Cingulotomy for refractory obsessive-compulsive disorder. A long-term follow-up of 33 patients.

To evaluate the feasibility of cingulotomy as a treatment for patients with intractable obsessive-compulsive disorder, we evaluated the records of all 35 patients with this diagnosis who had undergone one or more such procedures at Massachusetts General Hospital, Boston, during the last 25 years. Retrospectively, all but two of these patients met DSM-III-R criteria for obsessive-compulsive disorder. Six patients were deceased; four by suicide. Questionnaires were sent to the remaining 27 patients with obsessive-compulsive disorder; 17 patients returned the questionnaire and another agreed to an interview without completing the forms. Sixteen of these 18 patients participated in a telephone interview, and patient reports were corroborated by an informant in 10 cases. Despite the presence of some side effects, such as easily controlled seizures (9%) and transient mania (6%), the results of this investigation support the use of cingulotomy as a potentially effective treatment for patients with severe and disabling obsessive-compulsive disorder. With the use of very conservative criteria, we estimated that at least 25% to 30% of the patients benefited substantially from this procedure. Similar results were found in a preliminary prospective study of four patients who recently underwent cingulotomy after state-of-the-art preoperative treatments had failed.

Treatment of anxiety associated with electrophysiologic studies.

Programmed electrical stimulation, also known as electrophysiologic studies (EPS), is a cardiologic technique used to help guide physicians in their management of selected patients with cardiac arrhythmias. Data are presented for 14 consecutive patients undergoing EPS seen in psychiatric consultation who had a diagnosis related to anxious mood. Successful management strategies, which evolved from work with these patients, included psychologic approaches (supportive psychotherapy and education) and psychopharmacologic agents (most commonly alprazolam). EPS and related physiologic aspects of anxiety and stress are briefly reviewed.

Psychostimulant treatment of depressive disorders secondary to medical illness.

Hospital charts were reviewed for 66 medical and surgical patients who received dextroamphetamine or methylphenidate to treat a depressive disorder. Approximately three-fourths showed some improvement; in half of the sample, improvement was marked or moderate. Of those who improved, 93% reached their peak response within the first 2 days. Relapse occurred in only 5 patients. Side effects were minimal. Nonsignificant trends suggested that dextroamphetamine was more effective for major depression than adjustment disorder, while methylphenidate tended to be more effective for adjustment disorder. Psychostimulants appear to be a therapeutic option in the medically ill depressed population and may be more rapidly effective with fewer side effects than tricyclic antidepressants.

Use of high-dose intravenous haloperidol in the treatment of agitated cardiac patients.

Although previous reports have documented the safe and effective use of intravenous haloperidol in agitated cardiac patients, the dosages advocated have in general been relatively low: 1 to 2 mg every 2 to 4 hours. In this report, the authors demonstrate that such doses may be insufficient to control severe agitation in coronary care unit patients. Four cases are presented in which more than 100 mg/day of intravenous haloperidol were required for safe and effective control of confusion and agitation.

Propranolol and depression revisited: three cases and a review.

The occurrence of major depressive episodes as complications of treatment with propranolol has been a matter of controversy. Three cases are reported of depressions meeting DSM-III criteria following administration of propranolol for medical conditions. Possible relationships between beta blockade and affective illness are discussed.

Use of psychostimulants in medically ill patients with neurological disease and major depression.

The effective therapeutic response to dextroamphetamine and methylphenidate by five depressed patients with neurological disease is described. In four of these patients tricyclic antidepressants had to be discontinued due to the concomitant deterioration of their cognitive functions, and in one case they were not used due to cardiovascular complications. There was a rapid remission of depressive symptomatology with no adverse side effects, consistent with the findings of other investigators. The possible association of right hemisphere strokes and depression is also discussed. Further evaluation of the therapeutic role of psychostimulants in the treatment of depressed patients with structurally-compromised brain function is recommended.

Intravenous lorazepam in neuroleptic-induced catatonia.

Presented here are four cases of catatonic reactions which were felt to be neuroleptic induced. Intravenous lorazepam was rapidly effective in reversing the catatonia and attendant symptoms. Lorazepam's previous uses and pharmacological profile are discussed. Reviewed briefly are catatonia and its neuroleptic-induced forms. Possible mechanisms responsible for the therapeutic effect of intravenous lorazepam in these cases are then examined.

Monoamine oxidase inhibitors in obsessive-compulsive disorder.

The authors describe the use of monoamine oxidase inhibitors (MAOIs) in eight patients with severe obsessive-compulsive disorder. In four cases, the MAOIs produced rapid and sustained remission of symptoms; no response was seen in four other patients. All patients who responded to MAOIs, but none of the nonresponders, had phobic anxiety and/or panic attacks. Thus, a trial of MAOIs is indicated in obsessive-compulsive disorder, especially when phobic anxiety or panic attacks form part of the clinical picture.

Coping with poor prognosis in the pediatric intensive care unit. The Cassandra prophecy.

The intensive-care pediatrician who prophesies to parents that their child's illness is irreversible may encounter denial and hostility. The physician may compare his plight to that of Cassandra--the mythical Greek prophetess of doom, who was cursed to see into the future and not be believed. Four cases are reported in which parents rejected their child's hopeless prognosis, counterprophesied miraculous cures, resolved to obtain exorcism, criticized the care, or accused nurses of neglect. This produced a painful breakdown in the usually harmonious relationships between doctors, nurses, and parents. Parental denial as a coping mechanism is discussed. Guidelines are presented for the prevention and/or early recognition and management of the Cassandra Prophecy phenomenon. A miraculous recovery in one case is a potent reminder to physicians and nurses that they do not have the gift of divine prophecy and cannot see with certainty into the future.