Providentia

Screening for Violence

The July 2007 issue of the Journal of Advanced Nursing outlines a protocol for identifying potentially violent patients on admission to hospital emergency rooms.  A mixed method case study design involving semi-structured interviews, participant observation and field interview in patients admitted to a hospital emergency room in Australia identifed five distinctive elements of observable behaviour.  The five elements have been combined into a potential nursing violence assessment model known as STAMP.

• Staring and Eye contact
• Tone and volume of voice
• Anxiety
• Mumbling
• Pacing

The STAMP protocol has been recommended as an easily-remembered checklist to assist nurses in quickly identifying patients, family members or friends who have a potential for violence.   By identifying potential flashpoints, health care professionals are able to defuse potentially violent situations before they can escalate further.  The researchers suggest that STAMP could have value in a variety of settings where potential violence is a possibility including forensic and social service agencies.   

Click here for the study abstract.

Diminished Responsibility Verdict in Bizarre Wok Murder

A bizarre trial in the Netherlands ended when a judge sentenced the defendant (identified by the press only as L.L.G) to compulsory psychiatric treatment for the October 2006 murder of his roommate, Joost Vastenhouw.  In a confession made while being held in the Pieter Baan psychiatric centre, L.L.G. admitted to killing Vastenhouw, a 22-year old resident of the West Netherland town of Alphen aan Rijn, and subsequently chopping the body into pieces.  He then wokked, fried and baked parts of the body before disposing of the remains in a garbage dumpster and nearby canals.  When asked why he committed the murder, the defendant allegedly stated that he had done it for "spiritual reasons" and to "square a debt from the victim's previous life". 

L.L.G., a 30-year old immigrant from China, had been romantically involved with the victim's father at one point but denied any personal animosity towards the victim.  He described himself as a Falun Gong practitioner although clinicians at the Pieter Baan centre described him as "schizophrenic and paranoid".  While declaring him to be in a diminished state of responsibility, the court condemned the gruesome way in which the man treated the dead body. "It has caused trauma particularly to the victim's sister and father. It also shocked society deeply."

For more information on the case, click here.

The Leilani Muir Case

Born in Calgary in 1944, Leilani Muir was an unwanted child who was frequently neglected by her alcoholic mother.  After unsuccessfully placing her into a convent school, her mother was finally able to place Leilani into the Provincial Training School for Mental Defectives in Red Deer, Alberta when she was eleven years of age.  There is no indication that Leilani was ever formally diagnosed as being intellectually disabled, the school admitted her solely on the basis of information that her mother provided.  It was also her mother who authorized the school to sterilize Leilani in compliance with the Sexual Sterilization Act of Alberta.

Under the auspices of the Alberta Eugenics Board, the Sexual Sterilization Act passed by the Alberta legislature in 1928 led to the forced sterilization of individuals deemed to be "mentally defective" or otherwise unfit to bear healthy children.  Candidates for sterilization included those with low  IQ's and "those who had suffered serious mental breakdowns, and therefore could not be recommended for parenthood by any physician".  Family consent was usually needed to carry out the sterilization although, as with Leilani Muir, family permission to sterilize was often required as a condition for admission to facilities designed to care for children with special needs.  If no one was eligible to provide consent, the Minister of Health could do so.  The board was made up of four panellists who were to meet and discuss each sterilization on a case-by-case basis.  Among the most prominent and long-serving members of the board was the Chairman, Dr. J.M. MacEachran, co-founder of the Canadian Psychological Association and first Chair of the Psychology and Philosophy department of the University of Alberta.  To facilitate the board's operation, it was agreed in 1933 that  Dr. MacEachran (who served as Chairman until his death in 1965) would have the authority to dictate when an operation for sterilization would take place (usually for mental defectives as family permission continued to be needed for sterilizing the mentally ill).

From 1928 until the act was finally repealed in 1972, an estimated 2,832 sterilizations were carried out.  Aboriginals and Metis represented approximately 25 percent of those sterilized.  A disproportionately high number of young females from poor backgrounds were also sterilized with the rationale being that they would likely turn to prostitution (or at least promiscuity) and that sterilization would prevent them from having "defective" children. 

