Clinical management of neuroleptic malignant syndrome.

Neuroleptic malignant syndrome (NMS) continues to be an unpredictable and rare, but potentially fatal complication of antipsychotic medications. Presumptively linked to dopamine blockade, it nonetheless occurs in patients receiving newer atypical antipsychotics. The features of NMS, its pathophysiology, differential diagnosis, clinical course, risk factors, and morbidity and mortality are reviewed. Nonpharmacologic management centers on aggressive supportive care including vigilant nursing, physical therapy, cooling, rehydration, anticoagulation. Pharmacologic interventions include immediate discontinuation of antipsychotics, judicious use of anticholinergics, and adjunctive benzodiazepines. The utility of specific agents in actively treating NMS is reviewed. Bromocriptine and other dopaminergic drugs and dantrolene sodium have alternatively been considered without merit or efficacious. Guidelines for using these agents are presented. Electroconvulsive therapy, also somewhat controversial, is identified as a second line of treatment. Finally, management of the post-NMS patient is also reviewed.

Pregnancy during psychiatry residency : a study of attitudes.

Fifty-eight residents at two training sites at Cornell University Medical College responded to our questionnaire on attitudes toward pregnant peers. Male respondents were more likely than female respondents to believe that pregnancy interfered with work performance and to anticipate personal inconvenience from a peer's pregnancy. When residents of each gender were asked to estimate the opposite gender's responses to the same questions, men more accurately hypothesized what their female peers would say. Women overestimated the degree of negative male responses and underestimated male willingness to provide special considerations such as schedule changes for their pregnant colleagues.

Trait-state artifacts and the diagnosis of personality disorders.

The multiaxial nature of DSM-III has stimulated interest in the personality disorders. There are also indications that it has produced an increase in their diagnosis. However, there is clinical and psychometric evidence that a personality evaluation undertaken while a patient is in a dysphoric mental state may distort or misrepresent traits, the so-called trait-state problem in personality assessment. The present study appears to be the first to investigate this phenomenon with a clinical interview rather than with personality tests. It examined the effect of anxiety, depression, and level of global impairment on the diagnosis of personality disorder and the assessment of the criteria for the individual Axis II disorders. Eighty-four patients, most of whom had current Axis I diagnoses, were evaluated by seven experienced clinicians with a new semistructured interview, the Personality Disorder Examination. The sample evidenced a trend toward acknowledging fewer maladaptive personality traits at follow-up than at entry. There was no evidence, however, that anxiety or depression had affected either the diagnosis of a personality disorder or the criteria associated with most of the individual personality disorders.

Weaning and depression: another postpartum complication.

The dramatic endocrinologic changes that occur after childbirth and the coincident affective disturbances that range from "maternity blues" to major depression have stimulated much theorizing and some study. The role of breast-feeding and weaning has received remarkably little attention both in the more biologically oriented studies and in epidemiologic work. This paper reviews endocrinologic data which support the thesis that postpartum psychiatric disorders have a hormonal basis and discusses the possible psychiatric effects of breast-feeding and weaning. The cases of four patients who developed major depressions in close temporal association with weaning are presented and discussed.

Recurrence of neuroleptic malignant syndrome.

Presumptive risk factors for recurrence of neuroleptic malignant syndrome (NMS) and clinical evidence for its pathogenesis are discussed. All earlier reports describing patients who have had NMS and who were either safely restarted on neuroleptic or who developed recurrence are reviewed. The authors also present their own experiences with both outcomes. Possible risk factors for recurrent NMS are administration of high-potency neuroleptics and reintroduction of neuroleptics before the initial episode of NMS has completely resolved. Bipolar disorder and concomitant use of lithium may predispose to NMS and therefore could also heighten the risk of recurrence.

Reinduction of neuroleptic malignant syndrome by lithium.

The psychopharmacologic management of psychotic patients who have had neuroleptic malignant syndrome poses a dilemma for clinicians. Neuroleptic malignant syndrome can recur when neuroleptics are readministered, but there are equal numbers of reports of safe resumption of neuroleptic treatment in patients who have had the syndrome. In an effort to avoid reexposure to neuroleptics, the authors treated two bipolar patients who were clinically recovered from episodes of neuroleptic malignant syndrome with lithium alone. Both patients rapidly developed recurrent neuroleptic malignant syndrome after only 300 and 1,200 mg of lithium, respectively. Possible pathogenetic mechanisms are reviewed, although a definitive explanation for such a sudden and dramatic toxic effect is not available.

Neuroleptic malignant syndrome: review and analysis of 115 cases.

Neuroleptic malignant syndrome is a potentially fatal consequence of neuroleptic use that has recently gained wide attention. In this article the authors critically review the previous literature and analyze all case reports in the English-language literature (115 cases) for 43 variables. The results are discussed in light of prior literature, and recommendations are made for future research.

ECT as a treatment alternative for patients with symptoms of neuroleptic malignant syndrome.

The use of ECT as a treatment alternative in a clinical situation in which it is difficult to determine whether the patient is suffering from neuroleptic malignant syndrome (NMS) or an evolving catatonic state is investigated. Fourteen cases from the literature are reviewed and 3 new cases are presented. In 6 cases, ECT was rapidly effective in treating symptoms of NMS, but cardiac arrhythmias were reported in 4 cases. There was no evidence of malignant hyperthermia (MH) in patients receiving succinylcholine, suggesting that an association between NMS and MH may not be clinically relevant in patients being treated with ECT.

Symptoms of neuroleptic malignant syndrome in 82 consecutive inpatients.

This study, a retrospective chart review of 82 consecutive male inpatients, assessed the spectrum and prevalence of neuroleptic malignant syndrome. The prevalence of diagnosed neuroleptic malignant syndrome (2.4%) was greater than that generally reported. Eight additional patients manifested symptoms that abated without cessation of neuroleptic treatment. This suggests that neuroleptic malignant syndrome is a spectrum disorder that has milder variants. Affective illness may be a risk factor for its development.