ABSTRACT
BACKGROUND: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a relatively newly identified autoimmune neuropsychiatric disorder that predominantly affects children and young adults. Although psychiatric symptoms are highly prevalent and frequently severe, it has mainly been reported in neurological, but not psychiatric, literature. Understanding this form of encephalitis, its quick diagnosis and which treatment to provide are of utmost importance for consultation-liaison (C-L) psychiatrists. The aim of this paper was to describe a case of anti-NMDAR encephalitis with severe psychiatric manifestations, who showed impressive recovery but required intensive involvement of the C-L psychiatry team. We emphasise the behavioural aspects, psychiatric symptoms and challenges faced by the CL consultant across the different phases of the treatment. METHODS: We report the different treatment phases for a young woman with anti-NMDAR encephalitis who developed severe neuropsychiatric symptoms, with a focus on the role and challenges faced by the C-L psychiatrist. The literature is reviewed for each of these challenges. RESULTS: This case illustrated that even extremely severely affected patients may show impressive recovery, but require long lasting psychiatric care. C-L psychiatrists are faced with numerous challenges where only little literature is available. CONCLUSION: C-L psychiatrists play a pivotal role throughout the multidisciplinary care of patients with anti-NMDAR encephalitis and should be informed about this entity.
ABSTRACT
OBJECTIVE: The objective was to compare a brief interdisciplinary psychotherapeutic intervention to standard care as treatments for patients recently diagnosed with severe motor conversion disorder or nonepileptic attacks. METHODS: This randomized controlled trial of 23 consecutive patients compared (a) an interdisciplinary psychotherapeutic intervention group receiving four to six sessions by a consultation liaison psychiatrist, the first and last sessions adding a neurological consultation and a joint psychiatric and neurological consultation, and (b) a standard care group. After intervention, patients were assessed at 2, 6 and 12 months with the Somatoform Dissociation Questionnaire (SDQ-20), Clinical Global Impression scale, Rankin scale, use of medical care, global mental health [Montgomery and Asberg Depression Rating Scale, Beck Depression Inventory, mental health component of Short Form (SF)-36] and quality of life (SF-36). We calculated linear mixed models. RESULTS: Our intervention brought a statistically significant improvement of physical symptoms [as measured by the SDQ-20 (P<.02) and the Clinical Global Impression scale (P=.02)] and psychological symptoms [better scores on the mental health component of the SF-36 (P<.05) and on the Beck Depression Inventory (P<.05)] and a reduction in new hospital stays after intervention (P<.05). CONCLUSION: A brief psychotherapeutic intervention taking advantage of a close collaboration with neurology consultants in the setting of consultation liaison psychiatry appears effective.
Subject(s)
Conversion Disorder/therapy , Dissociative Disorders/therapy , Psychotherapy, Brief , Adult , Cooperative Behavior , Female , Humans , Male , Outcome Assessment, Health Care/methods , Patient Care Team , Surveys and QuestionnairesABSTRACT
Mood disorders represent the most prevalent psychiatric condition in patients infected by HIV virus. Screening and treatment of depression as well as the evaluation of the risk suicide is of the utmost importance. When psychopharmacological treatment is required, interaction with antiretroviral treatment must be carefully considered. More generally a close collaboration between the physician and the psychiatrist is recommended.
Subject(s)
HIV Infections/psychology , Mood Disorders/psychology , Anti-Retroviral Agents/therapeutic use , Antidepressive Agents/therapeutic use , Drug Interactions , HIV Infections/drug therapy , Humans , Mood Disorders/diagnosis , Mood Disorders/therapy , PsychotherapyABSTRACT
Subthalamic nucleus deep brain stimulation (STN-DBS) is a recognized treatment for advanced and severe forms of Parkinson's Disease. The procedure improves motor signs and often allows a reduction of the medication. The impact of the procedure on cognitive and neuropsychiatric signs of the disease is more debated and there is an international consensus for the need of a multidisciplinary evaluation of patients undergoing such programs, including a neuropsychiatric assessment. We present a review of the literature as well as the experience at our centre focused on the short and long term outcome on mood following STN-DBS.
