Non-pharmacologic therapies for systemic lupus erythematosus.

BACKGROUND: Non-pharmacologic therapies have been deemed as potentially beneficial for patients with systemic lupus erythematosus. We conducted an updated review to determine the effects of these therapies to inform practice. METHODS: A literature search was performed using PubMed (MEDLINE), EMBASE, Cochrane, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Google Scholar from inception until August 2018. We included randomized controlled trials of non-pharmacologic therapies in systemic lupus erythematosus patients with sample size ≥10. Systemic lupus erythematosus was defined by 1982 or 1997 American College of Rheumatology criteria. Studies were synthesized separately by patient-reported outcomes and disease activity. Due to the heterogeneity of interventions and comparisons, a meta-analysis was not performed. RESULTS: A total of 15 randomized controlled trials involving 846 participants met the inclusion criteria. Of the 15 trials, eight used exercise interventions, six used psychological interventions (one group psychotherapy, three cognitive behavioral therapies, one psychoeducation, one mindfulness-based cognitive therapy) and one used electro-acupuncture. Five of 15 studies utilized control groups consisting of usual medical care. Other studies included control interventions of relaxation, attention placebo, symptom monitoring support, education, minimal needling, isotonic and resistance exercise. Compared with the control conditions, non-pharmacological interventions were associated with a significant improvement in fatigue in three out of six studies. Three out of eight studies reported improved anxiety and depression, and one study reported improved pain after interventions. Seven out of 11 studies reported improvement in overall quality of life in at least one domain of the Short-Form Health Survey. Of note, no studies demonstrated an improvement in disease activity after 5-52 weeks of non-pharmacological therapies. CONCLUSION: This review showed promising results for physical exercise and psychological interventions as adjuncts to traditional medical therapy for improvement in fatigue, depression, pain and quality of life for systemic lupus erythematosus. Further high-quality randomized controlled trials with longer follow-up periods are warranted.

Gitelman's syndrome: report of a 19-year old woman with intractable hypomagnesemia and hypokalemia, and a review of the syndrome.

A case of refractory hypomagnesemia associated with hypokalemic alkalosis and hypocalciuria (Gitelman's syndrome) is described. The genetic mutations discovered to cause the hypokalemic alkalotic syndromes are described (the thiazide-sensitive sodium chloride co-transporter gene or TSC mutations in Gitelman's syndrome, and the sodium-potassium-chloride co-transporter gene or NKCC2 mutations in Bartter's syndrome). The molecular, electrolyte, and volume abnormalities are described, and the implications for diagnosis, therapy, and future research discussed.

Pseudoseizures: etiologic and psychotherapeutic considerations.

Pseudoseizures are a somatic form of communication involving dissociative mechanisms. This paper outlines basic strategies for psychotherapeutic management with a case example.

Ganyphilia : etiologic and psychotherapeutic concepts.

The author describes a role for psychotherapy in ganyphilia, the homoerotic interest by adult males in adolescents. This paraphilia, which is commonly pandered to by street hustlers, often comes to light when the subject is arrested. When ganyphilia is embedded within a framework of disordered narcissism, the personality disorder itself can be effectively treated by a psychoanalytic psychotherapy informed by contemporary self psychology. After locating ganyphilia in a historical/mythological context, the author presents aspects of the psychotherapy of a court-mandated case to demonstrate both etiologic forces and the treatment process.

Delusions of innocence and antagonistic delusory ideas.

The author describes a patient who developed a delusion of persecution followed by a secondary delusion of innocence. The patient was felt to suffer from a paranoid state previously described only in incarcerated prisoners and schizophrenics. The relationship between his delusions and his unconscious impulses is considered.

Frightening dreams and dosage schedule of tricyclic and neuroleptic drugs.

One previous study reported that psychiatric inpatients on bedtime-only doses of tricyclic or neuroleptic drugs reported more frequent frightening dreams than did those on divided daily doses. As a further test of this hypothesis, and in order to see whether differences in frequency of frightening dreams were a function of differences in total dream recall, we administered a questionnaire to outpatients in a Veterans Administration Hospital Mental Hygiene Clinic, asking about frequency of dream recall, frequency of frightening dream recall, and doses and times of any medications taken. Questionnaire reports of medications were checked with the medical record of the patient; for 48 patients on tricyclic or neuroleptic drugs the reports agreed, and the data of these patients were analyzed. Our findings corroborated the previous report of more frequent frightening dreams in patients on bedtime-only dosage schedules (p less than .01). In addition, we found no significant difference between the two groups with respect to frequency of dream recall; thus a difference in the affect of dreams, rather than a difference in quantity of dream recall, constituted the difference between the two groups. When a patient on bedtime doses of tricyclic or neuroleptic drugs has undesirable frightening dreams, the clinician should consider a change to divided daily doses.

Anniversary reactions presenting as physical complaints.

The literature concerning anniversary reactions is reviewed. Five cases seen by various medical specialists for physical complaints, and subsequently referred for psychiatric evaluation are presented. Each case was felt to represent an anniversary reaction. The necessity of considering the possibility of an anniversary reaction, when the genesis of a complaint is unclear, is emphasized.

Anniversary reactions masquerading as manic-depressive illness.

The authors suggest that many patients diagnosed as having manic-depressive illness, depressed type, may in fact be experiencing anniversary reactions--time-specific psychological and physiological reactions to a past trauma. They report three cases of cyclic depressive disorder, two of which were first diagnosed as manic-depressive illness, depressed type. Careful, complete interviewing and attention to temporal sequence led to the correct diagnosis of anniversary reaction.

Severe neurotoxicity despite "therapeutic" serum lithium levels.

One may not rely solely on serum lithium levels to detect or prevent lithium intoxication. A review of the reported cases of serious lithium intoxication despite "therapeutic" blood levels of lithium is presented, along with a discussion of possible explanations for the phenomenon. Possible alternate means of following a patient on lithium carbonate are discussed.

Free psychotherapy: an inquiry into resistance.

Psychotherapy for which the patient is not charged, such as that provided by the Veterans Administration system, can lead to unique conflicts and resistances within treatment. Patients may depreciate the value of therapy, feel obligated to the therapist, or expect him to make inappropriate nonfinancial demands. The authors present five cases illustrating that lack of a fee may become the focus of insoluble resistances to therapy, and suggest that, particularly in training situations, a token fee should be charged to obviate these difficulties.