Informal medicine: ethical analysis.

CONTEXT: Doctors have been known to treat or give consultation to patients informally, with none of the usual record keeping or follow up. They may wish to know whether this practice is ethical. OBJECTIVE: To determine whether this practice meets criteria of medical ethics. DESIGN: Informal medicine is analysed according to standard ethical principles: autonomy, beneficence and non-maleficence, distributive and procedural justice, and caring. SETTING: Hospital, medical school, and other settings where patients may turn to physicians for informal help. CONCLUSION: No generalisation can be made to the effect that informal medicine is or is not ethical. Each request for informal consultation must be considered on its own merits. GUIDELINES: Informal medicine may be ethical if no payment is involved, and when the patient is fully aware of the benefits and risks of a lack of record keeping. When an informal consultation does not entail any danger to the patient or others, the physician may agree to the request. If, however, any danger to the patient or others is foreseen, then the physician must insist on professional autonomy, and consider refusing the request and persuading the patient to accept formal consultation. If a reportable infectious disease, or other serious danger to the community, is involved, the physician should refuse informal consultation or treatment, or at least make a proper report even if the consultation was informal. If agreeing to the request will result in an unfair drain on the physician's time or energy, he or she should refuse politely.

MMPI profile characteristics of women with varying levels of normal dissociation.

MMPI-2 correlates of normal dissociation as measured by the absorption subscale items of the Dissociative Experiences Scale (DES) were examined in patients with diagnoses in the dissociative spectrum (n = 119) and not in the dissociative spectrum (n = 97). All patients completed the MMPI-2 and DES and were assigned to subgroups based on a cut-off score of 30 on normal dissociation. Results indicated that normal dissociation was unusually prominent among patients with mental disorders. The MMPI profiles of those with high imbalances of normal dissociation were skewed in the direction of more pathology across a broad range of mental symptoms. This was true for both dissociative and nondissociative patients. These findings provide preliminary evidence that high imbalances in normal dissociation may be related to psychopathology of a general nature.

Surviving roots of trauma: prevalence of silent signs of sex abuse in patients who recover memories of childhood sex abuse as adults.

Recent research suggests that victimization imagery is chronically accessible in sex-abused populations, which is helpful in distinguishing them from nonabused populations. Eight categories of victimization imagery were selectively activated by Rorschach stimuli. These 8 sex-abuse signs were replicated in a new sample of 36 patients with continuous memory of sex abuse. Classification accuracy was 83%. By contrast, these signs were present in only 4% (5 of 115) of the protocols of nonabused patients. Taken together, the 2 studies confirm reasonably high sensitivity of the 8 signs for sex-abused populations and high specificity for nonabused populations. The 8 signs were also differentially salient for patients who recovered memory of childhood sexual trauma as adults. The Rorschach protocols of 59 of 114 patients with delayed recall of sexual abuse possessed signs of sex abuse. There was no linkage between therapy and recovered-memory cases with and without sex-abuse signs. Emergence of trauma memories was not uniquely traceable to treatment. Memories arose outside of the context of therapy in over 56% of the cases. Implications for the false-memory debate are discussed.

Texture response patterns associated with sexual trauma of childhood and adult onset: developmental and recovered memory implications.

OBJECTIVE: Reduce texture sensitivity on the Rorschach is proposed as a sequela of early sexual abuse that is unlikely to be contaminated by situational variables. If this conceptualization has merit, texture attributes offer a roadmap for studying vying claims in the recovered memory debate. To explore this possibility, we examined the extent to which intense preoccupation with sexual trauma of childhood and of adult onset was related to reduced texture productivity. METHOD: Texture productivity was measured in 4 groups comprised of 108 patients using the Rorschach. Twenty-seven patients with recovered memory were compared with 27 patients with continuous memory of childhood sexual trauma, 27 post trauma stress patients with sexual trauma of adult onset, and 27 non-abused patients. RESULTS: The study replicated previous findings of reduced texture productivity among patients who always remembered sexual trauma of childhood-onset. The same texture deficiency pattern was observed among patients who recovered memory of childhood sexual abuse. This pattern was not observed in Post Traumatic Stress Disorder (PTSD) patients intensely preoccupied with sexual trauma of adult onset despite the fact that they mimicked the recovered memory group in respect to enduring preoccupation with distressing thoughts of sexual abuse. CONCLUSION: The findings indicate that intrusive memories of sexual trauma do not shape patients' response to textural cues on the Rorschach. Variations in texture productivity are primarily moderated by age of trauma onset. Dismissal of claims of recovered memories on the basis of intense sexual preoccupation is not warranted.

