Blackberry Hill Hospital

After a rather sedate evening with my doting parents, I returned home to my Bristol flat and fell into a deep and peaceful sleep. Several hours later I awoke …

Abstract Cognitive Behavioural Therapy (CBT) including Exposure and Response Prevention (ERP) is recommended by NICE as the psychological treatment of choice for obsessive compulsive disorder (OCD). Twenty-five percent of OCD patients refuse ERP, and many psychologists advocate formulation-driven cognitive therapy, including ERP, as opposed to ERP alone. However, a recent meta-analysis suggested there is insufficient evidence to suggest ERP is improved by cognitive methods. This paper proposes to contribute to this debate by providing a detailed description of the treatment of a patient with intrusive cognitions of a sexual nature, who was treated successfully using behavioural experiments designed to test cognitions, rather than ERP. This is, arguably, the way in which most cognitive behavioural therapists would work with someone with OCD. However, this approach is not reflected in the literature at present. The authors report the patient's feedback that therapeutic change was brought about through cognitive shift, as a result of the formulation-driven behavioural experiments.

BackgroundJoint hypermobility syndrome (JHS) is a heritable connective tissue disorder characterised by excessive range of movement at multiple joints accompanied by pain. Exercise is the mainstay of management yet its effectiveness is unclear. ObjectivesTo establish the effectiveness of therapeutic exercise for JHS. DesignSystematic literature review. Data sourcesA search of nine online databases, supplemented by a hand search and snowballing. Study eligibility criteria (participants and interventions)People diagnosed with JHS (rather than asymptomatic generalised joint laxity); therapeutic exercise (of any type) used as an intervention; primary data reported; English language; published research. Study appraisal and synthesis methodsMethodological quality was appraised by each reviewer using Critical Appraisal Skills Programme checklists. Articles were then discussed collectively and disagreements resolved through debate. Results2001 titles were identified. Four articles met the inclusion criteria, comprising one controlled trial, one comparative trial and two cohort studies. All studies found clinical improvements over time. However there was no convincing evidence that exercise was better than control or that joint-specific and generalised exercise differed in effectiveness. LimitationsThe studies used heterogeneous outcome measures, preventing pooling of results. Only one study was a true controlled trial which failed to report between-group statistical analyses post-treatment. Conclusions and implications of key findingsThere is some evidence that people with JHS improve with exercise but there is no convincing evidence for specific types of exercise or that exercise is better than control. Further high quality research is required to establish the effectiveness of exercise for JHS.

Multidisciplinary staff who work with end-of-life, pre-transplant patients with cystic fibrosis (CF) have to juggle two seemingly opposing care approaches; active care to maintain their patients' health and condition in anticipation of a transplant, and sensitive palliative care that takes their end-of-life wishes into consideration should they not receive a transplant. Little is known about the psychological impact on staff working within this care dichotomy. The aim of this study is to explore staff's experiences and understand more about the psychological impact of this work on them professionally and personally, and how this affects their ability to provide appropriate care for their patients. A qualitative explorative research design was used. Ten semistructured interviews with multidisciplinary staff working in cystic fibrosis centers and units across the United Kingdom were analyzed using interpretative phenomenological analysis (IPA). Two superordinate themes emerged from the analysis: factors contributing to the "juggle" of active and palliative care, and extent of emotional impact on staff. The study indicates that there is an emotional impact on staff working with patients with CF at end-of-life, pre-transplant stages. Specifically, it reveals the extent of the unpredictability that staff work with, and the range of emotions that staff experience, including uncertainty about professional identity and anxiety about working practices. The depth and intimacy of professional-patient relationships is highlighted, particularly for staff in close contact with and similar in age to their patients. Additionally, the strength of staff's commitment and desire to care for patients within broader humanistic terms that mesh with their own personal values is brought to light. Despite the difficulties with their work, the majority of staff adopted numerous coping strategies to manage their emotions, many of which emphasized the link between their professional and personal values in undertaking their roles.

