Controversial Ideas in Medicine

Not a particularly controversial post as the evidence is quite clear.

First: here is a review article from the American Journal of Obstetrics & Gynaecology 2009 going through the various studies on flu vaccine safety in pregnancy.

The conclusion is that influenza is pretty dangerous in pregnancy, while the influenza vaccine is pretty safe. Additionally, no long term side effects from the small dose of thimerosal which is a mercury based preservative.

Thimerosal free vaccines are available.

Second: here is an earlier review article from The Lancet Infectious Diseases 2008

Once again, conclusion is that benefit outweighs risk. As this was prior to the large prospective double blind randomised controlled trial in 2008, there was not enough data at the writing of that article regarding the flu vaccine and safety in pregnancy.

Finally here is the New England Journal of Medicine 2008 prospective double blind RCT that seals the deal with enough evidence- 340 patients.

Today's topic is that of domestic abuse and intimate partner violence (IPV). I am limiting this to abuse that occurs between those in an intimate/romantic/sexual relationship, as the topic of family violence and childhood abuse is beyond the scope of this article. There are of course parallels between the IPV and child abuse literature and both are focussed on the results of the abuse as the defining feature rather than a focus primarily on abusive acts. However the key difference is that while adult abuse is directed towards a presumably psychologically developed individual, child abuse is directed at a developing individual. Thus the range of behaviours considered abusive is overlapping but not completely comparable- examples include neglectful behaviour in child abuse.

First things first

Abusive relationships can involve emotional/psychological abuse, physical abuse and sexual abuse. Often these things can co-exist in fact: Emotional and psychological abuse can be difficult to detect to the outsider- resulting in low detection rates and low rates of complaints. Psychological abuse is better recognised in the child-abuse literature than in the IP literature. This can involve very varied tactics such as:

1. Threats to physical health: physical threats, damage to property
2. Control of physical freedoms: isolation and restriction of partner access to others, preventing partner from physically leaving, not letting partner sleep or fulfil basic human needs
3. General destabilisation of partner identity/perception of reality: convincing partner that they are responsible for and deserve abuse, threats of suicide, threats of abandonment, humiliation and ridicule, verbal abuse and criticism, forcing partner to beg for things, making partner believe they are crazy
4. Controlling behaviour: morbid jealousy and suspiciousness, threats of abandonment, emotional and sexual withholding and blackmail, excessive checking up on partner, following, stalking
5. Ineptitude: failure to live up to expected roles, clingy and needy behaviours, rigid gender role ideas

(Follingstad, DeHart 2000 - in order of decreasing severity of abuse) Additionally certain other more innocuous behaviours have been identified as being correllated with psychological and physical abuse- such as excessively physical behaviour in public, suicide threats and other behaviours. While psychological abuse may be perceived as less harmful, in actual fact it has been shown to have a similar or in some cases higher negative psychological impact on the victim of the abuse- perhaps due to the brainwashing, controlling, psychological and less easy to identify nature of psychological abuse. (Follingstad & DeHart 2000 "Defining Psychological Abuse of Husbands towards Wives" (Journal of Interpersonal Violence), Marshall L.L. "Physical and Psychological Abuse" (The Dark Side of Interpersonal Communication eds Cupach & Spitzberg) 1994, Engels & Moisan "The Psychological Maltreatment Inventory" (Psychological Reports) 1994) In addition, psychological abuse is also a predictor of long-term physical abuse. Physical abuse includes battering, slapping, punching, biting and otherwise physically assaulting a partner. Sexual abuse runs the gamut from coercive sexual assault to severe repetitive rape.

The Abuser

Let me trot out the old line: Domestic abuse is common. In particular, Intimate Partner Violence (sexual and physical abuse) has a lifetime prevalence of victimisation in Australia of 16-20% among females and 4-9% among males. (Roberts et al (1996), Robbe et al (1996), Krahe, Bieneck, Moller (2005) "Understanding gender and intimate partner violence from an international perspective" (Sex roles: A Journal of Research)) Once again as in other behaviour such as stalking, abuse has been reported to be perpetrated with comparable frequency by females as males. The range of behaviour and the physical threat is different, however- females are more likely use psychological forms of abuse and are less likely to inflict grievous bodily harm when physically abusing (perhaps reflected in the lower rate of male physical victimisation). There is, as ever, significant overlap. As in the previous articles, we will discuss various psychiatric syndromes and motivations behind the abuse.