Leilani Muir was at the Provincial Training School for two years before her case was reviewed by the Eugenics Board.  She was given an IQ test which determined that she had an IQ of 64 and it was on that basis that she was formally diagnosed as being a "Mentally Defective Moron".  This diagnosis, in conjunction with her developing sexuality and her presumed incapability of being a good parent, led to Leilani's sterilization in 1959 at the age of 14.  She was never told that she would be sterilized and only thought that she was having her appendix removed.  She remained at the school for another six years before being removed by her mother. 

Leilani blossomed and became independent in the following years but it was only during her first marriage that she finally learned why she and her husband were unable to have children.  Adoption was also impossible for her due to the stigma of having been a resident at the Training School.   In 1998, during her second marriage, she was administered another IQ test which determined that she was of normal intelligence.  This led Leilani to conclude that she had been wrongfully sterilized and she sought financial compensation from the Alberta government.   It would take years of legal battles but Leilani finally won her case.  On January 25, 1996, a court awarded Leilani Muir $740,780 CDN and a later $230,000 CDN for legal costs.  In making her decision, the presiding judge Madame Joanne B. Viet, concluded that the province wrongfully surgically sterilized Leilani Muir.  She also added that the “particular type of confinement of which Ms. Muir was a victim resulted in many travesties to her young person: loss of liberty, loss of reputation, humiliation and disgrace; pain and suffering, loss of enjoyment of life, loss of normal developmental experiences, loss of civil rights,  loss of contact with family and friends, and subjection to institutional discipline”.  About 700 other claimants were also awarded undisclosed damages as a result of a class action suit that arose out of the Leilani Muir decision. 

Leilani Muir now lives in Alberta and is currently working on an autobiography.  A movie titled The Sterilization of Leilani Muir was produced by the National Film Board of Canada in 1996. While her sterilization was hardly unique to Canada and similar tragedies occurred in other countries around the world, her case represents a warning of the ease with which people regarded as "marginal" can be stripped of their basic human rights.  It is a lesson we would do well to remember for the future. 

Schizophrenia and Suicide

The July 2007 issue of the Journal of Forensic Sciences presents the results of a retrospective study examining Medical Examiner cases of suicide in the state of Kentucky over a 10-year period (1993-2002).  Previous research examining incidence of suicide in schizophrenics determined that an estimated 10-13 percent of schizophrenics commit suicide.  Based on study results, the majority of cases were male (62.1 percent) and the average age at time of death was 41.6 years.  Firearm injury was the leading cause of death for both males and females (48.3 percent) followed by overdose (20.7 percent) and hanging (13.8%).  The researchers discuss their findings in terms of biopsychosocial factors that lead to suicide and the need for careful psychological autopsies to examine ways to prevent suicide in high-risk populations. 

Click here for the abstract.  The full journal article is also available for subscribers.

Canadian Psychological Association to Help Draft Disaster Guidelines

The Canadian Psychological Association has announced a new joint venture with the Public Health Agency of Canada to develop guidelines to help prepare the public and health professionals to deal with the psychological and social impact of public health emergencies.  Based on the examples of 9/11 and the SARS crisis, failure to provide public health information can lead to critical delays in the implementation of public health and mental health interventions.   The CPA web site includes public health fact sheets for:

• Families
• Children and youth
• Seniors
• People with special needs
• Workers and the Workplace
• Health Care Providers
• General Public

Click here for more information.   

