Modulation of dental anxiety--the role of past experiences, psychopathologic traits and individual attachment patterns.

OBJECTIVE: To evaluate factors affecting modulation of dental anxiety among adults. METHODS: A total of 183 adult members of a closed communal society (Kibbutz), who have been treated since childhood only by the dentists employed in their community, were investigated concerning their past and present dental anxiety, evaluation of their past and present dentists, psychopathologic symptoms and individual pattern of attachment. RESULTS: The best predictor of subjects' evaluation of their present dental anxiety was the scale of anxiety as recorded by the SCL-90R questionnaire. The best predictors of the decrease in subjects' dental anxiety over time were the evaluation of their past and present dentists and the secure and avoidant patterns of attachment. Patterns of attachment (avoidant and ambivalent) were the best predictors of subjects' evaluation of their present dentist. CONCLUSIONS: While psychopathologic traits are involved in subjects' present dental anxiety, pattern of attachment may have a dominant affect as to whether anxiety persists throughout life or can be modulated through a corrective emotional experience.

The patient's right to know, in the 1996 Israel law for the rights of the patient: the pains of progress.

The 1996 Israel Law for Patients' Rights, Sections 21 and 22, introduces to the field of health legislation two new entities: internal examination committees and quality-control committees. The former are to be established when there is a need to investigate unusual, irregular or exceptional events related to diagnosis and/or treatment. Furthermore, the 1996 Law directs the internal examination committee to reveal its findings to the patient or to his representatives. This approach has evoked strong controversy up until the present time. On the other hand, the quality-control committees which produce privileged information have been smoothly integrated into psychiatric practice. This paper presents the history of the creation of these two committees based on law, and examines their effect on the daily practice of medicine and the reaction of the physicians' guild to their activation. It also discusses the effect of the implementation of these committees on the level of mutual trust between therapist and patient, and on medical morality and its relationship to the social phenomenon known as defensive medicine. Feasible solutions for controversial issues are presented. These include participation of patients or their representatives in the internal examination committees, privileged peer reviews, increased utilization of quality control committees and of ethics committees.

Elevated serum creatine kinase activity in adolescent psychiatric inpatients on admission.

Studies in adults have indicated a significant relationship between high serum creatine kinase levels on admission and acute psychosis. However, data on children are sparse. The files of 183 hospitalized children and adolescents (93 boys, 90 girls) with severe psychiatric disorders were reviewed for serum creatine kinase activity on admission, psychomotor agitation, Clinical Global Impression Score, need for intramuscular injection, number of neuroleptic medications and presence of neuroleptic malignant syndrome. Serum creatine kinase levels > 201 IU/ml were considered abnormal. Boys had significantly higher creatine kinase activity than girls. Division of the cohort by diagnosis yielded significantly higher levels in those with schizophrenia, affective disorders and mental retardation. Higher levels were also associated with higher Clinical Global Impression score on admission, use of injections and physical restraint, and nonresponse to neuroleptic medication. There were no cases of neuroleptic malignant syndrome. This first large-scale investigation of serum creatine kinase activity in young psychiatric inpatients shows a significant association between high creatine kinase activity and acute psychosis, similar to that in adults. Furthermore, high creatine kinase levels on admission are predictive of the severity of the psychosis, but are not associated with neuroleptic malignant syndrome. Because psychotic adolescents with high admission creatine kinase levels tend to be nonresponders, clinicians should consider the early use of atypical antipsychotics in this subgroup.

Reduction in serotonin 5HT2 receptor binding on platelets of delinquent adolescents.

The possible involvement of serotonin receptors of the 5HT2 type in aggressive behavior was studied in juvenile delinquents. A group of 28 delinquent adolescents (13-18 years old) who had committed violent crimes was compared with a group of age matched controls. Subjects were drug and medication free during the study. 5HT2 receptors were labeled on platelet membranes using tritiated ketanserin. Receptor binding in the delinquent adolescents was significantly lower than in age matched controls. Mean +/- SD of 76 controls was 32.3 +/- 14.2 fm/mg, compared to 16.6 +/- 8.2 fm/mg in 28 delinquents (P < 0.002, Student's t-test). These results support a role for serotonin in general and 5HT2 receptors in particular in human aggressive behavior.

Clozapine treatment in very early onset schizophrenia.

