Mania with Aarskog-Scott syndrome.

Aarskog-Scott syndrome is transmitted as an X-linked trait and affects males. We report a 10-year-old boy presenting with complaints of increased temper tantrums, demanding behavior, grandiose ideas, over familiarity, abusive assaultive behavior and tobacco abuse. On examination, patient had most of the physical characteristics of Aarskog-Scott Syndrome. He also had global developmental delay and attention deficit hyperactivity disorder. This is the first case report of Aarskog Scott syndrome combined with mania.

Posttraumatic stress disorder as a risk factor for obesity among male military veterans.

OBJECTIVE: Obesity is a significant public health problem in the United States, particularly among military veterans with multiple risk factors. Heretofore, posttraumatic stress disorder (PTSD) has not clearly been identified as a risk factor for this condition. METHOD: We accessed both a national and local database of PTSD veterans. RESULTS: Body mass index (BMI) was greater (P < 0.0001) among male military veterans (n = 1819) with PTSD (29.28 +/- 6.09 kg/m(2)) than those veterans (n = 44 959) without PTSD (27.61 +/- 5.99 kg/m(2)) in a sample of randomly selected veterans from the national database. In the local database of male military veterans with PTSD, mean BMI was in the obese range (30.00 +/- 5.65) and did not vary by decade of life (P = 0.242). CONCLUSION: Posttraumatic stress disorder may be a risk factor for overweight and obesity among male military veterans.

Newer antipsychotic drugs and obesity in children and adolescents. How should we assess drug-associated weight gain?

OBJECTIVE: Antipsychotic drugs may contribute to weight gain in children and adolescents. METHOD: We used Medline's PubMed in the pediatric age using key words 'weight gain' and 'obesity', for each newer antipsychotic drug. RESULTS: We found 21 articles linking weight gain and obesity with newer antipsychotic drugs among youths. Risperidone was the most commonly cited agent. Weight gain from olanzapine was the largest among the more commonly prescribed newer agents. All studies reported absolute weight gain. Only a few studies used the better measure of body mass index (BMI). None incorporated growth charts to allow for changes in weight and height over time because of growth. CONCLUSION: Weight gain may be a major problem when prescribing newer antipsychotic drugs in the pediatric population. Risperidone is associated with less weight gain than olanzapine. Published reports and studies have not utilized state-of-the-art techniques using BMI with readily available growth charts.

Patient and direct-care staff body mass index in a state mental hospital: implications for management.

OBJECTIVE: Obesity is a major problem among chronically psychotic patients. METHOD: We assessed body mass index (BMI) of chronically psychotic patients on admission to a state mental hospital and in follow-up. We also compared patient BMI to staff BMI. RESULTS: The initial patient BMI (26.4 +/- 5.8 kg/m2) was in the overweight range. The patient BMI (29.1 +/- 5.8 kg/m2) increased (P < 0.0001) on follow-up and almost reached the level of obesity. Staff BMI (35.1 +/- 8.6 kg/m2) was in the obese range with 64.9% meeting criteria of obesity and 29.9% meeting criteria of morbid obesity. African-American women made up 84.5% of clinical-care staff and constitute the race-sex mix most vulnerable to obesity in the US. Morbid obesity (BMI > or = 40 kg/m2) was five times more common among these African-American female clinical-care staff than among African-American women in the general US population. CONCLUSION: Our findings may have treatment implications for chronically psychotic patients at risk for obesity.

Naloxone fails to prolong seizure length in ECT.

Electroconvulsive shock (ECS) in animals has been shown to enhance endogenous opiate systems. The anticonvulsant effects of ECS are also partially blocked by the opiate receptor antagonist naloxone, leading some investigators to postulate that the anticonvulsant effects of ECS are mediated by activation of endogenous opiates. If such a phenomenon occurs in humans, then naloxone might prolong seizure length in electroconvulsive therapy (ECT). In the present study, nine patients were given 2.0 mg intravenous (i.v.) naloxone 2 minutes prior to one-half of their ECT treatments. Motor seizure length was measured via the cuff technique. EEG tracings were read by an investigator blind to naloxone status. There was no difference between the two groups in either EEG or nonblindly evaluated motor seizure length. It is concluded that a dose of 2 mg naloxone does not effectively increase seizure length in ECT.

Is bipolar disorder still underdiagnosed? Are antidepressants overutilized?

