Role of flexible endoscopy in the evaluation of possible esophageal trauma after penetrating injuries.

OBJECTIVE: In urban medical centers, penetrating injuries of the chest, neck, and head are frequently encountered due to the use of firearms and sharp weapons. Successful management of esophageal injury requires a high index of suspicion and prompt diagnosis. The role of flexible endoscopy, a readily available modality, has not been studied extensively in the management of potential esophageal injuries due to trauma. METHODS: A retrospective chart review of 55 patients who underwent emergent flexible endoscopy for the evaluation of suspected penetrating esophageal injuries was performed to determine if endoscopy was safe and if it yielded information that altered patient management. RESULTS: Flexible endoscopy was performed safely in all patients. It yielded a sensitivity of 100%, specificity of 92.4%, a negative predictive value of 100%, and a positive predictive value of 33.3% for detecting an esophageal injury. Although positive findings (prevalence, 3.6%) are infrequent, no esophageal injuries were missed. Endoscopy altered patient management in 38 (69.1%) patients. CONCLUSIONS: Emergent flexible endoscopic examination of the esophagus is a safe and useful diagnostic tool in the early evaluation of penetrating injuries. Flexible endoscopy resulted in four negative surgical explorations, which was deemed acceptable by the Trauma Service, as the consequences of a missed esophageal injury is likely to be devastating.

Characteristics of women in jail and treatment orientations. A review.

Women who have been incarcerated are a high-risk group for criminal recidivism, and criminal justice statistics indicate that females are increasing in numbers more rapidly than the male detainee population. According to data from epidemiologic studies, incarcerated women are often young, single, mothers from ethnic minority backgrounds who have little education and poor work histories. Mental illness, drug abuse, and risky behaviors relating to contracting HIV/AIDS are common problems among female detainees. In this report, research into characteristics of women in jail and literature relating to treatment programs for incarcerated women are reviewed. Implications relating to treatment needs, program development, and further research are discussed. A case example and treatment intervention are presented based on this review.

Three-dimensional esophageal varix model quantification of variceal volume by high-resolution endoluminal US.

BACKGROUND: The purpose of this study was to evaluate the accuracy and reproducibility of three-dimensional volume measurements by high-resolution endoluminal ultrasound in an esophageal varix model. METHODS: An esophageal varix model was made by filling three esophageal dilatation catheters with various volumes of water. A 20 MHz ultrasonography transducer was then pulled along the length of the catheters at a constant rate (1.25 mm/sec) while videotaping the procedure. Cross-sectional surface area measurements of each catheter were taken every second and the cross-sectional surface area was multiplied by the length of each catheter, as determined by high-resolution endoluminal ultrasound, to determine the volume in each catheter. Interobserver variability was calculated, and three-dimensional reconstruction was performed. RESULTS: The measured volumes corresponded closely with the actual volumes with an error ranging from 0% to 15.4%. The correlation between actual and measured volumes was r = 0.988. The interobserver variability ranged from r = 0.951 to r = 0.994. Actual esophageal varices were then imaged in a similar fashion to determine the feasibility of this method in patients with esophageal varices. CONCLUSIONS: High-resolution endoluminal ultrasound is an accurate and reproducible method of measuring volumes in an esophageal varix model and can be used in a clinical setting to determine variceal volume. Volume studies are now underway in human subjects.

Detection of minimization of psychopathology on the Rorschach in cleric and noncleric alleged sex offenders.

The assessment of response-bias is critical in forensic psychological evaluations of alleged sex offenders because sex offenders frequently minimize psychopathology or personal limitations. This study tested predictions based on prior research that minimization on the Rorschach would be reflected by higher P, D, A, Lambda, and PER, and lower R, Blends, and Zf. We divided a sample of cleric and noncleric alleged sex offenders according to (a) whether they showed minimization on the MMPI, and (b) whether they admitted to their charges. We then compared these groups on the purported Rorschach validity indices. Our results do not support the use of any of these Rorschach scores in the assessment of minimization. We recommend that in forensic psychological evaluations, the Rorschach should not be used to assess defensiveness and is best used in combination with other psychometric instruments more sensitive to response-bias.

Cycle of abuse and psychopathology in cleric and noncleric molesters of children and adolescents.

