Research
Research in Forensic Psychiatry
New England Journal of Public Policy
March 2020
Abstract
This article explores the relationship between the social psychology of the individual and the final abyss of suicide terrorism. The boy on the high dive is a metaphor for the fearful pause before the leap. For a young child, the dive is exciting and dangerous: the fearful pause is somewhat analogous to thoughts and feelings before the terrorist’s catastrophically destructive contemplated homicidal/suicidal behavior. If we think about the leap itself, there may be a better analogy. Is there any corollary to a specific group of suicide completers? What can be learned from others who have contemplated and undertaken perhaps the most public type of suicide—plunging from an extreme height? To what degree are those individuals fully committed compared with ambivalent? For those who are ambivalent and turn back, what is it that dissuades them? For those who appear committed and fail in their attempt, what is the likelihood of their returning again? Because suicidal jumping and suicide terrorism are both public acts, do these two groups on the pathway to fatal performance violence share similar motivations and ambivalence? If there are similarities among those who act publicly in fatal ways, are there policy-related means or measures that have been successful in decreasing public suicide that might also be applicable for decreasing the incidence of suicide terrorism?
Through an examination of the content and process of public suicide, this article focuses on those individuals whose behavior is essential to the actual terrorist violence, especially if that behavior results in expected death to the individual. Not all persons engaged in terrorist activities will engage in a final fatal personal drama. Even in situations where lone actors conceive and execute terrorist actions, research has shown that there are bystanders who may have some preliminary knowledge of the event long before the audience to terroristic performance violence will witness the destructive event.
International Journal of Emergency Mental Health
January 2002
Abstract
In this article, we have introduced the concept of shielding as a public mental health intervention. Shielding addresses the core elements of bioterrorism when we consider that bioterrorism is best understood as terrorism, i.e., psychological warefare, which merely employs biologic agents, not to kill, but to terrorize. It is, therefore, to some degree dependent upon widespread contagion. Shielding is not a panacea. It is one aspect of an overall response plan. Nevertheless, it represents a potentially useful “antidote” for the bioterrorist assault. Perhaps most significant among its putative mechanisms of action appears to be controlling contagion, both physical and psychological. In the final analysis, in the wake of a terrorist attack, physicians can physically immunize and treat those who require such attention. Engineers can reconstruct buildings and roads. But who rebuilds the essence of humanity which has been violently ripped away from those who suffered the terrorist attack? How do we reconstruct a belief in justice and safety in the wake of a mass terrorist attack? Without attention to mental health, i.e., the “psychological side of terrorism,” we run the risk of rebuilding a nation without a spirit, without a vitality, without a sense of humanity.
Research in Toxicology
Farah R, Cole RJ, Holstege CP. Increasing Severity of Medical Outcomes and Associated Substances in Cases Reported to United States Poison Centers. Clinical Toxicology. 2024;62(4):248-255.
Abstract
Introduction
Poison centers provide free expert recommendations on the treatment of a wide variety of toxicological emergencies. Prior studies have called attention to the increasing complexity of cases reported to poison centers. We aimed first, to evaluate the trends in medical outcome severity, over a 15-year period in both the adult and pediatric populations. Second, we described the most frequently reported substances associated with major effect or death.
Methods
This is a retrospective review of exposures reported to the National Poison Data System from 1 January 2007 through 31 December 2021. All closed cases, for human exposures, reported during the study period were included. We assessed trends in frequencies and rates of medical outcomes and level of care received, among the adult (age greater than 19 years) and pediatric (age 19 years and younger) populations by reason for exposure.
Results
During the study period, the number of adult unintentional exposures resulting in major effect (37.4 percent) and death (65.3 percent) increased. The number of adult intentional exposures resulting in death increased by 233.9 percent and those resulting in a major effect increased by 133.1 percent. The rates of exposures resulting in major effect and death increased among both intentional and unintentional adult exposures. The number of pediatric unintentional exposures resulting in a major effect increased by 76.6 percent and the number of pediatric intentional exposures resulting in death and major effect increased by 122.7 and 190.1 percent, respectively. Moderate, major effect, and death rates increased in pediatric unintentional exposures and moderate and major effect rates increased in pediatric intentional exposures.