Imaginary Children - Part II

Queen Mary I of England (a.k.a. Mary Tudor, a.k.a "Bloody Mary") succeeded to the throne of England in 1553 and is best known for her ultimately futile attempt at returning England to Catholic rule.  Her husband, Prince Philip of Spain was immensely unpopular and Mary's failure to produce a proper heir virtually assured that she would be succeeded by her Protestant half-sister, Elizabeth.  Despite being in her late 30s and unlikely to conceive, Mary announced her pregnancy in 1554 and had thanksgiving masses to celebrate.  She experienced violent morning sickness, her abdomen grew and Mary began to prepare for the coming birth.  She went into labour after a grueling nine months and the bells of London rang out.  And then the labour pains ended...  Her condition continued and as the months dragged on it became apparent that Mary had never been pregnant.  She sank into a deep depression and her husband looked for excuses to leave her and return to Spain (it was only a political marriage, after all). It was largely a result of Mary's disappointment that the vicious persecution of Protestants began in earnest (which is what earned her the "Bloody" label) .  She announced a second pregnancy some time later but few took this one seriously and Philip returned to Spain.  Mary eventually died at the age of 42, (probably of ovarian cancer), still dreaming of a perfect Catholic heir. 

While cases of pseudocyesis (false pregnancy) rarely become a matter of geopolitical importance, it does happen in humans and animals alike.  The actual symptoms (morning sickness, cessation of menstruation and tender breasts) can be so convincing that expectant mothers and medical doctors are often fooled.  Distended abdomen is the most common physical symptom with intestinal bloating causing women to appear increasingly pregnant over time.  Even the quickening associated with fetal movements can be detected.  A small minority of women experiencing pseudocyesis undergo false labour as well.  While the average age for pseudocyesis is in the early 30s, cases in women as  old as 79 and as young as 6 have been reported.   

In one classic case reported in an early medical text: "A woman, married late in life, mistook the "change of life" for pregnancy, and passed though all the usual symptoms attendant upon that condition,including enlargement of the abdomen, tumefaction (swelling) pain in the breasts, morning nausea, and even swelling of the lower extremities.  At the expected "term" regular pains occurred, exactly simulating those of labor, and physician and attendants were summoned to this extraordinary scene where nothing was wanting, save for the presence of the baby." 

Counseling to deal with issues of disappointment and grief that women who have discovered that their pregnancies were false can be effective, especially with the very real depression that often follows. Proposed explanations for false pregnancy range from the psychodynamic to the hormonal although the actual incidence has declined with improved diagnostic procedures (especially ultrasound). Although the causes of pseudocyesis remain unclear, it is a prime example of the power that the mind can have over the body, especially when it comes to self-deception.

Dating Violence, Sexual Assault Linked to Suicide Attempts in Teenagers

In a study published in the June, 2007 issue of Archives of Pediatrics and Adolescent Medicine,  the results of a secondary analysis of the 2005 New York City Youth Risk Behavior Study are presented.  Of the 8,080 public high school students (14 years of age or older) surveyed, 11.7% of females and 7.2% of males reported attempting suicide in the previous year.  Lifetime experience of sexual assault, experience of dating violence in the past year, incidence of depression, sexual orientation and other potential risk factors were also examined.  Results indicated that, in this urban youth sample, recent dating violence was found to be a significant predictor of suicide attempts in females while lifetime experience of sexual assault was a significant predictor of suicide attempts in males.   The researchers concluded that educators and health professionals should screen for violence victimization in adolescents to identify potential suicide risks. 

Click here for the complete study.

Is the Hurricane Katrina Death Toll Still Rising?

While the official death toll stands at 1,100 from Hurricane Katrina, health professionals in the regions most heavily affected by the 2005 disaster maintain that deaths are continuing to occur.  In New Orleans, emergency wards of local hospitals and other medical facilities are reporting overcrowding and a lack of chronic care beds.  Despite calls for aid, federal and state agencies have been slow to respond.  Controvery remains over a recent study which noted only a slight increase in deaths in New Orleans over the first three months of 2006 with critics disputing the study's methodology and estimates of the current population of New Orleans.  Deaths resulting from stress-related conditions are not being seen as Katrina-related despite the role of posttraumatic stress disorder in aggravating existing conditions. 

Dr. Ronald Kessler, professor of health care policy at Harvard Medical School and head of a group that has monitored 3,000 exiled Katrina survivors, has noted that "There are high rates of mental health problems among the survivors and previous research has found that mental disorders are predictors of earlier death rates," Kessler said. "So putting the two together in New Orleans is not surprising."

Click here for more information.

