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Biomedical subjects

R Weinstock

Publications and source records attributed to R Weinstock.

At least 19 recordsLinked to original sources

Potential erosion of psychotherapist-patient privilege beyond California: dangers of "criminalizing" Tarasoff.

The "dangerous patient exception" to psychotherapist-patient privilege, adopted almost a decade before the celebrated case of Tarasoff v. Regents of the University of California (1976), was mentioned in a footnote to that decision in the context of an analogy. Although intended to permit testimony in civil commitment proceedings, this exception has been used to "criminalize" the Tarasoff duty in California. California courts eroded the privilege initially primarily to permit victims to sue psychotherapists and later to require psychotherapists to testify against their patients in criminal proceedings and appear to have confused evidentiary privilege and confidentiality. If consistent, similar reasoning in California in the future should allow therapists to testify against their patients if they were civilly committed in the past for dangerousness and attorneys to testify against their clients in criminal cases if at some earlier time they believed their clients represented a risk of future harm. Although most other jurisdictions may not word their privilege exceptions for civil commitment in the same way as California, most states have some type of privilege exception for civil commitment that could allow for such an interpretation. The United States Supreme Court in Jaffee v. Redmond (1996) found a psychotherapist-patient privilege, but stated in a footnote that an exception to the privilege would exist if a serious threat of harm to the patient could be averted only by means of disclosure by the therapist. Other jurisdictions have begun to consider these issues. Rather than being unique to California, similar reasoning could lead to the "criminalization" of Tarasoff in other jurisdictions and thereby compel therapists outside California to testify against their patients in criminal proceedings.

California↗

A classification of psychological factors leading to violent behavior in posttraumatic stress disorder.

Posttraumatic stress disorder has long been linked to violent behavior. However, the exact nature of that association remains poorly characterized due to the limitations of knowledge in the area of phenomenology, contextual factors, the biology, and the nature of the aggression involved in the disorder. A clear understanding of the genesis of violence in posttraumatic stress disorder can be helpful to those involved in assessing psychiatric-legal issues relevant to the disorder and in its therapeutic management. In this article, we review the potential psychological links between posttraumatic stress disorder secondary to combat exposure and violent behavior and suggest a tentative classification of the main psychological causes of violence in that syndrome.

Adult↗

Delusional misidentification and aggression in Alzheimer's disease.

Alzheimer's disease has been associated with serious behavioral disturbances including aggressive behaviors and agitation. Aggression in dementia of the Alzheimer's type may be associated with psychotic symptoms, particularly delusional misidentification phenomena. These phenomena are complex and varied in Alzheimer's disease and so far have been only rudimentarily described. In this paper, we explore the association of delusional misidentification and aggression in an individual suffering from Alzheimer's disease.

Aged↗

Evaluation of competence to consent to assisted suicide: views of forensic psychiatrists.

OBJECTIVE: Mental health evaluation of competence to consent has been proposed as an important safeguard for patients requesting assisted suicide, yet mental health professionals have not developed guidelines or standards to aid in such evaluations. The authors surveyed a national sample of forensic psychiatrists in the United States regarding the process, thresholds, and standards that should be used to determine competence to consent to assisted suicide. METHOD: An anonymous questionnaire was sent to board-certified forensic psychiatrists between August and October 1997. RESULTS: Of the 456 forensic psychiatrists who were sent the questionnaire, 290 (64%) responded. Sixty-six percent believed that assisted suicide was ethical in at least some circumstances, and 63% thought that it should be legalized for some competent persons. Twenty-four percent indicated that it was unethical for psychiatrists to determine competence; however, 61% thought such an evaluation should be required in some or all cases. Seventy-eight percent recommended a very stringent standard of competence. Seventy-three percent believed that at least two independent examiners were needed to determine competence, and 44% favored requiring judicial review of a decision. Fifty-eight percent believed that the presence of major depressive disorder should result in an automatic finding of incompetence. Psychiatrists with ethical objections to assisted suicide advocated a higher threshold for competence and more extensive review of a decision. CONCLUSIONS: The ethical views of psychiatrists may influence their clinical opinions regarding patient competence to consent to assisted suicide. The extensive evaluation recommended by forensic psychiatrists would likely both minimize this bias and assure that only competent patients have access to assisted suicide, but the process might burden terminally ill patients.

Attitude of Health Personnel↗

A case of Cotard's syndrome associated with self-starvation.

Cotard's syndrome is a psychotic condition often associated with nihilistic delusions. This syndrome can be associated with destructive behaviors directed at the self and/or others. In this report we highlight the psychiatric-legal issues involving a case of Cotard's syndrome associated with self-starvation.

Antidepressive Agents↗

Survey of forensic psychiatrists on evaluation and treatment of prisoners on death row.