BACKGROUND: Previous studies have suggested that bipolar disorder may be underdiagnosed, and that antidepressants may be over-utilized in its treatment. METHODS: Consecutively admitted patients (n =48) diagnosed with DSM-IV bipolar disorder, type I, (n = 44) or schizoaffective disorder, bipolar type, (n = 4) were interviewed systematically and their charts were reviewed to confirm diagnosis before admission. They were then treated according to systematic structured interview diagnoses. These data reflect the changes in diagnoses and treatment. RESULTS: 40% (19/48) were identified with previously undiagnosed bipolar disorder, all previously diagnosed with unipolar major depressive disorder. A period of 7.5+/-9.8 years elapsed in this group before bipolar diagnosis was made. Antidepressant use was high on admission (38%) and was reduced with acceptable treatment response rates. The adjunctive use of risperidone appeared to be a good treatment alternative. LIMITATIONS: While diagnoses were made prospectively, treatment response was assessed retrospectively, and was based on non-randomized, naturalistic therapy. CONCLUSIONS: Systematic application of DSM-IV criteria identified previously undiagnosed bipolar disorder in 40% of a referred population of patients with mood disorders, all previously misdiagnosed as unipolar major depressive disorder. Antidepressants appeared overutilized and risperidone was an effective alternative adjunctive therapy agent.

Neuroleptic malignant syndrome: a review.

OBJECTIVE: Neuroleptic malignant syndrome is an uncommon side effect of antipsychotic medications characterized by severe rigidity, tremor, fever, altered mental status, autonomic dysfunction, and elevated serum creatinine phosphokinase and white blood cell count. This paper presents a concise and comprehensive review of neuroleptic malignant syndrome, written with the practitioner in mind, to provide information that will be useful in actual clinical settings. METHODS: MEDLINE was searched from 1966 to 1997 for key reviews, reports on series of cases of neuroleptic malignant syndrome, individual case reports, and other clinically and theoretically important information. RESULTS AND CONCLUSIONS: Virtually all neuroleptics are capable of inducing the syndrome, including the newer atypical antipsychotics. The standard of care for the recognition of neuroleptic malignant syndrome has shifted considerably over the past 15 years. Neuroleptic malignant syndrome belongs in the differential diagnosis of any patient receiving a neuroleptic who develops a high fever or severe rigidity. In addition to measurement of creatinine phosphokinase and white blood cell count, important tests to rule out other etiologies include urinalysis to measure electrolytes, including calcium and magnesium; kidney, liver, and thyroid function tests; lumbar puncture; an electroencephalogram; and a computed tomography or magnetic resonance imaging scan of the head. Although specific treatment remains controversial, supportive treatment such as antipyretics, a cooling blanket, and intravenous fluids to correct dehydration and electrolyte abnormalities is critical and widely supported by consensus. Most patients recover from neuroleptic malignant syndrome in two to 14 days without any cognitive impairment, and new dysfunction usually is attributable to very high fever, hypoxia, or other complications, rather than neuroleptic malignant syndrome per se.

Bilateral ulnar nerve paralysis: an unreported complication of drug-induced extrapyramidal rigidity.

OBJECTIVE: This case report describes a very unusual consequence of drug-induced extrapyramidal side effects. CLINICAL PICTURE: The patient developed bilateral ulnar nerve paralysis. TREATMENT: The treatment consisted of anticholinergic medication and physiotherapy. OUTCOME: The patient made a complete recovery over a period of 8 months. CONCLUSIONS: There is a need to ensure compliance with anticholinergic medication when using depot neuroleptic medication.

Diversity in schizophrenia: toward a richer biopsychosocial understanding for social work practice.

By incorporating information from the neurosciences, the study discussed in this article supports the view that schizophrenia is a diverse and biopsychosocial phenomenon. Forty-two people with schizophrenia were placed in one of two groups: people with a larger ventricle-to-brain ratio (VBR) or cortical atrophy (CA) or both and people without these conditions. The authors hypothesized that the former would have lower levels of psychosocial adaptation, higher levels of stress, and lower levels of self-esteem and would have a different course of illness than people without these two conditions. The study found few differences between the two groups, but there were significant differences between women and men and between African American and white participants. Implications for social work practice in the area of serious mental illness are discussed.

Racial differences in the diagnosis of psychosis.

