Werner's syndrome (adult progeria): an affected mother and son presenting with resistant psychosis.

Age-related psychotic conditions may be studied by focusing on the unique group of progeroid syndromes. This report will focus on Werner's syndrome, one of the better defined and studied progeroid syndromes. We applied clinical and histophysiological evaluations to two patients, a mother and son, suffering from Werner's syndrome. Both patients presented with resistant psychosis and evidence of impaired cellular repair mechanisms. Psychiatric morbidity in Werner's syndrome is rarely reported. This syndrome can serve as a possible model for aging-associated development of psychosis.

Survey of patient satisfaction in adult psychiatric outpatient clinics.

A client satisfaction survey was undertaken in two adult psychiatric outpatient clinics. The anonymous self-report questionnaire covering demographic, setting and satisfaction with service variables was endorsed by 203 participants. The mean age of the subjects was 42.5 +/- 19 years, with a small majority (58.6%) of females. Overall satisfaction with psychiatric care was high (79.8%). None of the demographic or setting variables correlated significantly with satisfaction. Psychoeducation was significantly correlated with level of satisfaction with services. These findings further emphasize the importance of psychoeducation by service providers in mental health.

Is selectivity for serotonin uptake associated with a reduced emergence of manic episodes in depressed patients?

To determine whether selectivity for serotonin reuptake plays a role in antidepressant-associated mania (AAM), we evaluated the frequency of treatment-emergent mania in patients with unipolar depression who received either citalopram, a highly selective serotonin uptake inhibitor, or the adrenergic tetracyclic antidepressants (TTCAs) maproriline and mianserin, or placebo. Data were collected from post-marketing reports of adverse events, three placebo-controlled trials and four double-blind comparative trials. Of the total 4,004 depressed patients treated with citalopram (2482 from postmarketing data, 840 from placebo-controlled studies and 682 from TTCAs comparative studies), 25 (0.62%) had manic episodes. The rate of AAM in the comparative trials was significantly lower in the citalopram-treated patients (1/682, 0.15%) than in the TTCA-treated patients (5/389, 1.29%) (P = 0.03). In the placebo-controlled studies, no manic episodes were reported in the patients given placebo, but one manic episode occurred in a citalopram-treated patient (1/840, 0.12%). The citalopram-treated patients in whom AAM developed were significantly older than those in whom it did not (about 10 years, P < 0.001); gender distribution was similar. In conclusion, despite its limitations, our study apparently indicates that citalopram, a highly selective serotonin reuptake inhibitor, is associated with a significantly lower rate of treatment-emergent manic episodes than TTCAs, which have noradrenergic activity, but a similar rate to that reported for less selective SSRIs.

hKCa3/KCNN3 potassium channel gene: association of longer CAG repeats with schizophrenia in Israeli Ashkenazi Jews, expression in human tissues and localization to chromosome 1q21.

We demonstrate a significant association between longer CAG repeats in the hKCa3/KCNN3 calcium-activated potassium channel gene and schizophrenia in Israeli Ashkenazi Jews. We genotyped alleles from 84 Israeli Jewish patients with schizophrenia and from 102 matched controls. The overall allele frequency distribution is significantly different in patients vs controls (P = 0.00017, Wilcoxon Rank Sum test), with patients showing greater lengths of the CAG repeat. Northern blots reveal substantial levels of approximately 9 kb and approximately 13 kb hKCa3/KCNN3transcripts in brain, striated muscle, spleen and lymph nodes. Within the brain, hKCa3/KCNN3transcripts are most abundantly expressed in the substantia nigra, lesser amounts are detected in the basal ganglia, amygdala, hippocampus and subthalamic nuclei, while little is seen in the cerebral cortex, cerebellum and thalamus. In situ hybridization reveals abundant hKCa3/KCNN3 message localized within the substantia nigra and ventral tegmental area, and along the distributions of dopaminergic neurons from these regions into the nigrostriatal and mesolimbic pathways. FISH analysis shows that hKCa3/KCNN3 is located on chromosome 1q21.

Autistic subjects with comorbid epilepsy: a possible association with viral infections.

This study evaluates the comorbidity of epilepsy as a variable supporting a viral hypothesis in Autism. Data covering a 30-year period (1960-1989), including general population live births, autistic births, and incidence of viral encephalitis and viral meningitis, were collected for Israel. 290 autistic births were evaluated. The annual birth pattern of subjects with comorbid epilepsy fit the seasonality of viral meningitis. These findings support the role of viral C.N.S. infections in the causality of this disorder.

