The use of metaphors by the "ambulatory inpatients" of the managed care era.

An important effect of managed care is keeping partially decompensated patients out of the hospital, for this is the single most decisive factor in cutting the costs of psychiatric services. It is proposed that discharging sicker patients from inpatient units and denying admission to poorly compensated patients poses new challenges to their outpatient therapists. This calls for new, refined psychotherapeutic skills, especially around the development of a therapeutic alliance. Patient communications in the form of metaphors may help the clinician understand the patient's conflicts while avoiding excessive anxiety that might accompany more direct communications. Recognizing the meaning of the metaphor and working with it can keep the patient from regressing and assist in the formation of a therapeutic alliance. This statement is examined in a number of clinical examples. The similarities and differences between metaphors and dreams, symptoms, and the transference are discussed.

A highly successful and novel model for treatment of chronic painful diabetic peripheral neuropathy.

OBJECTIVE: To investigate why, in spite of a vast variety of treatment agents, the alleviation of pain in patients with diabetic neuropathy is difficult. Previous studies have not used a treatment algorithm based on anatomic site and neuropathophysiological source of the neuropathic pain. RESEARCH DESIGN AND METHODS: A model that categorizes the types of pain into three groups (superficial, deep, and muscular) was applied in 75 diabetic patients with chronic (> 12 mo) painful distal symmetrical polyneuropathy in a controlled case series. Twenty-two patients were untreated and 53 patients were treated with imipramine +/- mexiletine for deep pain, capsaicin for superficial pain, and stretching exercises and metaxalone +/- piroxican for muscular pain. Each type of pain was scored separately on a scale of 0 (none) to 19 (worst), and the total of all three types was used as an index of overall pain. Ability to sleep through the night was scored by a scale of 1 (never) to 5 (always). RESULTS: No significant differences were observed in initial pain scores, sleep scores, demographics, biochemistries, or physical findings between the two groups. After 3 mo a significant improvement in scores was noted in the treated but not the untreated patients. In addition, a significant difference was found in the change of scores between the treated and untreated patients: total pain (-18 +/- 2 vs. 0 +/- 2), deep pain (-7 +/- 1 vs. 0 +/- 1), superficial pain (-5 +/- 1 vs. 0 +/- 1), muscular pain (-6 +/- 1 vs. 0 +/- 1), and sleep (1.2 +/- 0.2 vs. 0.2 +/- 0.2), all P < 0.0001. In treated patients 21% became pain-free (total pain < 2), 66% had improvement (decrease in total pain > 5, but not total elimination of painful symptoms), and 13% were considered treatment failures (a decrease in total pain of < or = 5). This compares with 0 (P < 0.02), 10 (P < 0.0001), and 90% (P < 0.0001), respectively, in the untreated patients. CONCLUSIONS: This study presents a new rationale and hypothesis for the successful treatment of chronic painful diabetic peripheral neuropathy. It uniquely bases the treatment algorithm on the types and sources of the pain.

Effect of parasitism by Cotesia congregata on the susceptibility of Manduca sexta larvae to bacterial infection.

Eggs and larvae of the braconid Cotesia congregata are not encapsulated within the hemocoel of their habitual host, Manduca sexta. Experiments were performed to evaluate the status of antibacterial defensive responses in M. sexta larvae parasitized by this gregarious endoparasitoid. Previous investigations have shown that immunologically naive, nonparasitized M. sexta larvae are resistant to infection by Pseudomonas aeruginosa. Studies using naive, parasitized larvae demonstrated that inoculation with 10 colony forming units of P. aeruginosa 9027, one hour after oviposition, resulted in greater than 90% host mortality. Examination of the fate of P. aeruginosa and Escherichia coli injected into parasitized larvae suggested that the cellular antibacterial defenses of the host, nodule formation, and phagocytosis, were impaired.

The psychiatric uses of cold wet sheet packs.

The cold wet sheet pack is a treatment that is seldom discussed anymore. The authors present results of a national survey which demonstrated that this treatment is rarely used in modern American psychiatry. They retrospectively review its recent use for 46 hospitalized psychiatric patients and conclude that the treatment is safe and has interesting and useful effects that go beyond the concept of simple restraint. Further study of treatment with cold wet sheet packs is recommended before it disappears altogether.

Dyskinesias associated with lithium therapy in parkinsonism.

Five patients with the "on-off" phenomenon of parkinsonism who developed dyskinesias associated with a reduction in akinesia during treatment with lithium carbonate are described. The data show that lithium-induced dyskinesias may occur in the absence of lithium neurotoxicity and at normal serum lithium concentrations. These observations are interpreted in the context of recent evidence that indicates that lithium may "stabilize" dopaminergic and cholinergic receptor sensitivity.

Treatment of the "on-off" phenomenon in Parkinsonism with lithium carbonate.

Six patients with severe parkinsonism complicated by the "on-off" phenomenon were treated with lithium carbonate in addition to regular antiparkinson medications. A randomized double-blind crossover trial of lithium versus placebo was conducted, followed by an open trial of lithium therapy. Five patients had markedly reductions in akinesia (mean, 70%) and improved by one grade in Parkinson staging. This result was more striking in male than in female patients, and in all responders benefit has been maintained during the open phase of lithium treatment (mean follow-up of 36 weeks). In no patient was a reduction in akinesia observed during placebo treatment. Lithium carbonate appears to offer a new and potentially effective approach to treatment of the on-off phenomenon.