In clinical populations, it has been reported that African-American patients are more likely to receive a diagnosis of schizophrenia than similar Caucasian patients. Factors contributing to this racial discrepancy are poorly defined. The authors examined the hypothesis that racial differences in severity of first-rank symptoms of schizophrenia contribute to this diagnostic difference. Patients were recruited as part of the DSM-IV Field Trial for Schizophrenia and Other Psychotic Disorders, and evaluated using a structured rating instrument. Symptom and diagnostic comparisons were performed between black and white patients. Black patients were significantly more likely than white patients to be diagnosed with schizophrenia and less likely with psychotic depression. Racial differences in symptom profiles were observed with black patients demonstrating more severe psychotic symptoms, in general, and first-rank symptoms, specifically. There were no racial differences in rates of affective syndromes or severity of affective symptoms. Racial disparity in diagnosis of psychotic patients may be in part secondary to more severe first-rank symptoms in black patients, causing clinicians to stray from DSM-III-R criteria.

Mixture analysis of smooth pursuit eye movements in schizophrenia.

The goal of this study was to replicate and extend previous findings indicating that the eye movement data of schizophrenic patients is best represented by the mixture of two groups, one of which has distinctly poor performance. Forty-nine schizophrenic patients and 32 normal controls had their smooth pursuit eye movements quantified by calculating the root mean square (RMS) deviation between the target and eye waveforms. Based on the finding of mixture in the distribution of RMS error, the patients were divided into low (better tracking) and high (worse tracking) RMS error subgroups. The high RMS error patients had abnormally decreased gain. Both patient subgroups had abnormally increased frequency of catch-up saccades and increased phase lag. Distinguishing between these two subgroups may be useful in clarifying the pathophysiology of abnormal pursuit and its relationship to heterogeneity in schizophrenia.

Tardive dyskinesia in non-western countries: a review.

Tardive dyskinesia (TD) is a well-described adverse effect of treatment with neuroleptics. Studies from non-western countries are sparse and those that exist are not well publicized. We analyzed prevalence data on TD, published in English or French, and carried out in countries in Africa and Asia through December 1993. The estimated prevalence of TD among African subjects was 24% and among Asian subjects 17.2091. Both rates are in the middle range when compared with the western prevalence rates of 10-50%. Long-term hospitalization and older age were risk factors associated with TD. Female gender did not emerge as a risk factor. Also, several Asian studies showed that subjects with TD were taking lower doses of neuroleptics than subjects without TD. Prospective and controlled cross-cultural studies of TD are recommended for better understanding of associated risk factors and primary prevention.

Medical disorders in the schizophrenic patient.

OBJECTIVE: The primary purpose of this review of medical disorders in the schizophrenic patient is to provide the clinician interested in Consultation/Liaison psychiatry and psychosomatic issues a comprehensive and current review of the subject. METHOD: The authors used the Index Medicus and Medline to find recent review articles and research articles related to medical disorders in the schizophrenic patient. Also, the authors described their clinical experience in Consultation/Liaison psychiatry working with schizophrenic patients in a large, tertiary-care academic medical center. RESULTS: The authors divided their review into: 1) mortality and morbidity in schizophrenia, 2) differential diagnosis, 3) specific comorbidity management problems, 4) caring for schizophrenics on medical/surgical wards, and 5) antipsychotic drugs in the medical setting. Schizophrenia remains an important subject for Consultation/Liaison psychiatrists. CONCLUSIONS: Schizophrenia and its protean manifestations confound the care of the medical patient. The psychosis of schizophrenia may impair the patient's capacity to recognize or articulate emerging medical illness, or to respond to therapeutic interventions. The psychiatrist caring for and consulting on patients with medical illnesses bears major responsibility for understanding the complex interface of schizophrenia and medical illnesses. Psychiatrists need to educate our medical and surgical colleagues how schizophrenia alters the usual presentation, clinical course, and response to treatment of common medical and surgical illnesses.

Comment: the neglect of culture in psychiatric nosology: the case of culture bound syndromes.

Descriptive psychopathology and clinical phenomenology inform contemporary psychiatric diagnosis and nosology. The process of psychiatric diagnosis and classification is intricate and subject to continuous revision. This paper attempts to illustrate the effect of culture on psychopathology, with special emphasis on the diagnosis and classification of culture bound syndromes. There is a need for more clarity and specificity about the diagnosis and classification of culture bound syndromes. The paper suggests some questions that need to be addressed for the better integration of these syndromes into the main body of international classificatory systems. It is presumed that answers to these questions will provide a better nosological framework for culture bound syndromes.