Very early onset schizophrenic patients only partially benefit from conventional antipsychotic treatment and are at increased risk for developing tardive dyskinesia (TD). Clozapine, which lacks extrapyramidal side effects including TD, has been proved effective for adult schizophrenic patients who are resistant to other neuroleptics. Clozapine, therefore, may offer an alternative treatment for these patients. The authors report four successful trials of clozapine in children aged 10 to 12 years old with schizophrenia, the youngest group reported on to date, who were unresponsive to conventional neuroleptic treatment.

Psychopathology and management of hospitalized suicidal Ethiopian adolescents in Israel.

Between the years 1984 and 1989, 15 suicidal Ethiopian adolescents were hospitalized in the Adolescent Unit at the Geha Psychiatric Hospital. They were part of a large Jewish Ethiopian immigration to Israel, many of them children and adolescents who came on their own, having left their families behind. Despite difficulties, most of the Ethiopian adolescent immigrants have integrated into Israeli society; however, some have developed psychiatric problems requiring treatment. We describe the psychopathology and management of a group of immigrant Ethiopian adolescents hospitalized for suicidal behavior.

Multiple exostosis, brain ventricular enlargement and schizophrenia.

Case histories of two family members with multiple exostosis and schizophrenia are presented. There are no previous reports of such an association. The computerized axial tomography scan revealed signs of hydrocephalus in one patient and substantial enlargement of lateral brain ventricles in the other. The mutual occurrence of all three clinical findings (multiple exostosis, ventricular brain enlargement and psychosis) in two family members may suggest a subgroup of patients who manifest schizophrenic symptomatology.

Psychopathology and management of hospitalized Ethiopian immigrant adolescents in Israel.

Over a period of about 12 months a large number of Ethiopian Jews emigrated to Israel under very stressful conditions. Many of these immigrants were adolescents who came on their own, leaving their families behind. Despite the culture shock involved, most have done well. Nine of these youngsters, who developed psychiatric disabilities severe enough to warrant hospitalization, were referred to us. In this paper we describe the clinical and management problems posed by these patients.

A comparison of different diagnostic tools for childhood depression.

A comparison was made of the agreement of 5 different diagnostic tools for childhood depression. The diagnostic tools used were: 1) a non-directive interview with projective testing; 2) a semi-structured psychiatric interview developed by Herjanic; 3) the child behaviour check list developed by Achenbach; 4) the Kovacs child depression inventory and 5) the DSM-III criteria diagnosis. In the diagnostic tools using classic psychiatric techniques of interview there was a fairly high diagnostic agreement for depression, while the non-interview techniques (questionnaires) were less reliable in diagnosing affective disorder. Depressive symptoms were found to play an important part in non-affective disorder psychopathology in children. The good correlation between the standard intake procedure and the research methods is encouraging in that it seems that clinicians can make the diagnosis of childhood affective disorder in their everyday clinical work.

Bradycardia due to trihexyphenidyl hydrochloride.

A chronic schizophrenic patient was treated with an anticholinergic drug, trihexyphenidyl hydrochloride. The patient developed, paradoxically, sinus bradycardia. The reaction was specific to trihexyphenidyl and not to other anticholinergic drugs. This antidyskinetic drug is widely used in clinical psychiatric practice and physicians should be aware of this side effect.

A comparison of plasma cholesterol, triglycerides and high density lipoprotein cholesterol levels in women using contraceptive pills and a control group.

Plasma cholesterol, triglycerides and HDL cholesterol levels were compared in a group of 45 young, normotensive, nonobese and nondiabetic women who used modern combined minidose contraceptive pills, to a matched group of 39 women who did not use any hormonal preparations. Our results show an increase in triglyceride levels as well as significant increase in cholesterol level in the 'pill' users group. We failed to show a significant change in HDL cholesterol levels and HDL cholesterol to total cholesterol ratio between the two groups. Our results concerning triglyceride levels are in consent to previous studies in the medical literature, while the elevation in cholesterol levels has rarely been reported in contemporary papers about minidose pill users. It seems that the contradicting effect of estrogen and progesterone on plasma HDL levels neutralizes each other's effect on this lipoprotein fraction. The elevation in plasma triglycerides and cholesterol may have importance in the vascular abnormalities seen in such pill users.

Unilateral hydrocephalus due to obstruction of the foramen of Monro: another complication of intrauterine mumps infection?

Unilateral hydrocephalus due to foramen of Monro-obstruction was diagnosed in a newborn who presented with macrocephaly at birth. The mother had mumps in the second trimester of pregnancy and immunological studies indicated possible intrauterine infection of the baby with mumps virus. His condition deteriorated rapidly, and he developed myoclonic seizures. The possible relationship of intrauterine mumps infection to neonatal neurological complications is discussed.