Subject(s)
Deep Brain Stimulation/adverse effects , Mood Disorders/epidemiology , Mood Disorders/etiology , Parkinson Disease/psychology , Parkinson Disease/therapy , Subthalamic Nucleus/surgery , Aged , Antidepressive Agents/therapeutic use , Deep Brain Stimulation/methods , Female , Humans , Male , Middle Aged , Mood Disorders/diagnosis , Mood Disorders/drug therapy , Parkinson Disease/diagnosis , Prevalence , Prospective Studies , Psychiatric Status Rating Scales , Severity of Illness Index , Switzerland/epidemiology , Treatment OutcomeABSTRACT
Apathy defined as a loss of motivation and interest for novelty is a frequent symptom encountered in a number of psychiatric and somatic disorders. The purpose of this article is to provide an overview of the many different medical contexts where apathy may occur and help clinicians to differentiate it from a depressive syndrome. The treatment of apathy requires a diagnostic clarification in order to treat the underlying condition. Then, pharmacological or non-pharmacological interventions may help to specifically improve apathy.
Subject(s)
Affective Symptoms/diagnosis , Affective Symptoms/therapy , Depression/psychology , Interpersonal Relations , Brain/physiopathology , Depression/etiology , Depression/therapy , Humans , Limbic System/physiopathologyABSTRACT
The assessement of behavior is common part of the neurological examination. This article reviews the behavioral and mood manifestations in four classical syndroms: Epilepsy, stroke, Parkinson's disease and multiple sclerosis.
Subject(s)
Epilepsy/psychology , Mental Disorders/physiopathology , Multiple Sclerosis/psychology , Parkinson Disease/psychology , Epilepsy/physiopathology , Humans , Multiple Sclerosis/physiopathology , Parkinson Disease/physiopathologyABSTRACT
A variety of behavioral disorders occurring abruptly in patients with Parkinson's disease (PD) has been recently published and attracted considerable attention in the press. Taking the form of pathological gambling, compulsive shopping, addiction to Internet and to other recreational activities, hypersexuality or bulimia, impulse control disorders (ICD) related to PD are probably more frequent than previously appreciated and may have consequences as spectacular as disastrous for the involved patients. ICD are currently viewed as particular adverse reactions to antiparkinsonian medications, notably to dopamine agonists, and, accordingly, tend to improve or disappear when PD therapy is appropriately adjusted.
Subject(s)
Disruptive, Impulse Control, and Conduct Disorders/psychology , Parkinson Disease/psychology , Adult , Humans , Male , Middle AgedABSTRACT
It has been suggested that hysteria had waned and was an old-fashioned, stigmatizing and false concept, reflecting the incapacity of the medical community to establish a diagnosis in certain situations. Nowadays, however, those disturbances, now referred to as conversion or dissociative disorders, still remain a frequent and incapacitating condition that every clinician faces. These past decades, several studies have tried to better describe their clinical presentation and their neurobiological mechanisms, with the help of the development of new neuroimaging techniques. If the neurobiological correlates are now better understood, efficient treatments are still lacking and only a multidisciplinary (general practitioners, neurologists and psychiatrists) and individually-tailored therapy might be beneficial to the patients.
Subject(s)
Hysteria/physiopathology , Hysteria/psychology , Brain/physiopathology , Conversion Disorder/physiopathology , Conversion Disorder/psychology , Dissociative Disorders/physiopathology , Dissociative Disorders/psychology , HumansABSTRACT
Major depression IMD) is highly prevalent in the general hospital and adds a considerable burden to affected patients, but remains under detected and under treated. In an attempt to improve this situation, existing guidelines on MD were retrieved, systematically evaluated with the instrument AGREE (Appraisal of guidelines for research and evaluation), and adapted to the needs of the general hospital. These guidelines were made available on intranet, and actively implemented in two wards, where their impact on clinical practice was evaluated.