Abusive Personalities

In the IPV literature, there is a common trend for between 2-4 typologies of abusers to be identified. Generally speaking, there is a clear distinction made between the occasionally violent, mostly normal personality offender and the far more violent, personality disordered abuser. Attachment styles as pictured above are a way of conceptualising relationships. Those who have good self-esteem and see others as good are likely to form positive, secure relationships. Those who have poor self-esteem but see others as good are likely to be anxious and preoccupied about their worthiness in the relationship and thus preoccupied with thoughts and fears of abandonment- much like those with Borderline Personality Disorder. Those however with good self-esteem but who view others with suspiciousness or look down on others tend to have a "dismissing" attachment style- they look down upon their partners and tend to be colder and less responsive towards their emotional needs, thus making them comparable to those with Paranoid and Psychopathic/Narcissistic traits. Finally we have the "fearful" attachment style- that of those with poor self-esteem and who view others with suspiciousness or fear. This style is characterised by avoidance of intimacy due to fear of rejection. Thus one would expect that the "secure" and "fearful" attachers would be least likely to be abusive- they would either be content with no reason to abuse or too scared to enter a relationship in the first place. The "pre-occupied"/borderline attachers may lash out due to their insecurities and fear of rejection while the "dismissing"/antisocial/paranoid attachers may lash out due to seeing their partner as inferior or bad. Ehrensaft et al. (2006) find in their large longitudinal study that all personality disorder clusters are positively correlated with abusiveness. All clusters were moderately associated with each other- it was more likely for someone to exhibit other personality disorder traits if they had a personality disorder already. Cluster A and B were the most correlated with abusiveness. In particular, a combination of jealous, suspicious, paranoid (cluster A) and emotionally volatile, impulsive, unpredictable (cluster B) behaviour was found to be strongly correlated with abuse. After accounting for cluster A and B traits, however, the remaining compltely independent cluster C traits were actually found to be protective against abusiveness- perhaps because those who are fearful of others are also less likely to be aggressive towards them. Dutton (2007) in his book "The Abusive Personality" on the other hand notes 3 main typologies. There is the impulsive, brooding, cyclically loving, clingy, needy and abusive violent, angry, jealous type- most likely to score very highly on measures of borderline personality traits. Described as "Jekyll & Hyde", a person who seems like a perfect partner, then starts brooding and getting more and more volatile until he/she finally lashes out violently. This is followed by gifts and other behaviour to make up for the bad behaviour. There is the coldly calculating extremely violent (antisocial/psychopathic) type who controls, is constantly angry, batters severely and often uses instruments such as weapons, chairs, frying pans, what comes to hand to inflict severe violence. Finally there are those who are passive, avoidant and often quite dependent- those who, due to their overcontrolled nature bottle up all of their negative emotions and anger until they finally explode in a bout of rare rage, sometimes with lethal consequences. There are some parallels between this model, attachment theory and Ehrensaft's model. Dutton also speaks of 2 types of co-existing traits- combined violent and borderline traits and combined passive and borderline traits. These combinations tend to be associated with greater violence and adverse outcomes. Holtzworth-Munroe et al have the most complex model following a 3 year longitudinal study of 102 couples recruited from the community who had had an incident of IPV. By far the largest category of couples (55%) scored close to normal on personality testing, with very low scores on measures of both psychopathy and borderline traits. These they denoted FO or "Family Only" Batterers. They had some passive personality traits (but not enough to qualify for a diagnosis of personality disorder). They were the least likely to have suffered physical or sexual abuse as a child and least likely to suffer from substance abuse disorders. They were the most loving, securely attached and remorseful and had the most liberal political and gender ideas. They also committed the lowest level of violence and only reported occasional violence vs family with no violence outside the family. They also had the most stable relationships. They could be considered to  be securely attached. Next there was a category known as BD or "Borderline/Dysphoric". These had high scores on the Borderline Personality Organisation Questionnaire and reported low mood, self-esteem and the lowest relationship satisfaction of all groups. They were also the most jealous of all three groups, being morbidly jealous as a group. They tended to visualise their partner as part of their self-identity rather than another individual. Additionally they saw themselves at times as a "knight in shining armour" or "rescuer" of their spouse. They were needy and clingy and desired their partner to be dependent on them. Their relationships had intermediate stability. They could be considered to have preoccupied attachment. The most aggressive and violent category was the GVA, "Generally Violent Abuser" category. These abusers scored very highly on the Hare Psychopathy Self-Report Questionnaire measure of psychopathy. They were very likely to commit many acts of violence outside the family setting, have friends/peers with misogynistic/violent/criminal attitudes and to have significant alcohol and substance abuse problems. They were also the group who had experienced the highest rate of and most severe child abuse. They were emotionally void, felt the least love and tended to see their partner as an object rather than fellow human. They also tended to blame their victims, have the most conservative gender roles. They had the most unstable relationships with by far the majority experiencing repeated separations and many having had their partner file for divorce after 3 years. Lastly there was the LLA "Low Level Aggression" category. They were like a much less severe form of the GVA category. They had moderate scores on psychopathy and were intermediate on all measures between the GVA and FO categories. Interestingly although there were psychologiical differences found between the BD, GVA and LLA categories, these differences were not found to be statistically significant. The authors posited that this may mean that these categories have a great deal of overlap and may in fact be subtypes of the same psychological phenomenon, the cluster B/paranoid violent type. Also there were no significant differences between FO abusers and the general population- a finding which warrants further investigation as to how they differ from non-abusers.