Sexual abuse in childhood is frequently reported among sex offenders and has been hypothesized to be one of a number of psychological factors etiologically related to perpetration of child molestation in adulthood. In the current study we examine a sample of cleric and noncleric admitted child molesters and normal control subjects in their exposure to sexual abuse in childhood and current psychopathology. Odds ratios for the association between exposure to sexual abuse and child molestation were obtained while adjusting for group differences in demographic and psychological characteristics. Results indicated exposure to sexual abuse in childhood was associated with becoming a child molester for both cleric and noncleric offenders (p < .0002). Nonclerics indicated more severe psychopathology than clerics. Sexual abuse in childhood is one of many risk factors for becoming a perpetrator of child molestation in adulthood for both cleric and noncleric child molesters. Noncleric offenders demonstrated more sociopathy and mental disorder in general while cleric offenders indicated more sexual conflictedness, suggesting different psychoetiologies of offending among cleric and noncleric child molesters.

Psychological aspects of sexual functioning among cleric and noncleric alleged sex offenders.

Cleric sexual misconduct with minors is a problem receiving increased attention from the media, victims groups, and church authorities. Mental health professionals are increasingly being asked to assist church and civil authorities to help better understand the problem of cleric sexual misconduct with minors. In the current study we compared self-reported sexual functioning among cleric alleged child molesters, noncleric alleged child molesters, and normal control subjects. We hypothesized clerics would differ from nonclerics and normals in reported sexual functioning. Our sample included 30 Roman Catholic clerics and 39 nonclerics who were alleged to have engaged in sexual misconduct with minors, and 38 normal control subjects, all of whom took the Derogatis Sexual Functioning Inventory (DSFI) as part of their forensic psychiatric evaluation. Our results indicated clerics were more likely to report fewer victims, older victims, and victims of male gender than noncleric alleged child molesters. Clerics differed from nonclerics and normal control subjects on several dimensions of self-reported sexual functioning. Lower offense rate histories among clerics suggest that, as a group, clerics may be less seriously psychologically disordered than noncleric child molesters. Low DSFI scores among Roman Catholic clerics may be accounted for in part by their unique training and socialization process. Future studies should attempt to study the influence of social desirability on DSFI scores. Normative data from nonoffending celibate clergy are needed.

Can psychosis be malingered on the Rorschach? An empirical study.

Can psychosis be faked on the Rorschach? We examined this question by comparing 2 groups of subjects with a high incentive to malinger, persons accused of serious crimes. All subjects were administered both the Minnesota Multiphasic Personality Inventory (MMPI) and the Rorschach and were assigned to honest (N = 35) and malingered (N = 13) groups on the basis of MMPI validity scales. The Rorschach protocols of these 2 groups were compared to assess how successfully malingerers could deliberately produce records that appeared psychotic on empirically derived Rorschach indices of psychosis. Despite an attempt to portray themselves as psychotic on the MMPI, subjects in the malingered group did not differ from honest responders on Rorschach variables that distinguish psychotic from nonpsychotic patients, but did differ in the number of dramatic responses produced. Our data suggest that the combination of the MMPI and Rorschach provides a powerful psychometric technique for detecting deliberate malingering of psychosis.

Medroxyprogesterone and paraphiles: do testosterone levels matter?

We examine the associations between pretreatment testosterone (TTS) levels and sociodemographic, clinical, and sexual behavioral characteristics. Two groups, low and normal pretreatment TTS, were treated with medroxyprogesterone acetate (MPA) and compared on clinical response (deviant and nondeviant sexual behaviors; recidivism) and length of time to return to pretreatment TTS after discontinuing MPA. Thirteen paraphilic men who were treated with MPA and had TTS levels monitored at approximately three-month intervals during and after MPA were followed naturalistically. The principal outcome measures pertained to TTS levels and data from a self-report psychosexual inventory, which quantified deviant and nondeviant sexual activities. Time to return to baseline TTS levels were analyzed with Kaplan-Meier survival analysis. Nonparametric methods were used to compare the two groups on other variables. Multiple regression was used to examine the contribution of combinations of variables to TTS outcome. Subjects with low pretreatment TTS received MPA for longer periods of time, and older subjects took longer to return to pretreatment TTS levels despite being treated for shorter periods of time. Although subjects with lower pretreatment TTS levels may be more sensitive to MPA's TTS-suppressive effects, the multiple regression analysis showed that age may be an important determinant of the time it take for TTS levels to return to pretreatment baseline. Sociodemographic, clinical, and self-reported measures of sexual behavior did not distinguish between low and normal TTS level groups. Only one relapse was detected. Further studies with larger samples are required to better understand the role of TTS monitoring of sex offenders treated with MPA, in order to justify its continued use as a measurement of treatment adequacy and to study its potential role as a predictor of treatment outcome.