Parotid gland swelling is a less frequently reported side effect of clozapine and has no licensed treatment. A 58-year-old man treated with clozapine for treatment-resistant schizophrenia developed bilateral painful parotid swellings and hypersalivation. Initial trials of dose alteration and antihypersalivatory medication had limited success. A combination of benzatropine and terazosin was successful in treating the parotid hyperplasia. Clozapine was the probable cause of parotid swelling in our case, as established using the Naranjo adverse drug reaction probability scale and World Health Organization causality categories. Literature for treatments of clozapine-induced parotid gland swellings was reviewed. None of the published articles suggested a treatment regimen for clozapine-induced parotid hyperplasia. Most reports only highlighted the occurrence of salivary gland swelling with clozapine. Others mentioned management strategies, which included spontaneous resolution, or resolution on discontinuing clozapine. One report, a trial with benzatropine and ipratropium, had variable success. In this case the re-emergence of parotid swelling when terazosin and benzatropine doses were missed followed by a quick resolution upon recompliance, goes some way in proving that this combination is indeed effective. The combination of terazosin and benzatropine appears to have a role in treating parotid gland swellings induced by clozapine.

Self-conscious emotions such as humiliation and shame, along with problems of self-esteem, have been related theoretically to aggression, anger and violence for many years. However, as existing systematic reviews show, studies with offenders are relatively rare, small in scale and have conflicting findings. In this article, we have limited our review and discussion to violence rather than including the full range of offending, because we consider humiliation and particular self-esteem patterns to be key triggers and vulnerabilities, respectively, for violence. We have drawn on existing theories, our own theoretical and research work, and where evidence is lacking, we have tried to triangulate information from related studies. We begin with definitions before discussing possible mechanisms and inevitably refer to narcissistic personality structures in relation to aggression. We consider particular groups such as sexual offenders and psychopaths. We describe assessment methods, both interview and psychometric tests, with reference to problems of masking and ‘faking good’. We conclude with ideas for treatment, based on the theoretical background presented. However, the absence of randomised control trial evidence for many forensic interventions means that this largely constitutes a discussion about what could be tried and evaluated rather than what is known to work.

Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Settings Edited By John Gordon & Gabriel Kirtchuk, Karnac Books. 2008. £19.99 (pb). 176pp. ISBN: 9781855755628 - Volume 195 Issue 2

Aims and MethodOur aim was to explore attitudes of in-patient mental health staff to smoking and the smoking ban. A questionnaire was distributed to staff (n=450) working at National Health Service psychiatric units in three different locations.ResultsWe obtained 308 responses, at a response rate of 68.4%. Staff were generally less permissive towards smoking in mental health units when compared with previous studies. However, most (78.9%) feared that service users' states would deteriorate if they were not allowed to smoke.Clinical ImplicationsWe found small but noticeable change in staff attitudes following initial reforms in smoking policy. However, there is a need for further significant change in staff attitudes to facilitate implementation of a total smoking ban from July 2008.

The high-security hospitals are undergoing a retraction process. In conjunction with this, regional services are being developed for those patients who require longer-term treatment at medium-security units.

Our aim was to further characterize the clinical concept of mild cognitive impairment (MCI). We examined visual attention-related processing in 12 patients with amnestic MCI, 16 healthy older adults and 16 patients with Alzheimer’s disease (AD) by measuring performance on computer-based tests of attentional disengagement, alerting ability, and inhibition of return. Unlike the healthy older controls, the patients with AD and the patients with amnestic MCI exhibited a significant detriment in both the ability to disengage attention from an incorrectly cued location and the ability to use a visual cue to produce an alerting effect. The pattern of results displayed by the MCI group indicates that patients who only appear clinically to suffer from a deficit in memory also display a deficit in specific aspects of visual attention-related processing, which closely resemble the magnitude seen in AD. The authors would like to thank the Bristol Research Into Alzheimer’s and Care of the Elderly (BRACE) Charity [Registered Charity Number 297965] for financial support. The authors would also like to thank all the participants taking part and Mr A. Hughes for statistical support.