Sustained attention and positive formal thought disorder in schizophrenia.

Deficits in sustained attention and formal thought disorder (FTD) are two characteristics of schizophrenia that might be expressions of a common pathology. This study examined whether a measure of enduring (post-treatment, stabilized) deficits in sustained attention, the Continuous Performance Test (CPT) could predict FTD. In addition, a comparison was made of CPT performance between subjects with schizophrenia (n = 41) and healthy controls (n = 28). Results replicated previous findings of significantly poorer performance by individuals with schizophrenia compared to normal controls. Within the schizophrenia group, significant correlations were found between FTD and CPT measures. In order to assess predictability of FTD, a hierarchical multiple regression analysis was used. CPT errors and gender both significantly predicted FTD. The most robust prediction was of residual FTD (post-treatment, stabilized) by CPT commission errors. These results lend support to the proposition that a subsyndrome within schizophrenia exists that is characterized by deficits in sustained attention and positive formal thought disorder. Furthermore, this subsyndrome might be more common in males than females.

Brain structure changes in schizophrenics with high serum titers of antibodies to herpes virus.

We compared five indices of brain structure between two groups of schizophrenics, namely, those with high and normal levels of antibody in the serum to herpes virus. Eleven 'immuno-positive' and 21 'immuno-normal' subjects obtained from a concomitant study of serum IgG antibody to viruses underwent magnetic resonance imaging (MRI) utilizing a 1 Tesla magnet and 8 mm thick slices. We measured ventricle-brain ratio (VBR), 3rd ventricle width, cortical atrophy, area of corpus callosum, and frontal lobe area. The differences between groups were assessed by t-test and chi-square analysis. Eight of 11 immuno-positives compared to 7 of 21 immuno-normals showed evidence of cortical atrophy (chi 2 = 4.49, p < 0.03). The immuno-positives had smaller left frontal area (mean + s.d = 125.69 + 21.30 versus 143.76 + 19.84, t = 2.07, p < 0.05) and larger 2nd quadrant of the corpus callosum (mean + s.d. = 1.58 + 0.39 versus 1.27 + 0.52, t = 2.68, p < 0.01). The right frontal area also was smaller in immuno-positives but not significant. VBR, 3rd ventricle and the 1st, 3rd and 4th callosal quadrants did not differ between the groups. We conclude that high antibody titers to herpes found in the sera of some schizophrenics might reflect an earlier pathogenetic process that affected brain development. Further studies of antibodies in CSF and brain structure in these or similar subjects and those suspected to be exposed to viral infections in utero should be vigorously pursued to obtain definitive evidence for this hypothesis.

The consulting psychiatrist and the polydipsia-hyponatremia syndrome in schizophrenia.

OBJECTIVE: The authors seek to extend understanding and treatment of hospitalized schizophrenics presenting with complications of polydipsia and dilutional hyponatremia. Attending physicians may ask the consultation/liaison psychiatrist to see schizophrenics with hyponatremically-induced delirium or other psychiatric syndromes. The referring physician may or may not have identified polydipsia and dilutional hyponatremia and their complications. This article will help the consultation/liaison psychiatrist recognize early evidence of water imbalance, describe evaluation, and provide somatic and behavioral treatment approaches to this life-threatening syndrome. METHOD: Over the past ten years, the authors have treated more than 100 patients with the polydipsia-hyponatremia syndrome. The authors discuss their and others' experience with drugs that help and hinder patients suffering from dilutional hyponatremia. They review current key articles from the polydipsia-hyponatremia syndrome literature including articles identified via Medline search 1985-94. RESULTS: Schizophrenics with the polydipsia-hyponatremia syndrome most commonly present with polydipsia, polyuria, urinary incontinence, cognitive, affective, and behavioral changes, seizures, or coma. Quantitating polydipsia, hyponatremia, and diurnal changes in body weight facilitate therapeutic interventions. Treatment include patient and caregiver education, drug therapies to better treat psychosis and better treat osmotic dysregulation, behavioral interventions to interdict polydipsia, and diurnal weight monitoring. CONCLUSIONS: Once recognized, acute, subacute, and chronic complications of the polydipsia-hyponatremia syndrome are readily treatable. Besides treating the patient, consultation/liaison psychiatrists can teach their medical colleagues about this syndrome. In so doing, they will enhance the quality of their patients' lives and help the internist and surgeon feel more comfortable when working with schizophrenics.