Psychiatrists have debated their role in evaluating prisoners accused of capital crimes and in treating prisoners on death row when restoration of competence would result in execution. Despite debate, there are no previous surveys of psychiatrists' opinions on this issue. We sent an anonymous questionnaire to all board-certified forensic psychiatrists in the United States. Of the 456 forensic psychiatrists identified, 290 (64%) returned the survey. Most respondents supported a role, in at least some cases, for psychiatric evaluation of prisoners accused of capital crimes. Respondents were divided on whether or not psychiatrists should treat incompetent death row prisoners if restoration of competence would result in execution. Attitudes about the ethical acceptability of capital punishment were associated with views about the psychiatrists' role but were not determinative in every case.

Analysis of Variance↗

Tumor necrosis factor-alpha in sera of obese patients: fall with weight loss.

In view of the recent demonstration that obesity in animals and humans is associated with an increase in tumor necrosis factor-alpha (TNFalpha) expression, that this expression falls with weight loss, and that TNFalpha may specifically inhibit insulin action, the possibility that TNFalpha may be a mediator of insulin resistance has been raised. We have undertaken this study to investigate whether serum TNFalpha concentrations are elevated in obese subjects, whether they fall after weight loss, and whether this fall parallels the fall in insulin release after glucose challenge. Obese patients (age range: 25-54, weight mean +/- SD: 96.4 +/- 13.8 kg, body mass index: 35.7 +/- 5.6 kg/m2) were started on a diet program. The mean weight fell to 84.5 +/- 11.3 (P < 0.0001) and body mass index to 31.3 +/- 4.9 (P < 0.0001). Plasma TNFalpha concentrations were markedly elevated in the obese (3.45 +/- 0.16 pg/mL), when compared with controls (0.72 +/- 0.28 pg/mL), and fell significantly (2.63 +/- 1.40 pg/mL) after weight loss (P < 0.02). The magnitude of insulin release after glucose (75 g) challenge (area under the curve) also fell significantly (P < 0.01) after weight loss. The magnitude of weight loss and fall in TNFalpha were related to basal body weight (r = 0.57, P < 0.001) and basal TNFalpha (r = 0.55, P < 0.001) concentrations, respectively, but not to each other or to the glucose-induced insulin release (area under the curve). We conclude that obesity is associated with increased plasma TNFalpha concentrations, which fall with weight loss. Because circulating TNFalpha may mediate insulin resistance in the obese, a fall in TNFalpha concentrations may contribute to the restoration of insulin resistance after weight loss, Thus, TNFalpha may be an important circulating cytokine, which may provide a potentially reversible mechanism for mediating insulin resistance.

Adult↗

Diabetes prevalence and hospital and pharmacy use in the Veterans Health Administration (1994). Use of an ambulatory care pharmacy-derived database.

OBJECTIVE: To develop a diabetes registry from an outpatient pharmacy database to systematically analyze the prevalence of diabetes, patterns of glycemic medication and glucose monitoring, pharmacy costs, and hospital use related to diabetes care in the Veterans Health Administration (VHA) in fiscal year (FY) 1994. RESEARCH DESIGN AND METHODS: Veterans with diabetes were identified using a software program that extracted the social security number (SSN) of patients receiving insulin, sulfonylurea agents, or glucose-monitoring supplies. The cumulative FY94 cost for a drug was calculated by multiplying the units dispensed times the unit cost for each fill, using the actual drug cost that was in effect at the time of dispensing. Admission data were obtained by crossmatching the SSN registry with the VHA Austin Mainframe Patient Treatment Files to retrieve associated diagnosis-related groups (DRG), Physicians' Current Procedural Terminology (CPT), and International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes. RESULTS: From among 1,180,260 unique patients, 139,646 veterans with diabetes receiving insulin, oral agents, or glucose-monitoring strips were identified, accounting for a prevalence of 11.83% from 62 Veterans Administration medical centers. There were 63,078 individuals (52%) who received oral agents, of whom 26.3% also received blood glucose-monitoring supplies; 46,664 individuals (39%) received insulin, of whom 53.2% received blood glucose-monitoring supplies; and 9,440 individuals (8%) received both oral agents and insulin during FY94, with 64.4% receiving blood glucose-monitoring supplies. Only 1,482 (1.2%) individuals received monitoring supplies alone, and 129 patients (0.1%) were provided with an insulin pump. Using an adjusted data set, 12% of veterans accounted for 24% of all outpatient pharmacy costs, with an average expenditure of $622 for veterans with diabetes compared with $276 for veterans without diabetes. There was $454 (73%) for non-diabetes-specific prescriptions and $168 (27%) for prescriptions related to glycemic control. Of pharmacy expenditures for glycemic control, $101 (60.1%) was attributed to insulin, oral agents, and supplies, while $67 (39.9%) was attributable to glucose monitoring. Veterans with diabetes were admitted 1.6 times as frequently as veterans without diabetes. CONCLUSIONS: This study demonstrates the feasibility of using a pharmacy-based electronic diabetes database in a payor system that can track both claims and individual classes of medication based on a unique identifier number. While the prevalence of diabetes in the VHA is high relative to other health care systems and the general population, patterns of medication usage, pharmacy costs, and relative admission frequency are comparable to results from the private sector.