Discussion

All groups in the Holtzworth-Munroe study showed a reduction in violence as reported by both the abuser and victim over time- a finding which flew in the face of conventional wisdom. It is unknown at this stage whether this finding will be replicated and whether there was self-selection bias evident. This does however correlate with the finding that personality disorder scores in individuals and incidence in the community decrease slowly with age after a peak in the early 20s, reflecting greater maturity and moderation of undesirable traits with time. All studies found a strong correlation between child abuse (including physical punishment, neglect, more severe physical abuse, sexual abuse) and future IPV. This alone should be argument enough to oppose the use of physical force against children and to oppose sexual abuse of minors. There is also a dichotomy found in all studies between normal/passive occasional abusers and the cluster B (+/- A) impulsive/jealous/borderline/antisocial routinely violent abusers- often with a jealous subtype identified. The major weakness in these typologies is the lack of an explanatory model for the personality changes and future abuse as well as perhaps being simplistic in their formulations. On a population level this all makes sense- how about on an individual basis? It is also noted that co-abuse is common. How does this factor into models of abuse? There is a multifactorial Bayes network that has been produced to show risk factors to predict sexual offending. A similar sort of network may be what is needed in this area. I offer the following two theoretical flowcharts in lieu: As you see, there is one pathway for those with normal personality but low assertiveness and high partner dissonance. The other pathway depicts the evolution of the borderline and the psychopathic abuser via triggers and innate ideas about self and others. Further research must of course be done! Additionally, once again I must emphasise that these typologies and mechanisms suggest intervention strategies depending on underlying psychological pathology. The "normal" offender may benefit from assertiveness training and relationship counselling and other forms of psychotherapy. The "borderline" offender needs more intense psychotherapy and therapy directed towards the style of problem-solving and attachment style. The "psychopathic" offender of course  requires better problem solving strategies as well as behavioural controls and a large degree of monitoring in the community.

What is Rape

Sexual assault (including rape as sub-category) is a common crime in Australia affecting 0.3-0.7% of the total population per year and affecting close to 20% of 18-24 year old women in the past 12 months(!) Only 15% of sexual assaults are reported to the police. Let us define rape. This is difficult as can be evidenced by a quick google search for definitions of rape. Let us go with the following for now:

"Rape is defined as forced, manipulated or coerced sexual intercourse (or other sexual act) against the will of the victim. If the act occurs while the victim is unconscious, asleep or otherwise unable to communicate unwillingness, it is still considered rape."

(As per Massacheusetts law)

What is Stalking

Stalking too is a common phenomenon, affecting some 23% of people throughout their lifetime, and with rates of 32% amongst people aged 18-35. There are various definitions of stalking in legal and academic literature. The nature of the behaviours and the intent are controversial areas- if the intent is romantic in nature, is it stalking? Similarly, if it is a seemingly innocent gesture but is repeated and done in such a way to cause (reasonable) fear, is it stalking? Consensus however is reached when it comes to the effect on the victim: it is necessary that the conduct causes the victim to fear for his/her safety. Thus I use the following definition:

"Stalking refers to a course of conduct by which one person repeatedly inflicts on another unwanted intrusions to such an extent that the recipient fears for his or her safety."