Conclusions
We found a worsening severity of medical outcomes in adult and pediatric cases reported to poison centers. Poison centers are increasingly managing complex cases. Monitoring trends in which substances are associated with severe outcomes is imperative for future strategic prevention efforts.
Farah R, Rege SV, Cole RJ, Holstege CP. Suspected Suicide Attempts by Self-Poisoning Among Persons Aged 10–19 Years During the COVID-19 Pandemic-United States, 2020–2022. Morbidity and Mortality Weekly Report, 2023;72(16): 426-430.
Summary
What is already known about this topic?
In 2020, suicide was the second leading cause of death among persons aged 10–14 years and the third leading cause among those aged 15–24 years.
What is added by this report?
Analysis of National Poison Data System data found that the rate of suspected suicide attempts by self-poisoning among persons aged 10–19 years increased 30.0% in 2021 as compared with prepandemic rates (2019), with a 73.0% increase among children aged 10–12 years, 48.8% among adolescents aged 13–15 years, and 36.8% among females.
What are the implications for public health practice?
A comprehensive public health approach to suicide prevention measures focusing on children and adolescents and involving partnerships among families, school teachers, mental health professionals, and public health leadership is needed.
Holstege CP, Ngo DA, Borek H, Ait-Daoud N, Davis S, Rege S. Trends and Risk Markers of Student Hazardous Drinking – A Comparative Analysis Using Longitudinally Linked Datasets in a Public University. J Am Coll Health. 2022; 70(6):1680-1687.
Abstract
Aims: This study compares the incidence and risk-markers of student alcohol intoxication-related emergency department (ED) visits and alcohol-related incidents reported to student affairs. Methods: Enrollment data were linked to ED visits with alcohol intoxication and to alcohol-related incidents reported to campus authorities within one year following the first (index) annual enrollment. Incidence, annual trends and associated risk markers were analyzed. Results: The cohort consisted of 204,423 students aged 16–49. Incidence rates of first ED visit with alcohol intoxication and alcohol-related incidents were 59/10,000 and 311/10,000 person-years, respectively. Both outcomes shared common risk-markers including age, gender, race/ethnicity, fraternity and sorority (FSL) membership, an existing diagnosis of depression, etc. Being an athlete was associated with a lower risk of alcohol-related ED visits, and transfer students were at lower risk for alcohol-related incidents. Conclusion: Linking enrollment data with hazardous drinking events can help in better monitoring of student hazardous drinking and targeting interventions.
Rege S, Smith M, Borek HA, Holstege CP. Opioid Exposure Reported to U.S. Poison Centers. Substance Use & Misuse 2021;56(8):1169-1181.
Abstract
Objective
Opioid-related deaths are a leading cause of accidental deaths in the United States (U.S.). This study aims to examine the national trends in opioid exposures reported to U.S. poison centers (PCs).
Methods
The National Poison Data System (NPDS) was queried for opioid exposures between 2011 and 2018. We descriptively assessed the demographic and clinical characteristics. Trends in opioid frequencies and rates were analyzed using Poisson regression. Independent predictors of serious adverse events in opioid exposures were studied.
Results
There were a total of 604,183 opioid exposure calls made to the PCs during the study period. The frequency of opioid exposures decreased by 28.9% (95% CI: −29.6%, −28.1%; p < 0.001), and the rate of opioid exposures decreased by 21.2% (95% CI: −24.7%, −16.9%; p < 0.001). Multiple substance exposures accounted for 48.9% cases. The most frequent age group was 20–29 years (19.3%). Suspected suicides accounted for 34.9% cases. There were 7,246 deaths in our study sample, with 6.8% of cases demonstrating major effects. Hydrocodone was the most frequently observed opioid causing a toxic exposure and naloxone was used in 20.6% cases. Important predictors of a serious adverse event were age, gender, multi-substance exposures, and reasons for exposure.
Conclusions
Analysis of calls to PCs indicated a decreasing trend of opioid exposures. However, the proportion of SAEs due to such exposures increased. There was a high proportion of intentional exposures and occurred in older age groups. PCs are a vital component of real-time public health surveillance of overdoses in the current opioid crisis.
Parker-Cote JL, Rizer J, Vakkalanka JP, Rege SV, Holstege CP. Challenges in the diagnosis of acute cyanide poisoning. Clin Toxicol (Phil). 2018; 56(7): 609-617.
