The classification of conversion disorder (functional neurologic symptom disorder) in ICD and DSM.

The name given to functional neurologic symptoms has evolved over time in the different editions of the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM), reflecting a gradual move away from an etiologic conception rooted in hysterical conversion to an empiric phenomenologic one, emphasizing the central role of the neurologic examination and testing in demonstrating that the symptoms are incompatible with recognized neurologic disease pathophysiology, or are internally inconsistent.

Psychosocial assessment of living organ donors: clinical and ethical considerations.

This article outlines psychosocial and ethical issues to be considered when evaluating potential living organ donors. Six types of living donors are described: genetically related, emotionally related, "Good Samaritan" (both directed and nondirected), vendors, and organ exchangers. The primary domains to be assessed in the psychosocial evaluation are informed consent, motivation for donating and the decision-making process, adequacy of support (financial and social), behavioral and psychological health, and the donor-recipient relationship. Obstacles to the evaluation process include impression management, overt deception, minimization of behavioral risk factors, and cultural and language differences between the donor and the evaluator. Ethical concerns, such as the right to donate, donor autonomy, freedom from coercion, nonmaleficence and beneficence in donor selection, conflicts of interest, "reasonable" risks to donors, and recipient decision making are also explored. To fully evaluate living organ donation, studying psychosocial as well as medical outcomes is crucial.

The use of psychotropics in the medically ill.

Underlying medical illness may present a challenge when prescribing psychotropic medications. Disease-related changes in pharmacokinetics and pharmacodynamics, as well as vulnerability to side effects, polypharmacy, and potential drug interactions are all important considerations. Successful treatment of psychiatric disorders may have a beneficial impact on medical morbidity and mortality, as well as quality of life. This article reviews the relevant considerations when using psychotropic medications in six major medical populations (cardiac, cerebral vascular, pulmonary, liver, renal, and seizure disorders).

Neuroleptic malignant syndrome: a review.

OBJECTIVE: Neuroleptic malignant syndrome is an uncommon side effect of antipsychotic medications characterized by severe rigidity, tremor, fever, altered mental status, autonomic dysfunction, and elevated serum creatinine phosphokinase and white blood cell count. This paper presents a concise and comprehensive review of neuroleptic malignant syndrome, written with the practitioner in mind, to provide information that will be useful in actual clinical settings. METHODS: MEDLINE was searched from 1966 to 1997 for key reviews, reports on series of cases of neuroleptic malignant syndrome, individual case reports, and other clinically and theoretically important information. RESULTS AND CONCLUSIONS: Virtually all neuroleptics are capable of inducing the syndrome, including the newer atypical antipsychotics. The standard of care for the recognition of neuroleptic malignant syndrome has shifted considerably over the past 15 years. Neuroleptic malignant syndrome belongs in the differential diagnosis of any patient receiving a neuroleptic who develops a high fever or severe rigidity. In addition to measurement of creatinine phosphokinase and white blood cell count, important tests to rule out other etiologies include urinalysis to measure electrolytes, including calcium and magnesium; kidney, liver, and thyroid function tests; lumbar puncture; an electroencephalogram; and a computed tomography or magnetic resonance imaging scan of the head. Although specific treatment remains controversial, supportive treatment such as antipyretics, a cooling blanket, and intravenous fluids to correct dehydration and electrolyte abnormalities is critical and widely supported by consensus. Most patients recover from neuroleptic malignant syndrome in two to 14 days without any cognitive impairment, and new dysfunction usually is attributable to very high fever, hypoxia, or other complications, rather than neuroleptic malignant syndrome per se.

Abbreviated cognitive test for delirium.

The cognitive test for delirium (CTD) was recently developed to identify delirium in an intensive care unit (ICU) setting. Stepwise discriminant analyses using the original validation sample indicated that a total score formed by summing only two of the nine content scores (visual attention span and recognition memory for pictures) maintained good reliability (coefficient alpha = 0.79) and the ability to discriminate delirium from dementia, schizophrenia, and depression (p < 0.0001) and delirium from moderate to severe dementia (p < 0.0002). This abbreviated version of the CTD is more practical for use by ICU clinicians.

Validation of a cognitive test for delirium in medical ICU patients.

Patients with delirium, dementia, depression, and schizophrenia were administered a newly developed test designed to identify delirium in an intensive care unit (ICU) setting. Two alternate forms of the Cognitive Test for Delirium (CTD) were highly correlated. The delirium patients performed least well, and an optimal cutoff score derived from relative-operating characteristic analysis resulted in a sensitivity of 100% and a specificity of 95%. In a follow-up study, the Mini-Mental State Exam could not be administered to 42% of the ICU patients who completed the CTD. Early identification of delirium with the CTD may lead to timely treatment of specific etiologic conditions and a reduction in mortality and morbidity.

Rating scales for the psychosocial evaluation of organ transplant candidates. Comparison of the PACT and TERS with bone marrow transplant patients.

Two scaled formats for summarizing the results of psychosocial evaluations of transplant candidates have been published, the Psychosocial Assessment of Candidates for Transplantation (PACT) and the Transplant Evaluation Rating Scale (TERS). In this study, 40 consecutive candidates for bone marrow transplant were rated on the PACT and TERS. The PACT and TERS were comparable in interrater reliability. Similar conceptual items for each scale correlated fairly highly with one another. The PACT and TERS differ in several scale characteristics. The authors discuss the relationship between scale characteristics and clinical utility.

Psychosocial assessment of organ transplant candidates. Current status of methodological and philosophical issues.

Psychosocial assessments of candidates for organ transplant surgery are conducted to ascertain that potential patients are likely to benefit from the surgery through adequate coping, good compliance, and commitment to rehabilitation. Such assessments must be based on a realistic analysis of the behavioral demands of the transplant patient's role. Reliability of psychosocial assessments has been established within some programs, but wide discrepancies in the psychosocial criteria that are used exist among transplant centers. Validation studies are needed, with particular emphasis on outcomes for the patient and family as a whole, that go beyond the question of mere survival.

Controversial decisions regarding treatment and DNR: an algorithmic Guide for the Uncertain in Decision-Making Ethics (GUIDE).

We describe an algorithm to aid clinicians in making ethical decisions regarding interventions. Logically sequenced questions about competency, advance directives, treatment benefit, and patient and family preferences guide the decision maker to nine specific scenarios. Each scenario includes guidelines for action based on legal and ethical consensus.