Psychological impact of genetic testing in women from high-risk breast cancer families.

Psychological adjustment in 90 women (30 carriers and 60 non-carriers) who had undergone genetic testing for mutations in BRCA1 and BRCA2 breast/ovarian cancer susceptibility genes was compared with that of 53 women who were not offered genetic testing. Women were assessed prior to genetic testing and 7-10 days, 4 and 12 months after carrier status disclosure using self-administered questionnaires. Compared with women not offered testing, mutation carriers had significantly higher breast cancer distress 7-10 days (t=2.80, P=0.005) and 12 months (t=2.01, P=0.045) post-notification. Non-carriers showed a significant decrease in state anxiety 7-10 days post-notification (t=2.27, P=0.024) and in depression 4 months post-notification (t=2.26, P=0.024), compared with women not offered testing. These data show that non-carriers derive psychological benefits from genetic testing. Women testing positive may anticipate a sustained increase in breast cancer distress following disclosure, although no other adverse psychological outcomes were observed in this group.

Long-term outcomes of genetic counseling in women at increased risk of developing hereditary breast cancer.

This multicenter study evaluated the impact of genetic counseling in 218 women at risk of developing hereditary breast cancer. Women were assessed prior to counseling and 12-month post-counseling using self-administered, mailed questionnaires. Compared to baseline, breast cancer genetics knowledge was increased significantly at follow-up, and greater increases in knowledge were associated with educational level. Breast cancer anxiety decreased significantly from baseline to follow-up, and these decreases were associated with improvements in perceived risk. A significant decrease in clinical breast examination was observed at the 12-month follow-up. Findings suggest that women with a family history of breast cancer benefit from attending familial cancer clinics as it leads to increases in breast cancer genetics knowledge and decreases in breast cancer anxiety. The lowered rates of clinical breast examination indicate that the content of genetic counseling may need to be reviewed to ensure that women receive and take away the right message.

Intention to undergo prophylactic bilateral mastectomy in women at increased risk of developing hereditary breast cancer.

PURPOSE: To assess intention to undergo prophylactic bilateral mastectomy and psychologic determinants in unaffected women at increased risk of developing hereditary breast cancer. PATIENTS AND METHODS: Three hundred thirty-three women who were awaiting their initial appointments for risk assessment, advice about surveillance, and prophylactic options at one of 14 familial cancer clinics participated in a cross-sectional, questionnaire-based survey. RESULTS: Nineteen percent of women would consider and 47% would not consider a prophylactic mastectomy, should genetic testing identify a mutation in a breast cancer-predisposing gene, whereas 34% were unsure and 1% had already undergone a prophylactic mastectomy. In a bivariate analysis, women at a moderately increased risk of developing breast cancer had the highest proportion of subjects reporting that they would consider a prophylactic mastectomy (25%), compared with women at high risk (16%) (chi(2) = 7.79; P =.051). In multivariate analyses, consideration of prophylactic mastectomy strongly correlated with high levels of breast cancer anxiety (odds ratio [OR] = 17.4; 95% confidence interval [CI], 4.35 to 69.71; P =. 0001) and overestimation of one's breast cancer risk (OR = 3.01; 95% CI, 1.43 to 6.32; P =.0036), whereas there was no association with objective breast cancer risk (P =.60). CONCLUSION: A significant proportion of women at increased risk of developing hereditary breast cancer would consider prophylactic mastectomy. Although prophylactic mastectomy may be appropriate in women at high risk of developing breast cancer, it is perhaps less so in those who have a moderately increased risk. Such moderate-risk women are likely to benefit from interventions aimed at reducing breast cancer anxiety and correcting exaggerated breast cancer risk perceptions.

Post-ictal psychosis: an unusual clinical entity.

OBJECTIVE: The aim of this paper is to describe a case of post-ictal psychosis (PIP) and to discuss the literature surrounding this interesting disorder. CLINICAL PICTURE: A 32-year-old woman with epilepsy presented on three occasions with psychosis following tonic-clonic seizures. TREATMENT AND OUTCOME: The psychosis resolved within 14 days on haloperidol 7 mg daily. CONCLUSIONS: Post-ictal psychosis is an unusual clinical entity that is frequently recurrent and may be misdiagnosed and treated inappropriately. Prophylaxis of PIP is an area for important future research.

Use of a psychiatric proforma for accident and emergency officers.

OBJECTIVE: To devise a proforma for clinical documentation of psychiatric illness in an accident and emergency (A&E) department, since A&E senior house officers (SHOs) have little psychiatric experience before starting their jobs. METHODS: History taking and mental state examinations by 16 SHOs were compared before (n = 50) and after (n = 50) the introduction of the proforma. Comments on the proforma were provided by all participants on a questionnaire. RESULTS: There was an improvement in documentation with the use of the proforma (Mann-Whitney U test, P < 0.001). The senior house officers found the proforma useful and supported further development of this initiative. CONCLUSIONS: A standard form for documenting psychiatric history, designed according to local needs, is useful and should be available in A&E departments.

Violence in clinical forensic medicine.

OBJECTIVE: to investigate the levels of physical and verbal violence experienced in the preceding year by doctors working in clinical forensic medicine. DESIGN AND SUBJECTS: anonymised questionnaire sent to all full members of the Association of Police Surgeons. RESULTS: 517 eligible questionnaires were returned; 18.2 per cent of respondents had experienced physical violence, a total of 150 incidents. Of those incidents 'warning signs' of violence had been present in only 25 per cent. A total of 54 working days were lost. Injuries included a fractured wrist and corneal scarring. Of the respondents, 65.5 per cent had experienced verbal violence (of which the most common type was obscenity); 11.8 per cent had received training in dealing with verbal violence and 10.4 per cent in dealing with physical violence; 88 per cent believed that training on how to deal with violence should be part of police surgeon/forensic medicine training. CONCLUSION: verbal and physical violence are common in clinical forensic medicine. Training in dealing with these issues should be introduced.

Violence in the accident and emergency department.

A survey of Accident and Emergency nurses was undertaken to study the prevalence, types and possible precipitating factors of violence in the workplace. Violence was sub-divided into physical and verbal. Verbal violence was more common than physical assault but often not reported. Often physical violence is under-reported but in fact had affected one third of respondents. Associations with different types of violence are discussed. The need for further training in defusing violent situations and analysis of violent incidents is identified. Some suggestions for inclusion in a training programme are given.

Management of Gilles de la Tourette syndrome using sulpiride.

One hundred and fourteen patients with Gilles de la Tourette syndrome have been reviewed. Sixty-three were managed using sulpiride, and worthwhile beneficial effects occurred in 59%. Our experience with sulpiride compared to other drug treatments is discussed. The main adverse side effects of sulpiride treatment were sustained drowsiness and, possibly, depression. Tardive dyskinesia was not reported in our cohort.