Abstract
Objective: The aim of this systematic review was to identify isolated acute cyanide poison cases and to identify reported signs, symptoms, and laboratory findings.
Methods: We searched MEDLINE, Cochrane Reviews, and Web of Science case reports and series using a number of MeSH descriptors pertaining to cyanide, toxicity, and poisonings. We excluded studies on plants, laboratory analyses, smoke inhalation poisonings, animals as well as non-English language articles and those in which data were not available. Data extracted included demographics, exposure characteristics, acute signs/symptoms, and medical management and outcome.
Results: From the initial 2976 articles retrieved, 65 articles (52 case reports, 13 case series) met inclusion criteria and described 102 patients. Most patients were unresponsive (78%), hypotensive (54%), or had respiratory failure (73%); other signs and symptoms included cardiac arrest (20%), seizures (20%), cyanosis (15%), cherry red skin (11%), and had an odor present (15%). Medical management included cyanide antidote kit (20%), sodium thiosulfate (40%), and hydroxocobalamin (29%). The majority of cases (66%) required intubation with mechanical ventilation and a substantial number (39%) developed refractory hypotension requiring vasopressor support.
Conclusions: Contrary to general reviews published on cyanide toxicity, reports of cherry red skin and bitter almond odor were rare among published cyanide cases. Consistent with other studies, metabolic acidosis with significant lactic acidosis were the laboratory values consistently associated with cyanide toxicity. Healthcare providers may overlook cyanide toxicity in the differential diagnosis, if certain expected characteristics, such as the odor of almonds or a cherry red color of the skin are absent on physical examination.
Holstege, C. P., Neer, T., Saathoff, G. B., & R. Brent Furbee. (2010). Criminal Poisoning: Clinical and Forensic Perspectives. Jones & Bartlett Publishers.
Description
Criminal Poisoning: Clinical and Forensic Perspectives offers health care providers, investigators and attorneys a comprehensive look at the history, employment and ex post facto analysis of criminal poisoning.
Drawing on the vast expertise of the authors—law enforcement agents and physicians with robust experience in the realm of criminal poisoning—Criminal Poisoning: Clinical and Forensic Perspectives covers the illegal use of poisons to harm people and the methods of detection available to investigators and prosecutors.
Each chapter covers a specific toxin, from acids and herbals to drugs of abuse, and includes a case study that explains the diagnostic challenges associated with detecting and prosecuting a criminal poisoning. What’s more, the book delves into who may poison—including the psychological factors that motivate someone to kill—and who may be a likely victim.
Schouten, R., & Saathoff, G. (2011). Chapter 14 – Biosurety in the Post-9/11 Era. In Microbial forensics (pp. 221–237). Elsevier/Academic Press.
Chapter Summary
This chapter highlights biosurety in the Post-9/11 era. The anthrax mailings in the fall of 2001 fundamentally altered the security landscape in government and private biological laboratories. Originally feared to be a follow-on attack after the 9/11 airplane hijackings, the anthrax mailings were determined to be domestic in origin. Identifying and investigating the possible sources and perpetrators required a massive investigation, referred to as “Amerithrax,” by the U.S. Postal Service, Federal Bureau of Investigation, and the U.S. Department of Health and Human Services. The Amerithrax case highlights the need for a system ensuring that co-workers, as well as supervisors, maintain a sense of responsibility for the well-being of each other and the safety and security of their laboratories. No biosurety system can be successful without the endorsement and full cooperation of laboratory directors, principal investigators, and the research community at large. The fact that an individual does not pose a risk when hired does not mean that life and personal circumstances will not change. Initial screening of those working with BSAT should be discrete, based on valid risk factors, thorough, executed expertly, and repeated at intervals or in response to behavioral and other life changes. With an enhanced biosurety program in place, risks can be detected and addressed before adverse events occur.
