Anxiety in patients with multiple sclerosis.

Anxiety disorders are quite common, and frequently overlooked, in patients with Multiple Sclerosis (MS). This is often due to the difficulty differentiating anxiety from personality correlates or reactive tendencies in patients with neurologic disease. This chapter offers the consulting psychiatrist guidelines for providing psychological support to patients with MS at various stages of their disease. DSM-IV-based differential diagnosis, psychotherapeutic techniques, behavioral interventions, and pharmacological support (including the newer alternative therapies) are reviewed. The physical, functional, and symbolic losses caused by this chronic and progressive disease are considered in the broader context of individual patients' lives. Particular attention has been given to specific pharmacological treatment of steroid-induced anxiety. This is essential knowledge for the consulting psychiatrist. The overlap between depressive symptoms, manic symptoms and cognitive changes in MS patients is reviewed with special emphasis on the structural correlates. Current neuro-imaging techniques, including emerging technologies such as gadolinium enhancement, single photon emission computed tomography and brain electrical mapping (BEAM), now provide a far more accurate view of brain damage in MS. This permits diagnosis of the disease much earlier, and is also beginning to show correlation between neuropsychiatric clinical findings, and the nature and location of demyelinating plaques in the brains of MS patients. This chapter seeks to clearly define the associations between anxiety disorders and cerebral involvement in MS patients, suggesting that common neurological and biochemical mechanisms are more extensive than generally suspected. It is hoped that this information will aid clinicians in more accurately diagnosing and effectively treating anxiety in MS patients.

Organ donation. Psychiatric, social, and ethical considerations.

The authors examine the issues of solid cadaveric and living organ donation, taking into account the psychological, legal, and ethical issues of donating an organ. Future recommendations for increasing organ donations are made.

EEG in liver transplantation: visual and computerized analysis.

We prospectively evaluated 40 liver transplant candidates (including 28 recipients) with visually scored or computerized EEG. As expected, EEG frequencies rose significantly after successful transplant (P < 0.01). For all subjects, but especially for the transplant recipients, higher frequencies on computerized EEG at baseline had a strong association with survival at 18 months (P < 0.001). A logistic regression model allowed estimation of the odds for survival and indicated less than 50% long-term survival with central-occipital mean frequencies below 7.6 c/sec. Visual EEG scores closely paralleled the quantitative results, but only the latter were amenable to formal statistical analysis. EEG had much stronger predictive value for survival than serum albumin, although albumin improved more significantly in the months after transplantation.

Quality-of-life changes and psychiatric and neurocognitive outcome after heart and liver transplantation.

A prospective study compared psychiatric, neurocognitive, and quality-of-life changes of heart and liver transplant patients. The 51 heart and 61 liver transplant candidates and recipients completed the Beck depression inventory (BDI), state-trait anxiety inventory (STAI), sickness impact profile (SIP), mini-mental state (MMS), California verbal learning test (CVLT), Wisconsin card sorting test (WCST), trailmaking test (TMT), and the impact message inventory (IMI). Data were gathered before transplant and at 3-month intervals for up to 1 year after transplant. Psychometric tests scores were correlated with electroencephalograms for the liver patients. Both groups showed significant improvements after transplant in neurocognitive functioning, depressive symptoms, and quality of life.

Terminal cardiomyopathy, splitting, and borderline personality organization.

A 63-year-old married man with idiopathic terminal cardiomyopathy was admitted to the medical service for treatment of advanced heart failure. A psychiatric consultation was requested to assist the medical treatment team in dealing with the patient's abusive behavior. The case is presented and discussed within the context of understanding the borderline personality in the medical setting.

Psychogenic fugue states: a review.

In this paper we review psychologic theories on the development of fugue states, as well as organic causes of the disorder and the history of its diagnostic classification from DSM-I through DSM-III-R. We believe the diagnostic criterion that requires the patient to assume a new identity as part of the overall psychogenic fugue state should be reevaluated, since change of identity is not a consistent aspect of the syndrome as described in the psychiatric literature.

Evaluation and treatment of paranoid syndromes in the elderly: a review.

Paranoid symptoms in the elderly patient may be a manifestation of medical, neurologic, psychiatric, or medication-induced illness. Because of the potential for multiple interacting factors between underlying organicity and psychiatric illness precise assessment of the etiology of the patient's psychotic behavior may be difficult. This article reviews the medical and neurologic illnesses often associated with paranoia in the elderly as well as the psychiatric differential diagnosis. Psychotic depression, late-onset schizophrenia, and delusional/paranoid disorders are examined, as are their treatments. Revisions in the nosology of late-onset psychosis as they are affected by revisions in DSM-III-R are also discussed.