(Purcell, Pathé, Mullen 2004)

Who Rapes, Stalks- and Why?

Many models have been proposed for rape, stalking, sexual murder and sexual assault, striving to represent the diversity of motive and execution evident in the crime.

Summary of Convicted Rapists

Not all rapists (I must point out once again) are psychopathic- fully half are non-psychopathic. >95% of reported rapes have a male perpetrator. However female rapists are likely very underrepresented due to sociocultural factors and attitudes. It is also to be noted that rapists carry a recidivism rate (for all crimes) of roughly 50%- the highest rate for violent offenders; convicted paedophiles carry a rate of between 10-50% depending on study and subcategorisation, which includes both child rapists as well as those attracted to children.

Summary of Convicted Stalkers

Stalking has only recently entered the popular lexicon despite reports of stalking behaviours since at least the 1800s; it became a common term only some time in the 1980's, as a response to celebrity stalkers. This became more generalised to harrassment and predatory behaviour towards non-famous victims. In contrast with rape, the gender split with perpetrators is roughly 50/50. Once again, this difference may represent greater social acceptability for people to report female stalkers than female rapists. Various studies of stalkers have also shown that concurrent psychiatric problems (whether psychosis, mood disorder or personality related) were almost universal in this group.

The FBI Model of Violent Crime

The FBI have a model which divides rapists (and other violent criminals) into "organised" and "disorganised" subtypes. Organised being those who plan carefully, leave few traces of their crime, do not do random acts of "ultra-violence". Disorganised being those who display "chaotic" features (such as ultra-violence, lack of planning, messiness, etc.) The FBI model has very little evidence to back it and unsurprisingly is widely derided as simplistic, artificial, unreaistic and, well, incorrect.

More Modern Typologies of Rape, Stalking and Sexual Murder

The only reason for the multiplicity of categories in the diagram below is because of the overlap present in the typologies of rapists, sexual murderers and stalkers in the studies below. These studies took data from crime scenes, criminals and victims and came up with distinct behavioural and motivational clusters. (Click for larger version) However, when you compare the studies it would be more accurate to speak of roughly 6 subtypes as follows:

• 1a: Violent, aggressive types who are motivated by pure revenge against the victim. Thus, entirely violent, paranoid motivations, associated with paranoia as well as Cluster B* (antisocial, narcissistic, borderline, histrionic) personality traits.
• 1b: Violent, angry and power-obsessed types who are motivated because of (perceived) rejection by the victim. Thus, sex/intercourse is also a factor. Associated with Cluster B traits.
• 2a: Socially inept, intimacy seeking, incompetent types who do not know any other sure-fire method of procuring intimacy/intercourse and/or who rape because they feel socially inadequate and insecure. They are purely motivated by the desire for sex/intimacy and only use as much force is necessary to get what they want. Murder is an accidental sequel to this. Usually socially inept/of low IQ.
• 2b: Delusional, intimacy seeking types who believe that their victim is in love with them back. Associated with psychosis and schizophrenia.
• 3: Sadistic, fetishistic, predatory types who plan meticulously and whose motivation is complex violent sexual fetish- an extreme form of the combination of sex and violence. Very dangerous, unrepentant, skilled. Associated with psychopathy and extreme paraphilias.
• 4: "Other". This more nebulous group includes oppportunistic, inept, short term, unplanned acts of random violence, often associated with the commission of other crimes including robbery.

*Cluster B personality disorders include: antisocial (violence, disregard for others' rights, egocentrism, low empathy, includes the subgroup of psychopaths), narcissistic (egocentricity, inflated self-esteem, callous disregard for others), histrionic (attention-seeking, shallow but dramatic moods, egocentrism, overdramatic), borderline (unpredictable behaviour, low self-esteem, inner emptiness, clingy behaviour, mood swings, rapid change from idolisation to demonisation). This group of disorders has high overlap and there is a (possibly cultural) propensity for men to be diagnosed (or misdiagnosed) with APD or narcissism vs women and BPD or histrionicity. So you see, it is not as simple as "organised" vs "disorganised", "sane" vs "insane", or "rape as power". Rape has many many motivations including power, sex, revenge, delusion, opportunity. Similarly it is not just psychopaths who rape. Fully half of all rapes are committed by people who have other psychological problems, or even no identifiable psychological problem at all. The results of the rape are also varied. Someone who is motivated by an inept desire for intercourse may end up killing the victim. Someone motivated by psychopathic predatory thoughts may only stalk their victim and never proceed to rape or sexual murder.