Subject(s)
Depressive Disorder, Major/diagnosis , Depressive Disorder, Major/therapy , Algorithms , Humans , Practice Guidelines as Topic , Program Evaluation , Referral and Consultation , SwitzerlandABSTRACT
OBJECTIVE: To investigate the association between early depressive behavior after stroke onset and occurrence of poststroke depression (PSD) at 3- and 12-month follow-up evaluations. METHODS: The study prospectively included 273 patients with first-ever single uncomplicated ischemic stroke. In the stroke unit, nurses scored crying, overt sadness, and apathy daily using an observational method to include patients with comprehension deficits. The Barthel Index was used to assess disability. Follow-up evaluation at months 3 and 12 included psychiatric assessment based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. RESULTS: Crying (19.8%), overt sadness (50.5%), and apathy (47.6%) were observed. Of the patients observed crying, 4 showed pathologic crying, 19 emotionalism, and 12 catastrophic reactions. Crying and overt sadness, but not apathy, were associated with a subjective experience of depression (p < 0.05). Thirty of 52 (58%) patients observed crying, 12 of 19 (63%) patients with emotionalism, and 5 of 12 (41%) patients with catastrophic reactions developed PSD within the first year. Multiple logistic regression analysis showed that only severe functional disability (odds ratio [OR], 4.31; 95% CI, 2.41 to 7.69), crying behaviors (OR, 2.66; 95% CI, 1.35 to 5.27), and an age <68 years (OR, 2.32; 95% CI, 1.30 to 4.13) were (p < 0.05) predictors of late PSD development (13% of the variance). CONCLUSIONS: In the stroke unit, crying and overt sadness are more reliable indicators of depressed mood than apathy. In patients with first-ever stroke, crying behaviors soon after stroke, a younger age, and severe disability are predictors of poststroke depression occurrence within the first year after stroke onset.
Subject(s)
Brain Ischemia/psychology , Depression/etiology , Aged , Aged, 80 and over , Comprehension , Depression/epidemiology , Emotions , Female , Humans , Incidence , Male , Middle Aged , Predictive Value of Tests , Prospective Studies , Risk Factors , TearsABSTRACT
The authors observed a high rate of suicide (6/140 patients, 4.3%) in a large cohort of patients with movement disorders treated with deep brain stimulation (DBS). Apparent risk factors included a previous history of severe depression and multiple successive DBS surgeries, whereas there was no relationship with the underlying condition, DBS target, electrical parameters, or modifications of treatment. Paradoxically, all patients experienced an excellent motor outcome following the procedure. The authors propose that patients at high risk for suicide should be excluded from DBS surgery.
Subject(s)
Deep Brain Stimulation , Movement Disorders/therapy , Suicide , Adult , Aged , Cohort Studies , Comorbidity , Depression/epidemiology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Movement Disorders/psychology , Patient Selection , Prevalence , Remission Induction , Retrospective Studies , Risk FactorsABSTRACT
A series of 24 consecutive PD patients were prospectively studied prior to and within 6 months postoperatively for mood, motor, and cognitive status to investigate the effects on mood of subthalamic deep brain stimulation (DBS) in PD. In six patients (25%), mood state worsened significantly, and three were transiently suicidal despite clear motor improvement. Caregivers and patients should be educated about the potential impact of this neurosurgical procedure on mood.
Subject(s)
Affect , Electric Stimulation Therapy/adverse effects , Parkinson Disease/therapy , Subthalamic Nucleus/physiology , Adult , Aged , Cognition , Depression/etiology , Female , Humans , Male , Middle Aged , Parkinson Disease/psychology , Prospective Studies , Psychomotor PerformanceABSTRACT
Our objective in this study was to summarize the relevant knowledge on depression in palliative care and to provide a framework for clinical, scientific and educational efforts at improving its management. The Research Steering Committee (RSC) of the European Association of Palliative Care (EAPC) established an Expert Working Group (EWG) to address the issue of depression in palliative care. Each invited expert was allocated a specific topic and was asked to review the literature. These reviews were presented during the Sixth Congress of the EAPC in 1999 and then discussed in a closed meeting with members of the RSC. Based on these reviews, and the discussions that followed their presentation, a first draft of the paper was produced and circulated among the invited experts and members of the RSC who had been present at the meetings. After some debate the manuscript was revised, and a second draft was circulated, this time also to RSC members who had not attended the meetings. All persons consulted have agreed on this final version of the report. The EWG concluded that the current level of evidence did not lend itself to the development of clinical guidelines and decided to publish the results of their work as a pragmatic report. The report is divided into four sections, focusing on detection, training and nonpharmacological and pharmacological treatment of depression in palliative care. For each of these sections, general considerations are addressed on the basis of the literature review and of clinical experience and a short description of unresolved issues and recommendations is provided. Underdetection and undertreatment of depression is a serious problem in palliative care. Training of the nonpsychiatric staff should therefore have the highest priority. A proactive, flexible and comprehensive strategy embracing clinical, scientific, and educational aspects is advocated.