Antidepressant-associated mania: a study of anxiety disorders patients.

Antidepressants are related to the emergence of manic and hypomanic episodes in mood disorder patients. This study examined whether antidepressant-associated manic states are also present in anxiety disorder patients, so that this phenomenon may be defined as a side-effect. A total of 167 consecutive patients at a specialized outpatient clinic, suffering from anxiety disorders and treated by antidepressants, were assessed in a blind, retrospective chart review. Five patients (2.99%) were identified as having suffered an episode of antidepressant-associated mania within 3 months of initiation of treatment. All were females and all had an axis II diagnosis of a cluster B personality disorder. Antidepressant-associated mania appears to be related to risk factors such as personality disorder, even in non-mood disorder patients, tentatively suggesting that it is not simply an adverse event but rather a reflection of an underlying psychopathology.

Forensic psychiatric service in Israel: ten years experience in an in-patient hospital unit.

In 1991 legislators revised the Mental Health Act in Israel, placing responsibility for forensic psychiatric evaluations with the district psychiatrist. The aim of the present paper is to describe the changing patterns of the forensic service in Israel's largest psychiatric hospital in the light of changing legislation. In the last 15 years a psychiatric forensic team provided evaluations both in an ambulatory clinic and a special in-patient ward. All medical records of subjects referred for forensic evaluations between 1982-1992 were re-examined. Demographic, forensic and psychiatric data were recorded. During this period the service experience a 15% increase in the number of evaluations. The team tended to prefer ambulatory evaluations. During the latter part of the period studied more referrals were with a previous criminal record and less with a history of mental disorders. An increase in drug and sex crimes was noted with a corresponding decrease in property and financial offences.

Police attitudes toward mental illness and psychiatric patients in Israel.

The attitude of the public toward mental illness and toward psychiatric patients raises a serious and sensitive issue that indirectly affects the development of community mental health services. Most citizens feel that there is an association between mental illness and dangerous or violent behavior. Studies undertaken among police personnel in the 1970s demonstrated that their attitudes were similar to those of the general public in Israel. The objective of the present study was to assess the attitudes of police officers toward mental illness and psychiatric patients by means of a self-report questionnaire. Ninety-three policemen from five police stations within the Y. Abarbanel Mental Health Center catchment area participated in the study. All were young males (average age 32.1 years) and 75 percent had a high school education or higher. More than half (54.5%) had personally known a psychiatric patient in the past, and 20.4 percent of the police personnel graded mental illness as the severest form of disease in medicine. A minority (14.3%) of policemen agreed with the statement: "A psychiatric hospital should be fenced and manned by guards." One-third did not know whether psychiatric patients are dangerous. We conclude that training of police officers is called for to effect changes in their misconceptions about psychiatric patients. Psychoeducation may lead to improved handling by the police of incidents involving the mentally ill.

First night effect in depression: new data and a new approach.

Polysomnography was performed in 20 depressed patients and 8 normal controls for 2 consecutive nights. A subset of patients had 3 consecutive nights. Patients were assigned to groups according to the presence (group I) or absence (group II) of a first night effect (REM sleep latency on the first night in the laboratory was at least 30 min longer than on the second night). The groups were equivalent with regard to gender distribution, age, and severity of depression. In group I, REM sleep latency on nights 2 and 3 was significantly shorter than in group II. REM sleep percentage on the second night in group I was increased compared to the first night. A shift of REM sleep to the first cycle was prominent on the first night only in patients with a first night effect. On average, delta sleep was preserved in group I compared to group II. We suggest that the first night effect reflects a physiological system with greater capacity to respond adaptively and to preserve homeostasis when confronted with environmental stressors.

REM sleep in depressed patients: different attempts to achieve adaptation.

Twenty-seven depressed patients and 10 healthy subjects were investigated in the sleep laboratory during two to three consecutive nights. Eleven of the 27 patients demonstrated the "first night effect" (group I) and 11 other patients demonstrated a clear absence of the "first night effect" (group II). Five of the 27 depressed patients were omitted from the study because they did not fit criteria for first night effect. The 10 healthy controls demonstrated a first night effect. In group I, the duration of the first rapid eye movement (REM) sleep episode was increased on the first night and on the second night the REM sleep latency was decreased, whereas REM sleep duration and eye movement (EM) density was increased. The number of the short sleep cycles (less than 40 minutes) was greater in group I versus group II and the percentage of slow-wave sleep (SWS) was also higher in group I. In depressed patients with the "first night effect" the enhanced REM sleep requirement is satisfied not only by an increased REM sleep duration but also by the improved REM sleep quality that is crucial for adaptation. The adaptive role of the increased first REM period and the increased EM density in this period is very limited.