MTC:R3 - Towards a More Complex Model of Rape

I did lie. There was some significance to the multiplicity of categories. (Click for larger version) The Massachusetts Treatment Center Rapist typology, Version 3 (Knight & Prentky, 1990) This taxonomy (think species) of rapists is more nuanced and based on a larger set of data. Rather than relying on 4-6 unrelated categorisation, it incorporates underlying psychopathology, motive and the level of violent and/or sexual motivation that is behind these rapes. There is, then, an interesting distinction that comes about which I shall illustrate below: (Click for larger version) I have recoloured the diagram so that the level of red represents sexualisation and the level of yellow represents violence. In non-psychopathic sexual offenders, violence and sexualisation are inversely correlated- they range from red to yellow with only a very muted orange in-between. However, in psychopathic sexual offenders, violence and sexualisation are positively correlated- they are only various shades of orange. Note that this is true only for psychopathic RAPISTS, not for ALL psychopaths. Thus, perhaps in that minority of psychopaths who rape, violence and sex are much of the same emotion. This is in fact reinforced by the finding that while the VRAG (violent risk appraisal guide) which includes the PCL:R (the most common scale for measuring psychopathy) is a reasonable predictor for psychopathic rape and recidivism, an adjusted scale known as the SORAG (sex offending risk appraisal guide) which includes physical measurement of sexual arousal to sexual deviance in fact correlates with this criminal behaviour much better. And here we reach perhaps the crux of what I used to not understand about this crime. How such a thing could be done.

How could someone do this?

Some people do not know how to have sex, so they force it out of someone to get their way; they do not know much better. Some people are particularly angry and want to hurt and humiliate someone in particular and they know the effect that rape has; it is not about sex, it is about power and violence. Some people are just so horny and angry at the same time, or so turned on by domination and humilation that they plot and plan and find a victim to lash out at and fulfil their fantasies. And. Some people do it because there's someone right there and they just can, very easily- maybe just ignore that they're saying no or that they passed out or that they're drunk or drugged or happened to be there, pretend that it was the heat of the moment and they were really asking for it and how could someone stop themselves in that situation. I mean, you understand don't you? It's not like [person] would've ever been in that position if they didn't really want it, and you know how [person] is such a tease and they put me in this position where I just couldn't help myself. What are you gonna do in that situation? Just stop? I guess my point is that many people are apologists for the opportunity rapist and the date rapist. In fact, there are many who argue that it is not rape or that in that situation maybe they would do the same thing, or that the victim is to blame for the assault. Look at the underlying thought process and see its real meaning though:

"I raped because I could"

It is an abnormal thought process. It is in fact a psychopathic thought process. It is not the product of the usual human mind. The "I could not stop myself" and the "she was asking for it" are merely excuses and justifications for the true reason- "because I could".

Discussion

I believe that it is facile and simplistic to conclude that distinguishing particular patterns of rape means that some rapes (as defined above) are not rapes or that rape is a lesser crime according to motivation or psychopathology. The effect on the victim of the rape is dependent on many factors including the psychology of the victim- we do not claim that it is not a rape if the victim recovers better from the psychological trauma, so why should we claim that it is not a rape if the motivation for the rape was X, Y or Z? Sentencing is yet another issue and an altogether unrelated one. Sentencing takes into account societal impact, likelihood of recidivism and other factors- it is not and should not be interpreted purely as a measure of morality. It is a means by which society maintains social control, order, attempts to reduce the likelihood of crime and segregates the potential recidivist from potential future victims. Some rapists, stalkers, sexual murderers are far more amenable to rehabilitation than others. Some rehabilitation exercises do reduce recidivism and some do not. These factors are very important to find because of the following statistics:

• 50% of rapists re-offend in some way
• 50% do not
• Nearly all stalkers who harrass their victims have an associated psychiatric diagnosis- which may vary from frank schizophrenia/psychosis to an embedded personality disorder.
• Non-psychopathic offenders respond well to rehabilitation and therapy- some reoffend anyway but in significantly lower numbers
• Psychopathy as a personality trait has shown very little promise for treatment and psychotherapies used for non-psychopathic offenders in fact increase or have no effect on recidivism rate- but early research suggests psychopathic offenders may show lower recidivism rates as a result of punishment/behaviour based regimens

Thus, as a heterogenous group of people it is important that society does more research and action into finding appropriate stategies for managing these complex crimes. There is some suggestion that the gradually increasing sentence and taboo against rape has in fact led to a far lower rate of conviction for offenders than previously- someone is far more likely to plead guilty to a 2 year sentence than a 10 year one. Perhaps we should champion a graded system for rape and sexual assault- the first offence being 2 years and psychiatric evaluation, treatment and rehabilitation. The 2nd offence, 5 years with treatment and close community monitoring, the 3rd 10 years with treatment and very intensive community monitoring. First time offenders would be more likely to admit to their crime and all would undergo measures to attempt to rehabilitate them. However the punishment would increase with each subsequent offence- and remember it is much easier to reconvict someone than to convict someone on a first time offence. Accordingly there should be close surveillance of this vulnerable group to lessen the risk of re-offending. With stalking, the psychiatric diagnosis is paramount; some stalkers are experiencing a frank psychotic episode and requite psychiatric hospitalisation and treatment. Others may be motivated by a personality disorder such as borderline personality or psychopathy. Depending on what this is, treatment and punishment should proceed accordingly.

Conclusion

Rape and stalking are common crimes affecting a large percentage of the population. They are also under-reported crimes. Thus it is highly likely if not definitely true that we all know someone who has been raped, stalked or both. Even if the number of perpetrators is low - this would imply a high re-offending rate, consistent with the data. Not only are these crimes common, but their incidence far outweighs the likelihood of a false report. False reports no doubt happen and it is very unfortunate and vindictive if they do so; however such events are very rare indeed and far more common is true rape, stalking and sexual assault. Rapists and stalkers both commit their crimes for a variety of reasons, sexual, violent or both. These reasons include desire for intimacy, revenge/retaliation, sexual fetishism and pure opportunity. Both rapists and stalkers have a high rate of recidivism and co-existing psychiatric diagnosis, whether it be psychotic, mood-related or personality disorder including psychopathy. They are a complex group of criminals with varying motivations and modes of activity but this makes their crimes no less wrong. Similarly, victims range from young women of reproductive age to babies to old women to old men to young men and anywhere in between. This variability indeed highlights the fact that no victim of rape or stalking is deservent of the crime but is in fact a "convenient object" for the commission of the crime. If it were not them, it would be someone else, so to speak. It is important that we recognise that these crimes do happen to people we know and are far more common than we realise. It is also very important not to blame the victim and to realise that most of the perpetrators are mentally ill individuals who require psychiatric treatment, rehabilitation and/or even segregation from the greater community.

House of God by Samuel Shem is full of many sorry truths of hospital medicine, of General Medicine in particular. One of those is the art of the "buff" and "turf". No-one wants extra work. It is an eternal rule of human nature (unless you are a workaholic such as myself and find work somehow interesting, exciting or, heaven forbid - fun). And it is true that being in hospital for too long is bad for patients. The "buff" is the polishing up of the patient so that they are as healthy as you can get them from your point of view. The "turf" is the act of sending them to another medical team, to rehab or home or to a nursing home. And you want to do this in such a way that they don't "bounce" - otherwise known as a failed discharge. On the whole this can be an effective system. Certainly it is the kind of system that everyone seems to like - administrators, consultants, registrars, residents and the patients themselves. Less work, less costs, less time in hospital- you can see the advantages right there. Sadly though this leads to the very predictable problem wherein no-one wants patients unless somehow the rules state they can't be discharged or turfed. Usually the "buff" is very incomplete at this stage. Because we are all just focussed on the turf. So we have some 75 year old patient with an uncomplicated heart attack being admitted under general medicine rather than cardiology because she has a urinary tract infection as well. Or no-one has bothered to check liver function tests and someone with ascending cholangitis ends up on general surgery instead of gastroenterology. Or neurosurgery takes a patient who "definitely has an acute disc prolapse" because overnight no-one wants to argue with the emergency registrar who wants to get patients out of a full emergency department and they turn out to have septic arthritis. It is well documented that admitting patients under the appropriate speciality unit leads to significantly improved outcomes - in particular coronary care units and acute stroke units are cited as examples. It leads to shorter hospital stay, lower complication rates and marked improvements in morbidity and mortality. This is relevant to both speciality and general units, I feel. Often general medicine is better for complex or geriatric patients because rehabilitation and multiple referrals are streamlined, while speciality units can be very focussed- and can miss multisystem disorders. Perhaps what will happen in the futures is that we will have speciality multisystem units- those dealing with "metabolic syndrome and smoking diseases", those dealing with disorders of immunity and infections and such-like. Either way, appropriate unit protocols can be a way of reducing fighting over rejecting patients. It certainly simplifies the process of admission. Another thing that must be done is reducing bed pressures and simplifying routine task management for junior doctors. It is high (and unnecessary) workloads and often very unfair bed concerns that mean the "buff" is not complete. And so they bounce.