Revision of the Word Association Test for assessing associations of patients reporting satanic ritual abuse in childhood.

A growing number of psychiatric patients report satanic ritual abuse, prompting research into this controversial area. In the current study, the Word Association Test (WAT) was modified to assess experience with satanic abuse. Pilot work resulted in norms for two domains: normative and satanic. Female psychiatric patients were compared on their associations in two studies. Based on a sexual history, they were grouped into those reporting sexual abuse, those reporting satanic ritual abuse (SRA), and those without a history of sexual abuse (controls). In both studies, SRA patients gave significantly more total associations, significantly fewer normative associations, and significantly more satanic associations than did the other two groups. These results suggest that an experience base is shared by individuals reporting SRA that is not found in individuals who do not report satanic abuse (even if they do report sexual abuse). The implications of these findings are discussed from the perspective of arguments advanced by advocates and critics of SRA.

Rorschach indicators of dissociative identity disorders: clinical utility and theoretical implications.

The purpose of the present study was to replicate Rorschach signs of Multiple Personality Disorder (MPD) using DSM-IV criteria of Dissociative Identity Disorder (DID). Women admitted to either an inpatient dissociative disorder's unit (n = 27) or a general psychiatric unit (n = 72) were given the Rorschach, which was scored for the Labott, Barach, and Wagner Rorschach markers of MPD. Results indicated that Rorschach signs of the three different systems were significantly better than chance at classifying patients as DID or as non-DID. The Labott system, which performed the best, was able to accurately classify 92% of the sample. These results argue for the validity of the DID diagnosis. The Rorschach signs operate independent of external bias, yet correspond to the diagnoses obtained through psychiatric evaluation in an inpatient setting. The fact that two relatively rare sets of signs (DID and Rorschach) converge in the same small sector of the psychiatric population represents evidence of linkage that is clinically meaningful and not explainable on the basis of artificial creation.

False attribution of suggestibility to explain recovered memory of childhood sexual abuse following extended amnesia.

Suggestibility is central to arguments proffered by critics of recovered memory of childhood sexual abuse who believe that memories involving amnesia are false creations of treatment. The present study represents the first direct investigation of suggestibility among patients who report recovered memory. Suggestibility was measured in 44 patients who recovered memories and in a 31 patient comparison group without a history of sexual trauma using the Gudjonsson Suggestibility Scale. Results indicated that patients who recover memories were remarkably less suggestible than the clinical field has been led to believe by advocates of false memory. As a group, they scored low on suggestibility. Recovered Memory patients yielded to suggested prompts an average of 6.7 times per case. This compares to an average of 10.6 in the Psychiatric comparison group. Paradoxically, patients without a history of sex abuse were more at risk for altering memory to suggestive prompts. These findings appreciably challenge advocated theories of suggested memory.

Authenticity of recovered sexual abuse memories: a Rorschach study.

Distinguishing authentic abuse from false memory among adults who recover memories of childhood sexual trauma has far-reaching significance. This study initially examined 13 previously reported Rorschach signs of sexual abuse in women not abused, and women sexually abused (and not amnestic). The abuse signs were more prevalent in the abused group. A sexual abuse index composed of 8 signs correctly classified 93% of the abused, and 98% of the nonabused group. The index was then applied to women who recovered memories of abuse; some had analogues of dissociation in their protocols and others did not. Those exhibiting dissociative signs produced more signs of sexual abuse. The index classified 88% of the dissociative group as abused, but only 24% of the nondissociative group. The relevance of these findings for assessing authenticity of recovered memories is explored.

Ethical and cross cultural questions concerning pediatric clinical trials.

During a clinical trial of recombinant growth hormone in a population of short stature but otherwise healthy children the following ethical problems were confronted: What are the prospective benefits compared with the foreseeable risks associated with this therapy? Can the doctor really inform the parent and/or the child about the outcomes of the treatment? Who must make the decision about participation in the trial? From which age can the child himself decide about continuing or dropping out? Since the treatment requires frequent check-ups for years, to what extent does the child become psychologically dependent upon the medical profession? Given this possibility, is the child really free to withdraw from the treatment? Is there a conflict between the doctor's autonomy to propose the treatment and the patient's autonomy to decide about participation? Is there a clear threshold between life-threatening problems and minor, cosmetic problems? These dilemmas are discussed in a cross-cultural context.

