Factitious disorder (Munchausen's syndrome).

Factitious disorder, often referred to as Munchausen's syndrome, is a condition in which sufferers present to healthcare professionals seeking investigation and treatment for signs and symptoms that they have consciously fabricated for no obvious reason. Factitious presentations have been described all over the world, in every medical specialty and in every age group, yet by its very nature factitious disorder is difficult to study. There is therefore a dearth of evidence in the literature relating to epidemiology, aetiology and therapeutics. The disorder is notoriously difficult to recognise in clinical practice and there are as yet no definitive treatment options available. This article provides a brief overview of the literature before offering guidance on the diagnosis and management of factitious disorder presenting in the general hospital. It also considers fabricated or induced illness, also known as Munchausen's syndrome by proxy.

Structural MRI of the brain in presumed carriers of genes for schizophrenia, their affected and unaffected siblings.

BACKGROUND: Schizophrenia is a highly heritable disorder associated with structural brain abnormalities. The aim of this study was to establish if the gene(s) for schizophrenia are associated with specific abnormalities of brain structure. SUBJECTS: Six sibships from multiple affected families were recruited. Each sibship consisted of one patient with schizophrenia, one "obligate carrier" without the disorder but with an affected child, and one "non-affected non-carrier". Such sibships are very rare, but present a powerful opportunity to separate the associations of genotype and phenotype. Obligates presumably have the gene(s) but not the disorder, affected siblings have both, whereas non-affected non-carrier siblings have neither. METHOD: Brain MRI was conducted with a semiautomated region of interest analysis. The risk of false positive findings was reduced by collapsing brain regions and sides into five regions and comparing groups by repeated measures analysis of variance. RESULTS: In terms of whole brain volumes and volumes of cortical structures, obligates resembled their non-affected non-carrier siblings, both groups having significantly greater volumes than their schizophrenic siblings (p=0.01 and p=0.04). Obligates also had significantly smaller ventricles than their schizophrenic siblings (p=0.03). However, with respect to the amygdalohippocampal complex, the obligates' brains resembled those of their schizophrenic siblings, both groups showing a significant reduction in volume when compared with their non-affected non-carrier siblings (p=0.001). CONCLUSIONS: In the families studied, reductions in volumes of cortical structures and reductions in whole brain volume seem to be associated with the phenotype of schizophrenia. By contrast, reduced volume of the amygdalohippocampal complex seems to be associated with genetic risk for the disorder even in the absence of disease.

Diffusion tensor imaging (DTI) and proton magnetic resonance spectroscopy (1H MRS) in schizophrenic subjects and normal controls.

Several proton magnetic resonance spectroscopy (1H MRS) studies in schizophrenia have found reduced N-acetyl aspartate (NAA) concentrations in pre-frontal and temporal regions of the brain. Reductions in NAA may reflect abnormalities of neuronal structure (e.g. reduced neuronal density or viability) or abnormalities of neuronal function. Diffusion tensor imaging (DTI) measures diffusion anisotropy, an indicator of the structural integrity of a neuronal tract. Both techniques were used to examine the anatomical basis of pre-frontal dysfunction in schizophrenia. Ten patients with DSM-IV schizophrenia were compared with 10 healthy controls. 1H MRS and DTI were performed on a clinical MR system and analysed with a region of interest approach. NAA concentrations and diffusion anisotropy were measured in the same pre-frontal white matter region. Diffusion anisotropy was also measured in a control region (occipital white matter). 1H MRS revealed non-significant but consistently reduced NAA concentrations (by 10-15%) in the pre-frontal white matter in schizophrenic subjects. Diffusion anisotropy measures revealed no such differences between schizophrenics and controls. It is concluded that the abnormalities of 'connectivity' reported in brain-imaging studies of schizophrenia may not be attributable to structural abnormalities of white matter and that reduced NAA in the pre-frontal white matter may reflect abnormal function of structurally intact neurons.

Should the treatment of schizophrenia include old antipsychotic drugs?

Clozapine, although not suitable as a first-line drug, is superior to all other antipsychotics in terms of minimizing positive symptoms, reducing side effects, and treating treatment-resistant patients. There is little evidence that other newer drugs share these benefits. For certain patients it is not difficult to justify, on clinical grounds, the additional cost of prescribing clozapine. The case for prescribing one of the other newer drugs in preference to a traditional antipsychotic is often less clear-cut. Traditional antipsychotics clearly still have a role in the treatment of schizophrenia and they remain the authors' preferred choice of first-line therapy.

Pathways to psychiatric admission: a study of 100 consecutive admissions to south Glasgow acute adult psychiatric wards.

OBJECTIVE: To examine routes of admission to psychiatric beds and to identify factors that influence this. DESIGN: Retrospective casenote study. SETTINGS: Acute adult psychiatric wards in South Glasgow. SUBJECTS: One hundred consecutive admissions over a one month period. RESULTS: There were twelve discrete sources of referral. Psychiatrists and Community Psychiatric Nurses (CPNs) together accounted for 32% of referrals and General Practitioners for 25%. Schizophreniform and mood disorders affected 34% and 31% of the patients respectively whilst 25% of those admitted were deemed to have no major mental illness. Twenty-seven percent of patients were admitted to an inappropriate ward because the appropriate ward was full: personality disorders and drug problems were statistically significantly over represented amongst these "boarders". Over 80% of patients were admitted by the on-call psychiatric SHO rather than by a doctor from their own team. Only 32% of admissions occurred during office hours. Psychiatrists and CPNs were significantly less reliant upon emergency admission procedures than were other referrers. The pathway to admission was independent of patient's sex, diagnosis, legal status, previous contact with services and of ward location. Community-based psychiatrists and CPNs admitted relatively fewer patients with schizophrenia than did their hospital-based colleagues. CONCLUSION: Patients are referred for admission to acute psychiatric wards from a variety of sources. Most admissions occur outwith office hours. In a large majority of cases the admitting psychiatrist is the on-call SHO, rather than a doctor from the team responsible for the patient's management. Our data suggest that this is not a reflection of the type of cases referred for urgent assessment but rather a failure of certain aspects of service provision.

In vivo transfer of bacterial marker genes results in differing levels of gene expression and tumor progression in immunocompetent and immunodeficient mice.

To optimize gene delivery for the treatment of malignant mesothelioma, expression of the beta-galactosidase marker gene was examined in a murine model of intraperitoneal malignant mesothelioma. The beta-galactosidase gene was delivered to the peritoneal cavity of tumor-bearing mice by various plasmid-liposome complexes or by replication-incompetent retrovirus, used alone or complexed to liposomes. In tumor samples from immunodeficient nude mice, moderate levels of gene expression were achieved by liposome-complexed plasmids. Retroviral gene delivery was more effective, and was increased nearly 10-fold by complexing the retrovirus to liposomes. In contrast, in tumor samples from immunocompetent CBA mice treated with the same vectors, no marker gene expression was detected. In immunodeficient mice, tumor growth was not affected by beta-galactosidase gene transfer. However, immunocompetent mice showed a significant decrease in tumor size and increase in survival time after beta-galactosidase delivery. Induction of cytotoxic T cells capable of lysing beta-Gal-transfected tumor cells suggests that tumor cells transduced with the bacterial beta-galactosidase gene may be eliminated in immunocompetent hosts. Our findings also indicate that plasmid-liposome complexes, which achieve a low level of gene expression, and retrovirus-liposome complexes, which result in nearly 100 times higher levels of gene expression in tumor cells in vivo, are similarly effective in inducing an antitumor immune response.