Psychiatric injury

Psychiatric casualties from combat, especially from chemical weapons, have significant military importance (Augerson 1988 Brooks et al. 1983 Gilstead 1988). Significant numbers of Israeli civilians experienced psychiatric injury during the Gulf War. When Iraq attacked with missiles, civilians had instructions to put on gas masks, enter sealed rooms, and, if exposed to nerve gas, inject themselves with atropine (Carmeli et al. 1994). Of 1,059 total casualties, 230 resulted from false atropine injections, 544 from acute anxiety reactions, 7 from suffocation by improperly used gas masks, and 40 from injuries sustained rushing to sealed rooms (Karsenty et al. 1994). 

The duty of care for psychiatric injury lies on the fact that the contractor/employer... 

In case of nervous shock, it is necessary to distinguish between primary victim (the one who suffer from physical injury) and secondary victim (victim who sees the primary victim suffer and suffer from psychiatric injury afterwards). 

In some cases, psychiatric injury can be identified as an action for damages in Young V. Charles Church (Southern) Ltd 1997. The courts, however, have to distinguish physical and mental injury as their different characteristics make it inevitable that different considerations apply with regard to the evidence which proves that injury has occurred, and how it was caused. 

Adverse consequences of drinking include a variety of social, legal, medical, and psychiatric problems (Babor et al. 1987, 2003). Alcohol is among the top four causes of mortality in 1988, 107,800 deaths, or about 5% of all deaths in the United States, were attributed to alcohol-related causes (Stinson and DeBakey 1992). Approximately 17% of alcohol-related deaths were directly attributable to alcohol, 38% resulted from diseases indirecdy attributable to alcohol, and 45% were attributable to alcohol-related traumatic injury (U.S. Department of Health and Human Services 1994). Alcohol-related mortality declined during the latter part of the twentieth century. For example, the age-adjusted mortality rate from liver cirrhosis in 1993 (7.9 deaths per 100,000 persons) was just over half the rate in 1970 (14.6 deaths per 100,000) (Saadat-mand et al. 1997), and the proportion of automobile fatalities that was related to the use of alcohol fell to a two-decade low of 33.6% in 1993 (Lane et al. 1997). 

It is important to be aware of the fact that orthostatic hypotension is a common condition in the elderly and can lead to injuries and lowered quality of life. Drug treatment for cardiovascular, neurological and psychiatric disorders can cause hypotension as a side effect. The treatment of orthostatic hypotension should be concentrated on behavioural adaptation, intake of water and salt and in some cases drug treatment is necessary. 

Although traumatic brain injury (TBI) is not, in and of itself, a psychiatric illness, it nonetheless warrants attention in our discussion of psychiatric medicines for two important reasons. First, it is not unusual for TBI to produce psychiatric symptoms severe enough to require pharmacological treatment. Second, treatment with psychiatric medicines after TBI often raises clinical concerns that are unique to these patients. More specifically, an injured brain is often especially vulnerable to medication side effects. Thus, the medical axiom first, do no harm is particularly important when treating TBI patients and must be considered when deciding whether to use psychiatric medicines, and if so, what medicines to use, and at what doses. 

By definition, most patients who suffer a serious TBI present to an emergency room in the immediate aftermath of the traumatic event. However, patients may also be brought to medical attention days or even weeks after an apparently mild head injury when the symptoms are delayed or so subtle that they initially escaped detection. In some instances, patients may even visit a clinic unaware that their psychiatric symptoms are attributable to a remote head injury. One extreme example is so-called dementia pugilistica that occurs after years of repeated minor TBIs over the course of a boxer s career. 

The third factor to influence the likelihood of psychiatric complications after TBI is the patient s health prior to the injury. Elderly patients, those with preexisting... 

In our experience, victims of TBI most often come to the attention of mental health care providers when referred by other clinicians. Their first psychiatric encounter may be a consultation during the initial postinjury hospitalization or later during active rehabilitation. Patients may also be referred for mental health treatment during the postconvalescent phase when faced with the realization that some of their physical dehcits may be permanent. As we mentioned earlier, TBI patients infrequently seek psychiatric care on their own, because they are often unaware that their psychiatric symptoms are a consequence of a past brain injury. 

Beta Blockers. The beta blockers, which act by interfering with noradrenergic transmission, have been used to manage aggression and other behavioral disturbances in patients who have suffered brain injury due to trauma and stroke for over 25 years. Several beta blockers have been tested including propranolol (Inderal), pindolol (Visken), nadolol (Corgard), and metoprolol (Lopressor). Fat-soluble beta blockers such as propranolol and pindolol more readily cross the blood-brain barrier and are thus better suited to managing psychiatric symptoms such as behavioral lability. 

Kraus MF, Levin HS. The frontal Lobes and traumatic brain injury. In Salloway SP, Malloy PF (eds). The Frontal Lobes and Neuropsychiatric Illness. Washington DC American Psychiatric Publishing, 2001, pp 199-213. 

The part played by endogenous opioid systems in the regulation of these various physiological and behavioral functions has led to the experimental application of opiate antagonists in psychiatric disorders. This chapter focuses on autism and self-injury, which are two potential indications for opiate antagonists in pediatric populations. In adults, treatment with opiate antagonists has shown to be useful in the relapse prevention of alcoholism as part of a comprehensive treatment approach (Anton et ah, 1999, 2001). 

The cardinal features of PTSD include initial exposure to a traumatic event, with the subsequent development of three symptom clusters reexperiencing of the trauma, avoidance behavior, and hyperarousal. The DSM-IV (American Psychiatric Association, 1994) criteria state that the A-criterion for PTSD, traumatic exposure, involves experiencing, witnessing, or being confronted with an event that is life threatening or involves serious threat or injury to oneself or others. 

There have been numerous trials of use of the atypical antipsychotics in patients with developmental disabilities, but most of these trials were uncontrolled open-labeled studies or case reports (Aman and Madrid, 1999). Findings were reported for 86 adults and 1 child with prominent self-injury. The reports of adults assessed clozapine (1 report) and risperidone (4 reports). Improvement was observed for a majority of participants in all of these trials. The patients presented with a multitude of conditions, ranging from nonspecific MR and associated behavior problems, to pervasive developmental disorders (including autism), to various psychiatric disorders, including schizophrenia and manic disorder. Self-injury appeared to respond to treatment regardless of concomitant condition. In the only clozapine report with a child (who had autistic disorder), a mean dose of 283 mg/day caused a transient reduction in self-injury. 

Pediatric patients who develop psychiatric syndromes following acute medical illness or injury or invasive procedures (e.g., a child who develops post-traumatic stress disorder [PTSD] following a motor vehicle accident and trauma a child who develops PTSD following stem cell transplantation)... 

The clinical implications of such data point to a relationship between abnormalities in the central serotonin system and self-injurious behavior. These findings have led to an interest in developing specific drugs that alter 5-HT activity to treat suicidality, impulsivity, and aggressivity independent of any specific psychiatric disorder. Central serotonin function can be enhanced by agents such as lithium and various serotonin reuptake inhibitors. Recent studies have found that the use of such agents is associated with reductions in the likelihood of suicide attempts and completions in both patients with major depression and those with cluster... 

Other causes of gastric atrophy, such as those due to Helicobacter pylori,AIDS, or radiation injury, can lead to a similar outcome but from different pathogenic mechanisms. Therefore, vitamin B12 deficiency, resulting in neurological, psychiatric, metabolic, and hematological disorders, can arise from any one of the many causes listed in Table 28-1. For this reason, the term pernicious anemia (PA) is used here to describe only the classical disease that is associated with IF deficiency due to autoimmune gastritis. 

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