Normative data for the F(p) scale of the MMPI-2: implications for clinical and forensic assessment of malingering.

Data from several clinical samples and the Minnesota Multiphasic Personality Inventory--2 standardization group are presented to familiarize the reader with response patterns of different groups on a new validity scale designed to assist in the identification of exaggeration or fabrication of psychological disturbance. Sensitivity-specificity analyses are included along with suggestions for use of the F(p) Scale with other validity scales. Cautions about setting single cutoff scores are also discussed.

[Changes in the 24-hour rhythm of plasma melatonin in patients with liver cirrhosis--relation to sleep architecture]. / Veränderung des 24-Stunden-Rhythmus von Plasma-Melatonin bei Patienten mit Leberzirrhose--Beziehung zur Schlafarchitektur.

OBJECTIVE: To assess the 24 hr plasma melatonin profile as a marker of the output rhythm from the circadian clock and to study sleep diaries as reflection of subjective sleep quality in patients with liver cirrhosis. DESIGN: Prospective cohort study. PATIENTS: A total of 14 subjects, 7 non-alcoholic cirrhotics and 7 age-, sex-, and educationally-matched controls. Exclusion criteria were factors that could affect melatonin levels (intercontinental travel, shift work, therapy with betablockers or corticosteroids). MEASUREMENTS: Plasma melatonin was measured every 30 min for 24 hr by radioimmuno assay and sleep recordings by polysomnography. Neuropsychological testing included visual reaction time. Trailmaking test A and B and the Digit Symbol Test. Sleep diaries were kept for the week prior to admission. RESULTS: Time of onset of melatonin rise was displaced from 19:50 +/- 26 min in the controls to 21:30 +/- 13 min (p = 0.013) in patients with liver cirrhosis. The time of peak melatonin levels was consistently and significantly delayed from 00:36 +/- 33 min in controls to 5:36 +/- 29 min (p < 0.001) in patients. Cirrhotic subjects showed markedly elevated melatonin levels during daytime, when melatonin is normally absent. Polysomnographic tracings showed no differences in patients and controls, but sleep diaries indicated more frequent nocturnal awakenings (p = 0.05) and daytime naps. CONCLUSIONS: A marked alteration of plasma melatonin rhythm is found in cirrhotic patients with subclinical hepatic encephalopathy. This disruption may reflect changes in the output of the circadian pacemaker located in the suprachiasmatic nucleus (SCN) of the hypothalamus. It is possible that some of the metabolic disturbances that lead to hepatic encephalopathy may also alter the function of the biological "clock".

Disruption of the diurnal rhythm of plasma melatonin in cirrhosis.

OBJECTIVES: To assess 24-hour plasma melatonin profile as a marker of output rhythm from the circadian clock and to study sleep diaries as reflections of subjective sleep quality in patients with liver cirrhosis. DESIGN: Prospective cohort study. SETTING: Clinical research center in a university hospital. PATIENTS: Seven patients with cirrhosis but not alcoholism and seven age-, sex-, and education-matched controls. MEASUREMENTS: Neuropsychological testing to confirm subclinical hepatic encephalopathy. Plasma melatonin levels measured every 30 minutes for 24 hours by radioimmunoassay. Sleep diaries kept for 1 week before admission. RESULTS: Patients with cirrhosis had markedly elevated melatonin levels during daytime hours; in addition, the time of onset of melatonin increase and the time at which melatonin levels peaked were consistently and significantly delayed in these patients. Sleep diaries indicated more nocturnal awakenings and more frequent daytime naps in patients with cirrhosis. CONCLUSION: Disruption of the diurnal rhythm of melatonin may reflect alterations of circadian function that could contribute to the disturbances of the sleep-wake cycle frequently seen in patients with cirrhosis.

Fitness to drive in patients with cirrhosis and portal-systemic shunting: a pilot study evaluating driving performance.

It has been suggested that some patients with cirrhosis are unfit to operate a motor vehicle. However, performance while driving a motor vehicle has not been evaluated in such patients. In this pilot study, we assessed the fitness to drive of stable individuals with cirrhosis and clinical evidence of portal hypertension, portal-systemic shunting and no prior history of hepatic encephalopathy. We examined 15 ambulatory patients with cirrhosis together with 15 age-, educational level- and driving experience-matched healthy controls. Neuropsychological testing was performed with the Reitan trail test, block design and digit symbol tests as well as visual reaction time. A driving test in the laboratory used a film to measure complex visual reaction time (reaction to road symbols) and threat recognition (accident avoidance). Driving on the road was assessed by a licensed Illinois state driving evaluator. Penalty points were given according to 11 standardized driving categories. As a group, patients with cirrhosis had no significant differences in their performance on a simulator or during actual driving conditions when compared to matched controls. Sixty-six percent of the subjects with cirrhosis had two or more abnormal neuropsychological tests, a criterion used to define the presence of subclinical encephalopathy. No deficiencies in simulated or real driving performance was seen when compared to patients with cirrhosis with normal neuropsychological tests. In this study, stable subjects with cirrhosis and evidence of portal hypertension, portal-systemic shunting, abnormal neuropsychological tests and no prior history of overt encephalopathy did not exhibit a major impairment in their fitness to drive.

Countertransference and the multiple amputee patient: pitfalls and opportunities in rehabilitation medicine.

Current psychoanalytic literature on countertransference broadly defines the term as a helping professional's overall response to an individual patient. Reactions of rehabilitation professional to their traumatically injured patients can significantly impact on the patient's treatment as well as the individual therapist's and entire rehabilitation team's effectiveness. In this paper, a case is presented illustrating a process of understanding countertransference toward a multiple amputee patient. Implications for the rehabilitation team are also described. The analysis of a single case demonstrates how countertransference interpretation might be used as a vehicle to enhance understanding the patient and promote team effectiveness.

Driving safety after brain damage: follow-up of twenty-two patients with matched controls.

Driving after brain damage is a vital issue, considering the large number of patients who suffer from cerebrovascular and traumatic encephalopathy. The ability to operate a motor vehicle is an integral part of independence for most adults and so should be preserved whenever possible. The physician may estimate a patient's ability to drive safely based on his own examination, the evaluation of a neuropsychologist, and a comprehensive driving evaluation--testing, driving simulation, behind-the-wheel observation--with a driving specialist. This study sought to evaluate the ability of brain-damaged individuals to operate a motor vehicle safely at follow-up. These patients had been evaluated (by a physician, a neuropsychologist, and a driving specialist) and were judged able to operate a motor vehicle safely after their cognitive insult. Twenty-two brain-damaged patients who were evaluated at our institution were successfully followed up to five years (mean interval of 2.67 years). Patients were interviewed by telephone. Their driving safely was compared with a control group consisting of a close friend or spouse of each patient. Statistical analysis revealed no difference between patient and control groups in the type of driving, the incidence of speeding tickets, near accidents, and accidents, and the cost of vehicle damage when accidents occurred. The patient group was further divided into those who had, and those who had not experienced driving difficulties so that initial neuropsychologic testing could be compared. No significant differences were noted in any aspect of the neuropsychologic test battery. We conclude that selected brain-damaged patients who have passed a comprehensive driving assessment as outlined were as fit to drive as were their normal matched controls.(ABSTRACT TRUNCATED AT 250 WORDS)