The nuff-nuff is the bane of our existence. That person who comes in complaining of tummy pain or feeling weak or some vague and inconsistent symptomatology completely without medical explanation and almost certainly psychological in nature. They have some tawdry and dreary sort of social background and probably reside in a slumlike place (oh boo-hoo). They have all sorts of medications for somatic relief. The endones and pethidines and maxolons and valiums. Not to mention the psychiatric pharmacopoeia of zolofts and efexors and zyprexas. Some of them drink and smoke too much (but not enough, sadly). We do all the tests (or just enough to satisfy ourselves) and find nothing while they abuse us for "not caring". So we send them home, kicking and screaming while they threaten "if you send me home I will be back here tomorrow" (which we know is true). And sit back exhausted but relieved that they've finally left. They are the bane of our existence, the nuff-nuffs. The bane. But would you know that:

• Schizophrenia and other psychotic illnesses
• Depression, anxiety
• Personality disorders
• Substance abuse

are all associated with greater rates of illness and mortality? Multiple presentations to hospital are a bad sign that there is something going wrong- whether it be physical or psychiatric. Or both for that matter. Even worse, as they say "you can't prove a negative"; in other words there are many for whom we do not find the real answer (even though it exists). Additionally, chronic diseases lead to significant psychiatric burden- people become depressed, anxious, sometimes even epileptics have psychological "pseudo-seizures". And the mentally ill just do not look after themselves properly. So what do you do when faced with the nuff-nuff? There is I suppose only one thing you can do - exclude organic pathology while treating the psychiatric disorder.

• Approach things with an open mind each time. Ask yourself "why" and be prepared for a complex answer. Sometimes people with worsening disease become anxious and depressed and present to hospital even without a need to. Sometimes it is a cry for help. Sometimes despite mostly being psychiatrically unwell or having a pathological personality there is genuinely a medical cause for the symptoms.
• Involve a psychiatric team early. Sometimes the diagnosis is psychiatric and this in itself is the main thing.
• Keep a high index of suspicion for both organic and psychiatric disease- nuff-nuffs get sick too (and sometimes die)
• Have a sympathetic but professional attitude; be caring but consistent and do not get too wound up in the transferred anxiety.
• Do not get angry, violent or abusive. Additionally do not take on their stresses as your own.
• Be as prepared for gratitude as for the potential to be verbally abused for your approach (and don't take it too personally)
• Exclude dangerous things
• Do what your duty of care towards your patient behoves you to do; do not discriminate on the basis of psychiatric illness.

Doctors are angered by these patients for more than one reason. We are educated to believe that only organic disease is "real" or "significant". But even more than that, being (often unconsciously) manipulated and having large amounts of angst and anxiety offloaded onto us - and then finding that the underlying cause is not what it seems- makes people feel betrayed or lied to (even if that is not the conscious aim of the patient). But why should we feel betrayed? A psychiatric diagnosis (even that of a somatoform or personality disorder) is still a medical - and pathological- condition that causes harm. Often the best thing we can do for these people is to acknowledge their underlying issues and refer appropriately. Sometimes that is all they have been hoping for.