Subject(s)
Depression/diagnosis , Depression/therapy , Neoplasms/psychology , Palliative Care , Europe , Humans , Inservice Training , Neoplasms/therapy , Patient Care Team/organization & administration , Practice Guidelines as Topic , Societies, MedicalABSTRACT
Besides benzodiazepine, antidepressant and neuroleptic agents, all of which have established roles in supportive care, other psychotropic drugs deserve consideration in selected conditions affecting patients with advanced cancer. This article briefly reviews relevant aspects of miscellaneous psychotropics available for secondline treatment, including nonbenzodiazepine sedative, hypnotic and anxiolytic drugs, anaesthetic agents, stimulants, and analgesic adjuvants acting on the central nervous system. The proper use of such subsidiary psychotropic agents requires that both their specificities and the particular characteristics of palliative care patients are taken into account.
Subject(s)
Central Nervous System Depressants/therapeutic use , Neoplasms/complications , Pain/drug therapy , Palliative Care/methods , Psychotropic Drugs/therapeutic use , Sleep Wake Disorders/drug therapy , Anti-Anxiety Agents/therapeutic use , Central Nervous System Stimulants/therapeutic use , Humans , Neoplasms/psychologyABSTRACT
This review covers pharmacokinetics, adverse effects and drug interactions of antidepressants and the indications for them, with the aim of assisting the clinician working in palliative and supportive care in the prescription of such drugs. Practical considerations and decision trees to be used prior to the prescription of an antidepressant are also part of this review. Special emphasis is put on the management of depression, which is frequent in patients with advanced cancer and often remains underdetected and undertreated, or is treated at a stage when there is little time for medication to have an effect.
Subject(s)
Antidepressive Agents/therapeutic use , Depressive Disorder/drug therapy , Neoplasms/complications , Neoplasms/psychology , Antidepressive Agents/adverse effects , Antidepressive Agents/pharmacokinetics , Depressive Disorder/etiology , Humans , Pain/complications , Pain/psychology , Palliative Care , Practice Guidelines as Topic , Quality of LifeABSTRACT
OBJECTIVE: Although genetic factors have been implicated in the etiology of bipolar disorder, no specific gene has been conclusively identified. Given the link between abnormalities in serotonergic neurotransmission and bipolar disorder, a candidate gene association approach was applied to study the involvement of the monoamine oxidase A (MAOA) gene, which codes for a catabolic enzyme of serotonin, in the susceptibility to bipolar disorder. METHOD: In France and Switzerland, 272 patients with bipolar disorder and 122 healthy subjects were typed for three polymorphic markers of the MAOA gene: the MAOA-CA repeat, the MAOA restriction fragment length polymorphism (RFLP), and a repeat directly adjacent to the variable number of tandem repeats (VNTR) locus. RESULTS: A significant difference in the distribution of the alleles for the MAOA-CA repeat was observed between the female bipolar patients and comparison group. CONCLUSIONS: The results obtained in the French and Swiss population confirm findings from two studies conducted in the United Kingdom.
Subject(s)
Bipolar Disorder/enzymology , Bipolar Disorder/genetics , Monoamine Oxidase/genetics , Polymorphism, Genetic , Adult , Alleles , Female , Genetic Markers , Genotype , Humans , Male , Middle Aged , Monoamine Oxidase/metabolism , Polymerase Chain Reaction , Polymorphism, Restriction Fragment Length , Psychiatric Status Rating Scales/statistics & numerical data , Sex Factors , Tandem Repeat SequencesABSTRACT
Neuroleptics are frequently used in patients with advanced cancer. Most relevant and practical aspects of their use in supportive cancer care are reviewed, to assist the clinical oncologist and palliative care specialist when prescribing these drugs. This article reviews pharmacological properties, indications, such as delirium, nausea and vomiting, pain, anxiety and other symptoms, adverse effects, and drug interactions of neuroleptics and compares the profiles of different compounds. Special emphasis is put on the role of neuroleptics in the management of delirium.
