The clinician's role in assessing workplace violence.

Workplace violence can be an area of consultation for psychiatrists. However, the clinician must understand not only the limits of violence prediction, but also the corporate culture in which he or she will become involved. Evaluation of threats may involve review of written notes or taped recordings; the employee may or may not be seen. Corporate consultations sometime involve a split allegiance on the part of the clinician who must both advise the company and render a decision about the employee. The dynamics of violence within the workplace are discussed.

Threats against clinicians: a preliminary descriptive classification.

Threats against psychiatrists are common, but existing studies on the subject lack descriptive information about the nature and resolution of the threat. In the present study, clinicians who had received threats were interviewed in person or by telephone, and case histories were summarized. Threats were classified as situational and transferential. Demographic factors, precipitating events, and legal actions taken are described. The manner in which clinicians reacted to threats is also discussed.

Pharmacologic approaches to violence.

No one drug is specific for the management of violent behavior. Rather, the pharmacologic treatment of aggression is best approached by identifying and treating the underlying psychopathology, with the expectation that the violent behavior will resolve secondarily. Pharmacologic management is probably most successful when other treatment modalities such as family, group, and individual psychotherapies are used concurrently.

Psychiatric care for patients with self-inflicted gunshot wounds.

Self-inflicted gunshot wounds are the commonest form of suicide in this country. Seventeen individuals with such injuries were admitted to a trauma center over a 3-month period. Review of their records showed that psychiatric consultation was requested for only nine of the 13 patients who survived their wounds. Information on alcohol use was missing from half the case records and only six of the 13 survivors received psychiatric care after discharge. Use of guns in suicide attempts may evoke strong feelings in health care providers, resulting in omissions in history taking, evaluation, and follow-up.

Problems in the diagnosis of intermittent explosive disorder.

The authors studied the accuracy with which intermittent explosive disorder was diagnosed in a university hospital setting. An index of diagnostic features abstracted from the description of intermittent explosive disorder in DSM-III was used for chart review. Diagnosis of the disorder was made in 20 out of 830 admissions (2.4%). In 14 cases (1.7%) it was a primary one; in another five (.6%) it was secondary; and in one case (.1%) it was tertiary. The authors discuss the varied rigorousness of the diagnosis and the importance of using an index of diagnostic features to enhance diagnostic accuracy.

Diagnostic and therapeutic difficulties in atypical illness.

The discipline of psychiatry often polarizes clinicians into "biologically" and "psychoanalytically" oriented camps. The former use drugs to treat and focus on symptomatic relief while the latter attempt to resolve core psychological problems and eschew pharmacological aids. Atypical psychoses confront both groups with major problems. As the underlying etiology may be epileptoid, the analytically oriented clinician may miss diagnostic clues. His biologically oriented colleague may dismiss the psychological triggers to the episodic disturbance. Diagnostic difficulties are compounded by the mix of behavioral disturbances with affective features and by the erratic course of the illness. It is difficult to find colleagues to help with the diagnosis of atypical psychoses. Neurologists often focus on "hard" signs only while parameters for "abnormalities" vary among electroencephalographers. Some EEG labs are intolerant of patients who will not cooperate with sleep or hyperventilation procedures or are not acquainted with drug activation techniques for identifying limbic system dysfunction. It is known that psychological factors influence seizures, and increase or decrease the need for anticonvulsants. Yet pharmacological suppression of a seizure state may lead to personality change or deterioration. The changing picture of illness and its divergence from classical "textbook" illness may evoke anger and frustration in the therapist as he comes to view the patient as noncompliant.

Hyperaldosteronism (Conn's disease) presenting as depression.

A case of muscle weakness with hypertension is presented. The patient had symptoms of depression. Diagnosis of hyperaldosteronism was suspected because of a low serum potassium and confirmed by discovery of an adrenal adenoma. The role of hypokalemia in mental disturbances is reviewed. Emphasis is placed on possible metabolic etiologies when mood changes, muscle paresis and hypertension coexist.

Benzodiazepines in the treatment of aggressive patients.

A double-blind, controlled clinical trial of chlordiazepoxide, oxazepam and placebo was conducted in 65 outpatients with past histories of temper outbursts, assaultive behaviour and impulsiveness associated with anxiety, irritability and hostility. Of those tests showing statistically significant results, there was a tendency for oxazepam to be somewhat more effective in the reduction of anxiety than chlordiazepoxide. Oxazepam was also superior to the latter on 1 subscale of tests used to measure hostility. No paradoxical rage responses were noted.