Research in Critical Incident Analysis
Journal of Threat Assessment and Management
2018
Abstract
Violence risk and threat assessments have coexisted for decades as mutually exclusive endeavors of academia and law enforcement. In the years following September 11th, 2001, extremist violence has demanded that law enforcement and intelligence agencies identify, prevent, and respond to potential attacks perpetrated by radicalized civilians. This challenge has highlighted the gaps in the current risk and threat assessment methodologies. We seek to inform and improve these two processes by integrating theory into this process of violence risk and threat assessment, while focusing specifically on the radicalization of women to extremist violence. We present a Moral-Situational Action model for extremist violence which seeks to integrate theoretical tenets of Situational Action Theory with practiced principles of risk and threat assessment. The goal is to provide a causative model which will guide operational analyses and empirical research concerning an individual’s progressive involvement in or desistence from extremist violence. The model explores risk and protective factors as intertwined constructs on the same continuum. The model further integrates the quantitative coding of risk factors with a formulation-based outcome that includes behavior, motivation, and vulnerabilities, to assess fluctuating levels of risk, and individual-specific risk and threat management strategies. We describe the coding protocol that is being used to quantitatively examine this theory and posit that with modest revision it will be applicable to men.
Journal of Homeland Security and Emergency Management
2012
Abstract
This paper takes the current all hazards (with a special emphasis on the CBRNE) threat picture to military installations within and outside of the continental United States and their associated military communities, as well as evolving patterns of community vulnerability and changing preparedness concepts (community resilience, whole of community), as a point of departure for re-examining strategic leadership challenges (Boin et al, 2005) associated with crisis management and community-resilience development. The paper identifies two key modes of response to pervasive threat to military communities: evacuation and shelter in place. Both academic research and practical planning in both the civilian and military realms have tended to focus on evacuation to the relative neglect of shelter-in-place. The paper examines the pros and cons of each mode of response. While traditional shelter-in-place concepts have significant limitations, many of these are transcended by state of the art community-shielding strategies which provide a more robust and enhanced form of sheltering-in place. In fact, community shielding provides a potentially superior alternative in many contingencies in terms of force protection, mission assurance, and continuity of operations. The paper concludes with an agenda for improving the resilience (and crisis management) capacity of military communities.
Research in Disaster Resonse
Frey AS, PM Maniscalco, Holstege CP. Chemical Agents Encountered in Protests. Emergency Medicine Clinics. 2022;43(2):365-379.
KEY POINTS
The most common chemicals used in riot control agents are chlorobenzylidene malono-nitrile (CS), chloroacetophenone (CN), dibenz[b,f]- 1,4]-oxazepine (CR), and oleoresin capsicum (OC).
Ocular, respiratory, dermal, and gastrointestinal symptoms are the most common.
Clinical effects usually occur immediately to within several minutes of exposure, but latency periods of hours to weeks have been documented.
Effects usually improve within minutes to hours after removal from source, but some may
experience more severe effects that require intensive care and long-term management.
Soft tissue, ocular, and neurologic injuries have been seen from the kinetic impact of
launched or thrown riot control agent canisters, sometimes with lethal results.
Treatment consists of symptomatic management. There is no antidote for these agents.
Maniscalco PM, Holstege CP, Cormier SB. Chapter 91: Operations Security, Site Security, and Incident Response. In Ciottone, et. al. (eds): Ciottone’s Disaster Medicine. 3rd Edition. Elsevier, Philadelphia, PA. 2024. ISBN: 978-0323809320
Abstract
Operations security and site security are processes for protecting and safeguarding something—personnel, information, “things,” plans, or actions. These two concepts span the realm of strategic, operational, and tactical responses to an event. Moreover, these concepts must be addressed and institutionalized in response policies/protocols prior to an event, allowing for all staff members to be trained, exercised, and fully prepared for their utilization. These steps will provide for reducing certain risks and concurrently ensuring a more stable and safer environment for operations.
Holstege CP, Kirk M, Sidell FR: Chemical warfare: Nerve agent poisoning. Crit Care Clin. 1997;13(4):923-942.
Summary
Nerve agents are organophosphate anticholinesterases that have commanded a great deal of media attention in the past decade. Their military use by Iraq against Iran and the Kurds, the terrorist attacks in Japan with sarin, and the public fear pertaining to the disposal of these agents have all been well publicized. The general medical community itself has limited experience with these agents, but the recent experience in Japan points out that intensivists may be confronted with large numbers of civilian casualties from nerve agent exposure. This article provides a general review of the history, chemical properties, pathophysiology, and treatment of nerve agent poisoning. The article is limited to the four main nerve agents: (1) tabun, (2) sarin, (3) soman, and (4) VX.