Side effect profile of azathioprine in the treatment of chronic schizophrenic patients.

Various findings suggest auto-immune changes in schizophrenia. We have recently demonstrated that platelets from schizophrenic patients bear autoantibodies (PAA) which cross-react with brain antigens. Accordingly, treatment of schizophrenia with an immunosuppressant might be of potential benefit. In a recent case study, a chronic schizophrenic patient treated with azathioprine has demonstrated a clear psychiatric improvement preceded by a decrease in PAA level. A phase I study designed for assessing side-effects of short-term azathioprine treatment in a group of schizophrenic patients is described here. From a group of 40 chronic non-responsive patients, 14 patients demonstrating high PAA level have entered the study and 11 have complied all along. Two groups were tested in parallel. In the first (6 patients) 150 mg/day was given for 7 weeks while in the second (5 patients) the same regimen was given for two periods of 7 weeks with an interval of 6 weeks. Blood biochemistry and cell count, as well as determination of PAA were carried out weekly, starting 3 weeks before the trial and continuing up to 7 weeks after the treatment. Two out of 11 patients developed leucopenia in week 4. No other side-effects were recorded in any of the patients. A substantial reduction in PAA was observed in 3 out of 6 patients in group I and 4 out of 5 in group II. Two patients showed improvement of psychiatric symptomatology. Our results demonstrate that short-term azathioprine treatment induces transient leucopenia in 18% of the patients receiving the drug, much alike the percentage reported for other patient populations.

Medicated chronic schizophrenic patients do not demonstrate left turning asymmetry.

Twenty-seven medicated chronic schizophrenic female patients were tested for right or left turning behavior. No substantial right or left asymmetry was found, nor did the addition of the indirect dopaminergic agonist amantadine influence these results. Previous studies demonstrated left circling preference in chronic unmedicated schizophrenics and it seems that this previous finding is abolished by neuroleptic treatment. However, our patients were all females and further research with a heterogenous group of schizophrenic patients is needed.

The views of psychiatric patients and their treating physicians of court-ordered compulsory hospitalization for criminal acts.

The legal responsibility for the mentally ill has long been a dilemma. Public opinion regarding the law which states that the mentally ill, in a psychotic state, are not responsible for their actions, is divided. The study assessed 30 psychiatric patients, committed by court order, following a criminal act on their part. No relationship was found between the nature of their offense and a psychiatric disorder. Patients who committed more serious crimes, such as murder, tended to have committed fewer criminal acts in the past. Sixty-nine percent of the patients think that the mentally ill are not responsible for their actions and 59% agreed with the judge's decision to hospitalize them. On a concrete level, over two-thirds of the patients were able to distinguish right from wrong. The treating physicians related mainly to the patients' illnesses rather than to the crimes for which they were committed.

Acute neuroleptic induced leukopenia in Ethiopian jews with benign familial leukopenia.

Benign familial leukopenia (BFL) has been described in various ethnic groups around the world; in Israel it is found among Yemenites and Ethiopians. Neuroleptics infrequently cause acute leukopenia. We described nine Ethiopian subjects who were treated with conventional antipsychotics for four weeks. In three subjects probable BFL was demonstrated prior to treatment. By the end of four weeks of treatment 6/9 subjects developed leukopenia with neutropenia. Reduction in mean WBC counts and neutrophil counts was significant (p=0.014 and p=0.001, respectively).None of the subjects developed an acute illness or an infection during the studied period. We tentatively suggest that in subjects belonging to ethnic groups where BFL is common antipsychotics may induce its expression without significant clinical symptomatology.

Hepatitis among psychiatric inpatients: a high-risk group?

Viral hepatitis B (HBV) and C (HCV) have been reported to be prevalent among residents of custodial institutions and health-care workers. Among psychiatric inpatients sparse research was undertaken and results are controversial. We designed the present study to evaluate rates of HBV and HCV among psychiatric inpatients and to characterize the "typical" carriers. All newly admitted patients to the Y. Abarbanel Mental Health Center who were judged by the admitting psychiatrist to be at high-risk underwent laboratory tests for acute and chronic HBV and/or HCV. The period covered in the present study was from January 1993 to December 1995. Inclusion in the high-risk group was based on one (or more) of the following: history of blood transfusion; I.V. drug abuse; homosexuality; promiscuous sexuality; prostitution; positive HIV test. Of 1327 newly admitted patients, 121 (9.1%) were clinically judged to be at risk. Of these 42 (34.7%) were positive for HBV (37/42) or HCV (5/42). The mean age among infected patients was 37.1+11.6 years; the majority were males (30/42) and the most frequent psychiatric illness was schizophrenia (24/42). In more than half (26/42) of the infected patients the clinical judgement of risk was promiscuous sexuality.Although as a group psychiatric patients newly admitted for treatment do not seem to constitute high risk for HBC and/or HCV carries, sexual promiscuosity should prompt psychiatrists to test for possible hepatitis infections in order to reduce risk to other inpatients and staff.

