Intravenous Ketamine Exacerbating Symptoms of Acute Stress Disorder: A Case Report and Systematized Review of Existing Literature.

BACKGROUND: Ketamine is an anesthetic and analgesic known for its psychotomimetic properties, such as dissociation and altered perception. Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are characterized by unwanted memories, intrusive thoughts, and dissociative flashbacks following an acute traumatic event. It is unknown how analgesic ketamine affects the symptomatology of ASD when administered to patients in the posttraumatic period. OBJECTIVE AND METHODS: In this article, we present the case of a 26-year-old man who sustained gunshot wounds and developed worsened ASD after receiving analgesic ketamine. We also present a review of the current literature on peritraumatic ketamine and its subsequent effect on ASD and PTSD. RESULTS: In 2 out of 3 articles examining ketamine and ASD, ketamine was associated with worsened symptomatology of ASD. There were 6 articles examining ketamine and PTSD. In 1 of 6 articles, ketamine was associated with increased incidence and/or severity of PTSD, and in 2 of 6, it was associated with decreased incidence and/or severity of PTSD. There was no relationship between ketamine and subsequent PTSD in 3 of 6 articles. CONCLUSION: We conclude that ketamine's psychotomimetic properties may exacerbate the dissociative and perceptual symptoms of ASD, but its long-term effects on PTSD are still unclear. In patients with preexisting ASD, the potential risks and benefits of using analgesic ketamine must be weighed carefully.

Psychotropic Medication Effects on Seizure Threshold and Seizure Duration During Electroconvulsive Therapy Stimulus Titration.

OBJECTIVES: Decisions about psychotropic medication administration before electroconvulsive therapy (ECT) are central to management of a very psychiatrically ill patient population. Given that many psychotropic medications are thought to either promote or prevent seizures, there is ongoing concern about concurrent psychotropic medication and ECT administration. This study examined the effect of psychotropic medications on seizure threshold and duration during ECT stimulus titration. METHODS: The study sample consisted of 550 patients receiving ECT stimulus titration at a single site during a 27-month period. Systematic chart review provided clinical data, including patients' demographics, psychiatric diagnoses, medications administered in the 48 hours before ECT, and information on the ECT procedure. Referring psychiatrists were advised to discontinue lithium before ECT but otherwise managed psychotropic medications as clinically indicated. A fixed charge titration schedule was used to estimate seizure threshold. Electroconvulsive therapy motor seizure duration was estimated by the cuff method, and electroencephalogram seizure duration was estimated by review of a 2-lead strip. RESULTS: Administration of psychotropic medications, including benzodiazepines, antiepileptics, selective serotonin reuptake inhibitors, tricyclic and tetracyclic antidepressants, bupropion, and stimulants, was not associated with seizure threshold as estimated by electrical charge eliciting a generalized seizure or duration during the initial ECT titration. Tricyclic and tetracyclic antidepressant dosage was associated with seizure threshold. CONCLUSIONS: Psychotropic medications may have little effect on seizure threshold and duration during titration of electrical dose at ECT initiation. Integrating this work with other literature supports making recommendations for medication discontinuation before ECT on an individual basis.

Anthrax Exposure, Belief in Exposure, and Postanthrax Symptoms Among Survivors of a Bioterrorist Attack on Capitol Hill.

BACKGROUND: Following chemical, biological, radiological, and nuclear disasters, medically unexplained symptoms have been observed among unexposed persons. OBJECTIVES: This study examined belief in exposure in relation to postdisaster symptoms in a volunteer sample of 137 congressional workers after the 2001 anthrax attacks on Capitol Hill. METHODS: Postdisaster symptoms, belief in exposure, and actual exposure status were obtained through structured diagnostic interviews and self-reported presence in offices officially designated as exposed through environmental sampling. Multivariate models were tested for associations of number of postdisaster symptoms with exposure and belief in exposure, controlling for sex and use of antibiotics. RESULTS: The sample was divided into 3 main subgroups: exposed, 41%; unexposed but believed they were exposed, 17%; and unexposed and did not believe that they were exposed, 42%. Nearly two-thirds (64%) of the volunteers reported experiencing symptoms after the anthrax attacks. Belief in anthrax exposure was significantly associated with the number of ear/nose/throat, musculoskeletal, and all physical symptoms. No significant associations were found between anthrax exposure and the number of postdisaster symptoms. CONCLUSIONS: Given the high incidence of these symptoms, these data suggest that even in the absence of physical injury or illness, there may be surges in health care utilization. (Disaster Med Public Health Preparedness. 2019;13:555-560).

Deficits in self-awareness impact the diagnosis of asymptomatic neurocognitive impairment in HIV.

A recent national survey of HIV(+) adults noted that nearly three-quarters of cognitively impaired individuals are categorized as having asymptomatic neurocognitive impairment (ANI), lacking documented compromise of everyday function. The clinical impact and long-term consequences of ANI are unknown and the importance of this asymptomatic diagnosis has raised concerns in clinical care settings where competing priorities often exist. In this study, we conducted structured tests of everyday functioning in a sample of HIV(+) subjects over 60 years of age and asked subjects to rate their performance relative to peers. We demonstrate that individuals with neuropsychological testing impairment often lack self-awareness of functional performance deficits. Specifically, ANI subjects rated functional performance similar to that of HIV-negative control subjects, despite noted deficits in objective measures of function. These findings have important implications for use of self-report of function in the diagnosis of HIV-associated neurocognitive disorders (HAND), likely underestimating symptomatic impairment.

Screening for cognitive impairment in human immunodeficiency virus.

Recent publications estimate the prevalence of human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) exceeds 50%, and this rate is likely higher among older patients. Cognitive impairment may impact medication adherence, and symptomatic impairment has been linked to all-cause mortality providing some impetus for early detection. There are currently insufficient data to inform solid recommendations on screening methods. Most HIV-specific tools have poor performance characteristics for all but the most severe form of impairment, which accounts for <5% of cases. Reliance on symptoms is likely to miss a substantial proportion of individuals with HAND due to poor insight, confounding mood disturbances, and lack of well-informed proxies. In the aging HIV-positive population, broader screening tools may be required to allow sensitivity for both HIV and neurodegenerative disorders. We describe the clinical presentation of HAND, review existing data related to screening tools, and provide preliminary and practical recommendations in the absence of more definitive studies.

Current HIV therapeutics: mechanistic and chemical determinants of toxicity.

This review discusses current recommendations for initial therapy in HIV-infected individuals and the toxicity of certain components of these therapeutic regimens. In developed regions, therapy is headed in a direction of individualized treatment where AIDS can be converted into a treatable, chronic disease that is characterized by viral loads below assay detection levels. In developing nations, where sophisticated diagnostics are less applicable, treatment continues on a population basis. Because nucleoside reverse transcriptase inhibitors remain a cornerstone of current recommended regimens both in developed and developing regions, the mechanistic and chemical determinants of mitochondrial toxicity are highlighted and discussed in detail.