Deep brain stimulation of the ventral internal capsule/ventral striatum for obsessive-compulsive disorder: worldwide experience.

Psychiatric neurosurgery teams in the United States and Europe have studied deep brain stimulation (DBS) of the ventral anterior limb of the internal capsule and adjacent ventral striatum (VC/VS) for severe and highly treatment-resistant obsessive-compulsive disorder. Four groups have collaborated most closely, in small-scale studies, over the past 8 years. First to begin was Leuven/Antwerp, followed by Butler Hospital/Brown Medical School, the Cleveland Clinic and most recently the University of Florida. These centers used comparable patient selection criteria and surgical targeting. Targeting, but not selection, evolved during this period. Here, we present combined long-term results of those studies, which reveal clinically significant symptom reductions and functional improvement in about two-thirds of patients. DBS was well tolerated overall and adverse effects were overwhelmingly transient. Results generally improved for patients implanted more recently, suggesting a 'learning curve' both within and across centers. This is well known from the development of DBS for movement disorders. The main factor accounting for these gains appears to be the refinement of the implantation site. Initially, an anterior-posterior location based on anterior capsulotomy lesions was used. In an attempt to improve results, more posterior sites were investigated resulting in the current target, at the junction of the anterior capsule, anterior commissure and posterior ventral striatum. Clinical results suggest that neural networks relevant to therapeutic improvement might be modulated more effectively at a more posterior target. Taken together, these data show that the procedure can be successfully implemented by dedicated interdisciplinary teams, and support its therapeutic promise.

Panic disorder in primary care: a cause of unexplained symptoms.

Patients with panic disorder often believe they are suffering a myocardial infarction or another life-threatening illness. The history and physical examination and a few tests usually suffice to diagnose this disorder, which is treatable with behavioral therapy, antidepressants, and benzodiazepines.

New antidepressants: more options for tailoring treatment.

Newer antidepressant drugs cause fewer, less-severe side effects and therefore usually elicit better patient compliance than do older drugs. The newer drugs have slightly differing mechanisms of action and effects and thus offer additional options for tailoring treatment to the individual patient. Yet they are not completely innocuous and can cause serious drug interactions.

Psychiatric effects and psychoactive substance use in anabolic-androgenic steroid users.

The purpose of this study was to assess the psychiatric effects of anabolic-androgenic steroid (AAS) use and assess the frequency of other psychoactive substance use in a population of AAS users compared with non-AAS-using weight-lifter controls. One hundred sixty-four subjects were administered a demographic survey, including psychiatric history, substance use history, AAS use history, and medical history. Psychiatric diagnoses were made and psychological testing was performed. User categories were determined by history and urine testing. The user categories did not differ significantly on psychological testing. Past AAS users had a higher incidence of psychiatric diagnosis than the nonuser and current user groups. Hypomania was correlated with AAS use, and major depression with AAS discontinuation. Present psychoactive substance abuse or dependence was relatively low across all user categories. AAS dependence was seen in 12.9% of current users and 15.2% of past users of AAS. In conclusion, AAS use may lead to psychiatric disorders in certain individuals. Concurrent use of psychoactive drugs other than AAS does not appear to be common in intensively training weight lifters and bodybuilders.

The use of fluoxetine in depression associated with anabolic steroid withdrawal: a case series.

BACKGROUND: Depression can result from the discontinuation of high-dose anabolic steroids. Whether this type of depression responds to antidepressants in a manner similar to other types of depression is not clear. METHOD: Four patients suffering from anabolic steroid withdrawal depression were treated with fluoxetine. RESULTS: All four patients responded to fluoxetine in a time course consistent with the response of major depression to antidepressant medications. CONCLUSION: Because of the widespread use of anabolic steroids, this type of depression may be more common than realized. Anabolic steroid withdrawal depression should be treated with antidepressant medications. Further study is encouraged.

Ophthalmologic effects of psychotropic medications.

This article reviews the effects of psychotropic medications on the eye. Although some of these effects have been known for years, they have been largely ignored by psychiatrists. The ophthalmologic effects of antidepressants, neuroleptics, benzodiazepines, carbamazepine, and lithium in therapeutic doses and overdose are reviewed and their implications discussed. Recommendations are made for appropriate monitoring, treatment, and ophthalmologic referral of patients on these medications.

Successful treatment of acquired Tourettism and major depression.

The authors report a successfully treated case of an 81-year-old man with acquired Tourettism and secondary depression. Organic causes of acquired Tourettism are reviewed and treatment strategies are discussed.

Blunting of TSH response to TRH in chronic cocaine and phencyclidine abusers.

The TRH stimulation test was administered to 10 cocaine and 10 phencyclidine abusers as well as to 10 controls. No subjects had clinical evidence of depression. Significantly more blunting of the response of TSH to TRH was shown in cocaine and phencyclidine abusers compared with that seen in controls. No significant differences in blunting of response were seen between the cocaine and phencyclidine groups.

Enterococcal bacteremia in two large community teaching hospitals.

This report reviews 55 episodes of enterococcal bacteremia at two large community teaching hospitals. Fifty-eight percent of the patients were older than 60 years, and 84 percent of the patients had some underlying illness. The most common sources of bacteremia were the urinary tract (24 percent), cutaneous wound infection (11 percent), and intra-abdominal infection (11 percent). Five patients had enterococcal endocarditis. Antimicrobial therapy in the week preceding enterococcal bacteremia (42 percent) and polymicrobial bacteremia (38 percent) were common. Despite the institution of appropriate antimicrobial therapy in 75 percent of the patients (41 of 55 patients), the overall mortality rate was 44 percent. Male sex and the presence of a rapidly or ultimately fatal underlying illness were the only factors that showed a statistical tendency toward adversely influencing the mortality risk in enterococcal bacteremia.

Treatment of depression in chronic cocaine and phencyclidine abuse with desipramine.

An open field trial was conducted comparing desipramine and an active placebo in separate populations of chronic cocaine and phencyclidine (PCP) abusers, who discontinued their abuse. Subjects who received desipramine showed a decrease in depressive symptoms after a 20-40 day period regardless of whether they abused PCP or cocaine.

The serotonin irritation syndrome--a new clinical entity?

The literature on the possible existence of a "serotonin irritation syndrome" is examined. This syndrome is an anxiety state occurring in the presence of elevated levels of atmospheric or ambient cations and is associated with elevated central and peripheral serotonin levels. Investigation of these cations' effects on microbes, insects, and mammals, including humans, shows a disruption of normal activity. It is suggested that clinicians become acquainted with the potential relationship between cation exposure and serotonin in their treatment of anxious patients. Further research exploring the etiology and diagnostic definition of this entity is urged.

Comparison of chlorpromazine, haloperidol and pimozide in the treatment of phencyclidine psychosis: DA-2 receptor specificity.

Three neuroleptics were used to treat phencyclidine (PCP) psychosis. These included chlorpromazine, a DA-1 and DA-2 dopamine antagonist with noradrenergic effects; haloperidol, a predominantly DA-2 antagonist with noradrenergic effects; and pimozide a predominantly DA-2 antagonist with no noradrenergic activity. Three cohorts of randomly selected young white adult males were studied. Responses to haloperidol and pimozide were statistically equivalent and both were significantly superior to chlorpromazine. These results further support the role of the DA-2 receptor in PCP psychosis and tend to rule out a noradrenergic role. The authors therefore suggest that DA-2 blockers, such as haloperidol or pimozide be employed as treatment of choice in PCP psychosis.