. Schizophrenic drift and increased family pathology in schizophrenic families, however, may predispose people suffering from schizophrenia to these demographic variables. Interestingly, these variables do not seem as relevant in the emergency room or inpatient wards where violence seems to be mainly affected by the severity of psychopathology, substance abuse, neurologic signs, and the environment within the mental health setting. The implications for the practice of psychiatry are diverse. Clearly clinicians in both hospitals and community mental health settings must have experience, training, and an awareness of the literature relating to the prevention, causes, and management of violence. It behooves us in the mental health field, having vociferously supported the community mental health movement, to assist police in the management of the mentally ill who are now in the community, perhaps by the use of mobile crisis intervention teams and by a considerably increased amount of effort and cooperation. Correctional services require urging to develop resources for identifying and tracking the mentally ill so as to be able to provide programs and continuity of care. Community mental health and criminal justice systems need to cooperate in planning the transition of mentally abnormal offenders from prisons into the community and then providing support and after-care for them. One exemplary program that has developed and benefited from the coordination and planning at the interministerial level is the Inter-ministerial Project (IMP) program in Vancouver. This program identified the people whose histories revealed repeated admissions to both correctional and mental health facilities, bouncing between one and the other. Using a case management approach with a limited caseload, clinicians were able to reduce the number of admissions to both types of facilities. This program should serve as a model for other jurisdictions.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of sexual assault on a small isolated community.

This paper documents the case of one family in which the two young boys were sexually abused by a school principal. Each family member suffered deleterious psychological sequelae as a result of the abuse. Since more than half the boys of one generation in this community were assaulted by the same perpetrator, we have postulated that the whole community suffered from a sense of betrayal, powerlessness and stigmatization.