Subject(s)
Antipsychotic Agents/therapeutic use , Delirium/drug therapy , Neoplasms/psychology , Palliative Care , Psychotropic Drugs/therapeutic use , Antipsychotic Agents/adverse effects , Antipsychotic Agents/pharmacology , Drug Interactions , Humans , Psychotropic Drugs/adverse effects , Psychotropic Drugs/pharmacologyABSTRACT
Benzodiazepines are widely utilized in the cancer setting. Most aspects relevant to their use in supportive care are reviewed to assist the clinical oncologist in prescribing such drugs. This review covers pharmacokinetics, indications, adverse effects and drug interactions, and compares the profiles of different benzodiazepines. Finally, controversial issues with regard to benzodiazepines are discussed.
Subject(s)
Anti-Anxiety Agents/therapeutic use , Neoplasms/psychology , Anti-Anxiety Agents/adverse effects , Anti-Anxiety Agents/pharmacokinetics , Behavior Therapy , Benzodiazepines , Central Nervous System Depressants/adverse effects , Drug Interactions , GABA Modulators/pharmacokinetics , Humans , Neoplasms/therapy , Stress, Psychological/drug therapy , Stress, Psychological/therapy , Substance Withdrawal Syndrome/etiologyABSTRACT
The National Institute of Mental Health developed the semi-structured Diagnostic Interview for Genetic Studies (DIGS) for the assessment of major mood and psychotic disorders and their spectrum conditions. The DIGS was translated into French in a collaborative effort of investigators from sites in France and Switzerland. Inter-rater and test-retest reliability of the French version have been established in a clinical sample in Lausanne. Excellent inter-rater reliability was found for schizophrenia, bipolar disorder, major depression, and unipolar schizoaffective disorder while fair inter-rater reliability was demonstrated for bipolar schizoaffective disorder. Using a six-week test-retest interval, reliability for all diagnoses was found to be fair to good with the exception of bipolar schizoaffective disorder. The lower test-retest reliability was the result of a relatively long test-retest interval that favored incomplete symptom recall. In order to increase reliability for lifetime diagnoses in persons not currently affected, best-estimate procedures using additional sources of diagnostic information such as medical records and reports from relatives should supplement DIGS information in family-genetic studies. Within such a procedure, the DIGS appears to be a useful part of data collection for genetic studies on major mood disorders and schizophrenia in French-speaking populations.
Subject(s)
Genetic Testing/methods , Mood Disorders/diagnosis , Psychiatric Status Rating Scales/standards , Psychotic Disorders/diagnosis , Schizophrenia/diagnosis , Adolescent , Adult , Aged , Diagnosis, Differential , Female , France , Humans , Language , Male , Middle Aged , Observer Variation , Reproducibility of ResultsABSTRACT
A 2-year-old Siberian polecat (Mustela eversmanni) from a breeding colony presented for ultrasound evaluation for pregnancy. It was paired with a male for 2.75 months and had remained absent of pregnancy signs when it was anesthetized and clinically evaluated. Until this time, the animal had eaten well and shown no outward signs of debility. On palpation, the animal had a fluid-filled tubular structure in the caudal abdomen, consistent in location and size with the uterus. No sign of vaginal discharge was present. Ultrasonography revealed 10 fluid-filled evaginations (approximately 12 mm in diameter) of the uterine horns. A presumptive diagnosis of a fluid-filled reproductive tract and likely reproductive failure was made in light of the animal's history, its clinical signs, and the ultrasound findings. Euthanasia was performed because the animal was nonreproductive and might yield information relevant to the breeding colony as a whole. Necropsy of the polecat revealed a distended fluctuant uterus containing mildly odiferous, thick, yellow-green, purulent material. Histopathology confirmed the diagnosis of pyometra. A pure and heavy growth of Enterococcus fecalis was cultured from the uterine contents. In light of results from routine minimal inhibitory concentration antibiotic sensitivity screening, this isolate was resistant to all antibiotics tested in the standard teaching hospital screen.