Depression and anxiety as a single disorder: evidence from brain stem auditory evoked potentials.

Anxiety and depression are often interlinked as demonstrated by clinical, epidemiological, psychopharmacological and even genetic studies. However, robust biochemical and electrophysiological evidence for linkage or separation of mood and anxiety disorders is scarce. Brain stem auditory evoked potentials (BASEP) can easily and non-invasivly be measured in psychiatric patients and reflect neurophysiological processes in the brain stem. The aim of the present study was to evaluate BASEP in drug-free patients suffering from panic disorder or major depression and to compare these to healthy controls. Patients (n = 26; panic = 16, depression = 10) were diagnosed according to Diagnostic and Statistical Manual (DSM)-III-R criteria assessed by the Hamilton Anxiety and Hamilton Depression Scales, and all underwent 3 weeks of medications washout. All subjects (n = 36) completed the study. N3 latency was decreased in the patient group (P < 0.05), N3-5 interval was lengthened (P < 0.05), the N3 latency correlated with anxiety scores and depression scores correlated with the N3 and N5 latency periods. In conclusion, our small sample demonstrated shared electrophysiological variables in panic disorder and depression, further supporting the concept of spectrum disorder.

Word associative production in affective versus schizophrenic psychoses.

The production of association word to stimulus words, which was found to be correlated with conceptual disorganization, as clinically measured by the Brief Psychiatric Rating Scale, was developed as a quantifiable measure of formal thought disorder. Associative word production in patients with affective psychoses (acute episodes of mania or schizoaffective disorder) was found to be higher in a statistically significant manner than in patients with acute episode of paranoid schizophrenia. The production of associative words in the two groups of acutely psychotic patients was significantly higher than in normal subjects, unipolar depressed, or residual schizophrenic patients. These quantitative differences reflected qualitative differences in the pattern of the production of word associations. Indeed, while patients with paranoid schizophrenia showed a sinusoidal-like type of oscillation in associative word production, patients with affective psychoses were characterized by exponential-like phases in associative word production. Associative word production may thus serve as a simple quantitative test for differentiating formal thought disorder in acute psychoses between patients with mania and patients with schizophrenia.

Maintaining schizophrenic patients on benzodiazepines.

The role of benzodiazepines (BZDs) in the treatment of schizophrenia is widely researched since the sixties. Nevertheless the role of BZD's as sole agents for the maintainance phase in pharmacotherapy of schizophrenic patients received little attention. We have conducted a retrospective review of all medical records of ambulatory schizophrenic patients in an out-patient setting receiving only BZD maintainance treatment. Three factors characterized these patients: long duration of illness, few hospitalizations and a relatively low dose response to BZD's.

Psychiatric hospitalization of senile and arteriosclerotic dementia patients by commitment order under the 1991 Israeli Mental Health Act.

Data regarding commitment orders issued by district psychiatrists for elderly patients aged 65 years or older were obtained from the national psychiatric case register. Out of a total of 2,284 commitment orders issued in Israel in the period 1 January 1992 to 30 June 1993 under the 1991 Mental Health Act, 191 (8.3%) involved patients aged 65 and over; these orders were issued for the commitment of 169 patients who suffered from the following ICD-9-CM diagnoses on discharge: senile and arteriosclerotic dementia; transient organic psychotic conditions; schizophrenic disorders; affective psychoses; paranoid states; or other psychiatric disorders. Demographic and clinical characteristics of the senile and arteriosclerotic dementia patients were compared with the same variables in the other diagnostic categories. Results showed that (a) involuntary commitment of senile and arteriosclerotic dementia patients involved a small minority of dementia sufferers; (b) it was usually the patients' first psychiatric admission; (c) most of the patients were discharged within a one-month period; and (d) most of the patients were referred for continuation of treatment in non-psychiatric institutions. Findings (c) and (d) characterized other diagnostic categories as well. The relevance of these findings to the Mental Health Act is discussed.