State psychiatric hospital patients with past arrests for violent crimes.

OBJECTIVE: This study examined associations between four types of major psychopathology--schizophrenia, schizoaffective disorder, and bipolar and unipolar affective disorders--and history of violent crime. The effects of demographic variables, substance abuse, psychosis, and paranoia on history of violent crime were also determined. METHODS: Diagnostic assessments using the Schedule for Affective Disorders and Schizophrenia and Research Diagnostic Criteria identified 172 state hospital inpatients with the four diagnoses of interest, as well as those with co-existing substance use disorders. Based on arrest records, patients were categorized according to the most violent crime for which they had been arrested. RESULTS: Patients with schizoaffective disorder were significantly more likely than those in the other diagnostic groups to have been arrested for a violent crime. Similar results were found for psychotic patients compared with nonpsychotic patients, patients who had paranoid schizophrenia compared with patients who had schizophrenia without paranoid features, and patients who had co-existing substance abuse compared with those with no history of substance abuse. Patients from racial minority groups and male patients were also more likely than white patients and female patients to have been arrested for a violent crime. CONCLUSIONS: Demographic features, a diagnosis of schizoaffective disorder, psychosis, paranoid symptoms, and substance abuse may all be associated with violent behavior.

Predicting the "revolving door" phenomenon among patients with schizophrenic, schizoaffective, and affective disorders.

OBJECTIVE: A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. METHOD: Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. RESULTS: Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. CONCLUSIONS: Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Medroxyprogesterone treatment for paraphiliacs.

This study addresses the following questions: (1) what are the essential components of a medroxyprogesterone acetate (MPA) pretreatment evaluation?; (2) do paraphilic men treated with MPA (Depo-Provera) report a lowering of both deviant and nondeviant sexual drive and activities?; (3) is behavioral improvement associated with testosterone level reductions?; and (4) what significant side effects are associated with MPA treatment? A total of 29 paraphilic men who underwent a comprehensive psychiatric, medical, and legal evaluation and were eligible for treatment with MPA were followed naturalistically while receiving concurrent MPA and group therapy. The principal outcome measures were data obtained from a weekly self-reported psychosexual inventory that quantified five dimensions of deviant and nondeviant sexual activities and testosterone levels that were drawn pretreatment and after three and six months of MPA. Self-reported data were analyzed by nonparametric methods. Because MPA's effectiveness is evident early in treatment, we report on data from the first six months. Subjects reported a differential rate of suppression of sexual activities, a median of up to two weeks for deviant and 2 to 10 weeks for nondeviant behaviors (p < or = .01 for each of the five dimensions). Testosterone levels suppressed to less than 0.5 ng per milliliter for all but two subjects at three months and for all at six months. Recidivism was reported for one subject. Except for one subject who developed pulmonary emboli, no major medical problems were encountered. MPA safely and effectively reduced sex drive, controlled deviant sexual impulses and behavior, and lowered the testosterone levels of these paraphilic men during the first six months of treatment. However, the relative rapidity and completeness of the response raises questions regarding possible distortions in self-reported sexual activities. This should alert the practicing clinician to consider the use of collateral sources of information in interpreting treatment outcome for patients with paraphilic behaviors. Also, longer follow-up periods are required for monitoring treatment efficacy.

Profiling psychological distortion in alleged child molesters.

Sex offenders frequently show denial and distortion during forensic psychological evaluations, but research into assessment of rationalizations and cognitive distortions among sex offenders has been limited. We examined patterns of psychological distortion in 59 alleged child molesters. We compared fake-good and fake-bad orientations on the MMPI with psychological distortion on the Multiphasic Sex Inventory questionnaire which assesses various psychosexual characteristics among sex offenders. Analysis indicated that distortion on the Multiphasic Sex Inventory indices of minimization and exaggeration was significantly associated with response-bias on the MMPI. Cognitive-distortion indices were highly influenced by response-bias. Admitters differed from deniers on scales with items requiring admission or denial of offenses. Caution is warranted in clinical interpretation of the validity scales of this questionnaire, which are of limited utility for deniers. Subtle items on cognitive-distortion indices may be useful in assessment of those who deny and should be subjected to further research.