Educating nurses for their future role in bioethics.

The emerging new multidisciplinary and crosscultural field of bioethics will require sensitive, open-minded professionals to take the lead in hospital ethics, in genetic counselling, and in the teaching of bioethics to students in nursing, medicine and the basic sciences. Nurses with ward experience who return to university to gain an MA or PhD in bioethics are eminently suited for this leadership role, for they may be more likely than physicians to study for a liberal education to supplement their professional knowledge; their first-hand experience in nursing is an antidote to the pointless subtleties into which philosophical ethics so often degenerates. When teaching ethics to nurses one must remember that, while some will simply use this knowledge in their own clinical work, others will go on to be teachers and researchers in bioethics. Their training must therefore be broad and interdisciplinary, including real substantive philosophy (as opposed to philosophical ethics), as well as mystical bioethics, religious law, ethics of genetic counselling, clinical approaches to ethical pseudo problems, research skills, etc.

Factors influencing the cost of chronic low back injuries: An analysis of data from independent medical examinations.

Cost factors were examined in 157 patients with work- related spine injuries who were referred to a second opinion program between 1985 and 1991. The independent medical examination (IME) included a history, physical examination, and review of imaging and other studies. Data on demographic variables, litigation, work, injury history, physical examination, and imaging studies were recorded. A standard measure of psychological status (Low Back Pain Symptom Check List) was filled out. The instrument uses pain language as a clinical marker of psychological disturbance linked to a range of conflictual issues such as suppressed anger, burdensome feeling of inferiority, damaged self- esteem, role confusion, abnormal mentation, fear of responsibility or intimacy, gender issues, sexual concerns, disturbing arousal, and the like. Since it relies exclusively on pain language for diagnosis, it does not identify the specific nature of the psychological conflict. Data on treatment, final resolution, and cost were obtained from computerized files of the insurance company. The total cost incurred was $6,551,139. This averaged to $41,727 per case. More expensive cases were associated with a surgical intervention, psychological disturbance, litigation, motor weakness, and positive radiographs. These five variables accounted for 48% of the cost variance. Surgery accounted for 19.9% of the variance and contained the most expensive cases ($68,310 vs. $31,423). Psychological disturbance was detected in 27% of the sample and accounted for 10.5% of the cost variance. Litigation was present in 72% of the cases and accounted for 9.1% of the cost variance. Motor strength and radiographs taken together accounted for 8.4% of the variance. The usefulness of this information was explored from an actuarial and medical perspective.

Development of the Hispanic Low Back Pain Symptom Check List.

STUDY DESIGN: The Low Back Pain Symptom Check List identifies psychological disturbance in patients with low back pain. This report traces the development of a translation for Hispanic populations. OBJECTIVE: The study explores the reliability and assesses the equivalence of the translation in providing pain and psychological information. SUMMARY OF BACKGROUND DATA: A number of psychometric measures appear suitable for routinely assessing psychological disturbance among back injured patients. Unfortunately, there are few measures with language translations that can be applied to Hispanic populations. METHODS: In study 1, the English form was translated by two bilingual physicians. In study 2, reliability was examined using Cronbach's measure of internal consistency. In study 3, the equivalence of the Hispanic and English forms in predicting treatment outcome was examined. RESULTS: Coefficient alphas and mean pain scores were similar for the English and Hispanic forms. Overall agreement between the two forms in tracking psychological disturbance was 91%. The Hispanic form was equally accurate in predicting treatment outcome. CONCLUSIONS: The Hispanic form is reliable and provides pain and psychological information much like the English form.

Clinical correlates of alleged satanic abuse and less controversial sexual molestation.

Despite growing public interest and debate concerning satanic ritual abuse, few objective studies examine this controversial subject matter. To address this issue, measures of general psychopathology and dissociation were administered to patients alleging satanic ritual abuse and to patients alleging less controversial forms of sexual trauma. The subjects were women alleging a history of sexual abuse starting prior to the age of 12, involving penetration, and lasting for a period of at least 12 months. High but nondiscriminating levels of psychiatric pathology characterized both patient groups. Key differences were limited to dissociative symptomatology. Patients alleging satanic ritual abuse reported higher levels of dissociation, in the range often exhibited by patients with multiple personality disorders. The implications of the findings for SRA credibility are addressed.