Imaginary Children- Part 1

The life and death of William Ward, 1st Earl of Dudley seems unremarkable enough based on existing accounts of the period.  Born in 1817, his list of life accomplishments seems relatively short and his death in 1885 was from natural causes.  A somewhat irreverent obituary of the late Earl published in an American newspaper of the time tells a different story however.  Describing him as "another titled crank that has been removed by death", he was further described as "a mental and physical wreck for years" and the obituary devoted words of praise to his "young and beautiful second wife" whose devotion to her husband had "made her revered throughout England".

In addition to his other ailments, the Earl was prone to a series of bizarre delusions in which be believed himself to be giving birth.   As the obituary stated, "When he was possessed of this hallucination, he imagined himself that he had all the approaching symptoms of maternity and demanded that he be treated accordingly.  He was always humoured in this matter, as it was the opinion of expert alienists (psychiatrists) that opposition to his whimsical fancy would cause the mania to develop into dangerous madness.  Accordingly, the noble Earl would be put to bed, the family doctor would be summoned and would go seriously through his part of the farce, and a borrowed baby would be exhibited to the patient after a due interval".  The Prince and Princess of Wales witnessed one of these odd episodes during their stay at Dudley Castle in the year before the Earl's death.  Watching their host give birth resulted in an abrupt ending to the royal visit (at least he didn't give birth to a rabbit).

Couvade Syndrome (a.k.a., sympathetic pregnancy in men) in which men develop morning sickness, vomiting or other symptoms in conjunction with the pregnancies experienced by their wives is well recognized. Some men seem particularly susceptible to Couvade symptoms and, although various hormonal and psychological explanations have been advanced, the causes remain obscure.  The cure seems simple enough: once the wife gives birth, the couvade symptoms usually disappear as well. 

Actual delusions of pregnancy in males tend to be considerably rarer.  Cases reported in the medical literature usually occur in conjunction with psychiatric diagnoses such as schizophrenia.  In one recent case, a diagnosed schizophrenic developed delusions of pregnancy during both of his wife's pregnancies.  Poor sexual adjustment may also play a role as well.  in the case of the Earl, while his wife had five children during their marriage, his delusions do not appear to have been directly linked to her pregnancies although it certainly worked as an attention-seeking measure.  While I worked in the prison system, I dealt with a schizophrenic inmate who, in conjunction with a range of psychotic delusions, maintained that he had once given birth to two children who then became angels.  The delusion was well-entrenched and didn't respond to medication (it's just as well that he was kept in solitary confinement).

Although delusions of pregnancy in males tend to be rare, imaginary pregnancy in females (pseudocyesis for you clinicians and Scrabble players out there) is not.  More on that next week...

 

American Psychological Association to Revisit Gay Conversion Therapy

The American Psychological Association has announced the formation of a task force to review current scientific trends and its ten-year old stance on "gay conversion therapies".  Given the contentious nature of the subject and the growing focus on forcing adolescents to undergo sexual conversion, the six-person task force will review the current APA policy and make recommendations for the future.

In a press release dated May 21, 2007, APA president, Dr. Sharon Stephens Brehm welcomed the new task force as its work will " help inform all mental health practitioners about appropriate and effective therapeutic responses to sexual orientation".  The issue of sexual conversion of adults and adolescents will be addressed separately and the final report is expected to cover the following points:

1. The appropriate application of affirmative therapeutic interventions for children and adolescents who present a desire to change either their sexual orientation or their behavioral expression of their sexual orientation, or both, or whose guardian expresses a desire for the minor to change;
2. The appropriate application of affirmative therapeutic interventions for adults who present a desire to change their sexual orientation or their behavioral expression of their sexual orientation, or both;
3. The presence of adolescent inpatient facilities that offer coercive treatment designed to change sexual orientation or the behavioral expression of sexual orientation;
4. Education, training, and research issues as they pertain to such therapeutic interventions; and
5. Recommendations regarding treatment protocols that promote stereotyped gender-normative behavior to mitigate behaviors that are perceived to be indicators that a child will develop a homosexual orientation in adolescence and adulthood

A preliminary report is expected in December of this year but the date for final completion has yet to be determined.

Click here for more information.