Ambulatory Care↗

Dangerous misidentification of people due to flashback phenomena in posttraumatic stress disorder.

Misidentification of people may occur in a number of psychiatric disorders associated with delusional thinking. Misidentification of people may also occur in the context of visual flashback phenomena associated with post-traumatic stress disorder. People who misidentify someone during a flashback associated with previous war combat experience may perceive and conceptualize the misidentified object as an enemy who may be both feared and disliked. This might make the misidentified objects become the targets of violent attacks by the affected person. In this article we present five cases of flashback-induced misidentification of people who were subsequently attacked within the context of the flashback experience. The nature of the misidentification of persons due to flashback experiences is discussed. The association between the type of misidentification and aggression is also discussed.

Adult↗

A comprehensive typology for the biopsychosociocultural evaluation of child-killing behavior.

The homicide of children by their parents has been reported across numerous cultural settings around the world and in many historical periods. A comprehensive and systematic understanding of parental child killing can be optimally obtained through a biopsychosociocultural approach. In this article we present the case of a woman who committed neonaticide. We illustrate the cultural formulation of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and recommend that this formulation has a central role in the evaluation of cultural factors of parents who kill their children.

Adolescent↗

Exercise in the treatment of obesity: effects of four interventions on body composition, resting energy expenditure, appetite, and mood.

This study investigated changes in body composition, resting energy expenditure (REE), appetite, and mood in 128 obese women who were randomly assigned to 1 of 4 treatment conditions: diet alone, diet plus aerobic training, diet plus strength training, or diet combined with aerobic and strength training (i.e., combined training). All women received the same 48-week group behavioral program and were prescribed the same diet. Exercising participants were provided 3 supervised exercise sessions per week for the first 28 weeks and 2 sessions weekly thereafter. Participants across the 4 conditions achieved a mean weight loss of 16.5 +/- 6.8 kg at Week 24, which decreased to 15.1 +/- 8.4 kg at Week 48. There were no significant differences among conditions at any time in changes in weight or body composition. Women who received aerobic training displayed significantly smaller reductions in REE at Week 24 than did those who received strength training. There were no other significant differences among conditions at any time on this variable or in changes in appetite and mood.

Adult↗

A new variant of "subjective" delusional misidentification associated with aggression.

Delusional misidentification syndromes are psychotic conditions in which the affected individual experiences delusions of radical change concerning the identity of others and/or of the self. These syndromes may lead to aggression, including serious violence toward others. In this article, we describe and analyze in detail an aggressive individual who suffered from a delusion that physical and psychological replicas of himself existed. We specifically analyze the link between the patient's subjective misidentification delusion and his resulting aggression. Both the roles of phenomenology and biology of delusional misidentification are evaluated as potential contributors of aggression.

Adult↗

The role of mania in the genesis of dangerous delusional misidentification.

The delusional misidentification syndromes are characterized by a misidentification delusion of the self and/or others. Delusional misidentification syndromes frequently occur in psychotic disorders such as schizophrenia, psychotic disorder due to general medical condition, or psychotic disorder not otherwise specified. On rare occasions these syndromes may be associated with manic states secondary to bipolar disorder, schizoaffective disorder, or general medical conditions. The delusional misidentification syndromes may also be associated with verbal and physical aggression. In this article we present three cases of dangerous delusional misidentification associated with mania. We will discuss the role that mania may have in the genesis of dangerous delusional misidentification.

Adult↗

Violent behaviors associated with the antichrist delusion.

Delusions involving the antichrist concept have been occasionally reported. Some cases of the antichrist delusion have been associated with violent behavior. In this article we describe the case of a man who suffered from a chronic antichrist delusion and who also displayed repeated and serious violent behaviors. We also discuss the role of the antichrist delusion as well as other psychotic symptoms in the genesis of violence in the present case.

Adult↗

Dangerous delusional misidentification and homicide.

A case involving a delusional misidentification syndrome associated with homicide is presented. The anglophonic literature concerning delusional misidentification and homicide is reviewed. Delusional misidentification may be a risk factor for potential violence toward others, including homicide of a delusionally misidentified person.

Adult↗