Every speciality has its bugbear. Emergency departments have D-dimers (always positive if you spend more than 2 mins in a hospital, seemingly). Gastroenterologists have "melaena" (often just dark brown stool or even frank PR bleeding). Rheumatologists, chronic back pain (the worst thing you can do is admit them to hospital). And cardiologists have troponins. Good ol' troponin. Touted as "the" test for myocardial infarction (heart attacks to the layman), troponin has gone from being the wunderkind of cardiology to a much maligned villain due to its (sometimes) excessive sensitivity. "Why did they order a troponin?" I hear you cry. "Don't bother with it, it's just troponinitis." What is troponinitis? What is this entity which like "acopia" appears to have entered the everyday parlance of the hospitalist? It is, quite simply, a troponin higher than the 3 times the reference range which for whatever reason is not felt to be due to a myocardial infarct. Troponin is an enzyme that only occurs in cardiac muscle, and thus is only released during death or damage to cardiac myocytes. There is obviously a small baseline amount of damage that is normal wear and tear. The main worry with a very high troponin, then, is a large amount of cell death secondary to a clot or stenosis completely obliterating arterial supply to cardiac muscle - an acute myocardial infarction. Rises in troponin can also occur secondary to sepsis, uncontrolled tachycardia, pulmonary embolus, cardiomyopathy and other causes for cardiac strain. Additionally a troponin can be mildly elevated when it isn't been excreted by the kidneys- in renal impairment. So should we worry about a high troponin in the setting of sepsis, tachycardia or other causes? The key issues here are as follows. Is this:

1. A real myocardial infarction, and if so:
   1. Is this caused by thrombus (clot) post plaque rupture (type I MI)?
   2. Is this caused by cardiac failure/hypotension in the setting of fixed coronary artery disease (type II MI)?
2. Is this another condition causing a raised troponin, and if so:
   1. Does the raised troponin mean there is cardiac damage?
   2. If not, does the raised troponin have any significance?
3. Is there coexisting cardiac as well as other pathology?

Obviously the above must be evaluated in every patient. Additionally any test - including a troponin - should be ordered at an appropriate time when you have a high pre-test probability of an acute coronary syndrome. Thus, underlying risk factors (especially diabetes), clinical features- history and examination, an appropriate acute deterioration, etc. Now, for the controversial bits:

• It is possible to have a watershed infarct in the setting of fixed coronary artery disease where hypotension, tachycardia or cardiac failure is present (eg sepsis or arrhythmia)
• It is also possible to have clinically significant cardiac damage in those settings even without true infarction secondary to strain
• Raised troponin has been shown to be associated with a significantly worse prognosis in acutely unwell patients where another pathology is shown to be the cause

Which leads to my next conclusion:

A raised troponin in an acutely unwell patient, especially one with risk factors and evidence of haemodynamic compromise and/or heart failure should never be ignored.

"But what are you going to do about it?!" you say, incredulously. Watershed infarct without a thrombus? "Troponinitis" due to sepsis? What the heck are you going to do about that? Shouldn't we just stop checking the damned thing? Given that these patients have in fact had the possibility of thrombosis, fixed coronary atherosclerosis, severe cardiac strain/hypoxia or just very bad underlying disease the following should be done:

1. Follow up troponins to monitor trend - MI less likely if troponin persistently raised
2. Aspirin (if not contraindicated) and prn anginine
3. Optimisation of fluid status, strict fluid balance and daily urea, electrolytes and creatinine
4. A transthoracic echocardiogram to assess heart function and see if there is in fact evidence of either infarction or heart failure
5. Cardiologist review in all patients
6. Referral for percutaneous coronary intervention/angiogram:
   1. In patients with ST elevation and likely infarction and who are well enough for the procedure and do not have sepsis (risk of septicaemia and endocarditis)
   2. In patients who will benefit and are well enough for the procedure in whom there is high pre-test probability- as an elective procedure when well.
7. Therapeutic anticoagulation for 48-72 hours in patients with high pre-test probability of infarct with no ST elevation and no contraindication to anticoagulation
8. Addition of cardiac risk factor modifying agents and optimisation of cardiac failure medications
9. Treatment of acute illness, underlying problems and optimisation of chronic conditions
10. Discussion with the patient and family regarding diagnosis and prognosis

Of course, unfortunately the one thing that everyone will groan about is the fact that I have listed 10 things that need to be done for sick patients with "troponinitis". It is much easier to ignore it and do nothing- but that is a grave disservice to our patients and very contradictory to the actual evidence on the matter.