Denial of hostility and psychopathology in the evaluation of child molestation.

We administered the Buss-Durkee Hostility Inventory (Buss & Durkee, 1957) and the Minnesota Multiphasic Personality Inventory (Hathaway & McKinley, 1967) to 82 alleged child molesters. Denial of hostility was significantly associated both with minimization of psychopathology and with denial of charges of sex offense. No subjects who denied charges acknowledged psychopathology, whereas one third of admitters acknowledged psychopathology. Our results suggest that alleged sex offenders may show complex patterns of impression management and that self-report hostility inventories are highly vulnerable to response bias.

The psychometric assessment of alcoholism in forensic groups: the MacAndrew scale and response bias.

Although the MacAndrew Alcoholism scale is the most widely used Minnesota Multiphasic Personality Inventory (MMPI) measure of vulnerability to alcohol abuse, its accuracy has not been studied in patients intrinsically motivated to exaggerate or minimize psychopathology. We examined the usefulness of the MAC in predicting alcohol abuse in a forensic clinical sample. Results indicate the MAC (a) was not more effective than direct inquiry in this group, (b) scores were correlated negatively with minimization and positively with exaggeration for subjects with histories of alcohol abuse, (c) offered advantages over direct inquiry both in screening for alcohol history (sensitivity) and in confirming it (specificity), and (d) scores were only moderately more accurate in valid than in minimized or exaggerated MMPI protocols. The results suggest that clinicians should use the MAC cautiously, particularly when they suspect motivation to minimize psychopathology.

Denial and social desirability in clinical evaluations of alleged sex offenders.

Clinicians are increasingly being requested to evaluate alleged sex offenders. Denial of sex offenses and minimization of psychopathology is common in such patients. We studied the relationship between denial of deviant sexual behavior and minimization/exaggeration of problems (i.e., response bias) during clinical evaluations in 59 alleged sex offenders. The data indicated that patients who denied allegations of deviant sexual behavior showed significantly more minimization of problems than did admitters (p < .001), and patients who admitted allegations showed more exaggeration of problems than did deniers (p < .05). Response bias was significantly associated with a number of personality characteristics. In particular, alleged offenders who denied deviant sexual behavior were more likely to be defensive about undesirable personality characteristics and to minimize problems than were those who admitted to deviant sexual behavior. When defensive, alleged sex offenders were likely to minimize anxiety and personality disorders. The data support the forensic utility of psychological testing in the assessment of alleged sex offenders.

The evaluation of truthfulness in alleged sex offenders' self-reports: 16PF and MMPI validity scales.

The evaluation of response bias (i.e., minimization or exaggeration) is central to forensic psychological evaluations. Yet few studies have assessed forensic samples to investigate the ability of psychological tests to detect response bias. We studied the relationship between the Sixteen Personality Factors Questionnaire (16PF) and the Minnesota Multiphasic Personality Inventory (MMPI) validity scales for 65 alleged sex offenders and assessed the effects of different cutoff scores for the 16PF validity scales. Results indicate consistent significant correlations between the validity scales of the 16PF and the MMPI for measures of minimization and exaggeration. use of a priori cutoff scores resulted in the classification of our sample in proportions parallel to those found in previous research for the 16PF Fake-Good scale but not the Fake-Bad scale. Our results indicate that 16PF validity scales are useful, but interpretations must take into account different base rates of response bias between sex offenders and the general population.

The detection of malingering in criminal forensic groups: MMPI validity scales.

Despite the value of the MMPI to the forensic assessment of malingering (exaggeration) of psychopathology, few studies have assessed the accuracy of the MMPI validity scales in criminal forensic populations. We administered the MMPI to 35 insanity defendants undergoing evaluation for fitness to stand trial and/or sanity at the time of the crime, who stood to benefit from being assessed as psychologically disturbed, and 39 subjects previously found not guilty by reason of insanity (NGRI), who did not stand to gain from such an assessment, Insanity defendants showed significantly more malingering than NGRI subjects, p less than .05. Racial differences did not affect the data. These findings support the efficacy of MMPI validity scales in assessing malingering within criminal forensic groups, and support the generalizability of the scales across race.