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.

Torsade de pointes in a patient with complex medical and psychiatric conditions receiving low-dose quetiapine.

OBJECTIVE: Describe potential cardiac complications of low-dose quetiapine and other atypical antipsychotic drugs. METHOD: We present a case report of a 45-year-old Black woman with multiple medical and psychiatric problems taking low-dose quetiapine. RESULTS: Coincident with a generalized seizure, the patient developed 'ventricular fibrillation'. She was countershocked with restoration of normal sinus rhythm. The initial electrocardiogram showed QT interval prolongation. Shortly thereafter, classical torsade de pointes appeared, lasted 10 min, and resolved spontaneously. Hypomagnesemia was present. A cardiac electrophysiologist was concerned that the very slow shortening of the prolonged QTc interval after magnesium replacement implicated quetiapine as a risk factor for QTc interval prolongation and torsade de pointes. A psychosomatic medicine consultant asserted that the fragmented medical and psychiatric care almost certainly contributed to the patient's medical problems. We discuss other cases of QT interval prolongation by newer antipsychotic drugs and previous reports by our group concerning the association of psychotropic drugs, QT interval prolongation, and torsade de pointes. CONCLUSION: Atypical antipsychotic drug administration, when accompanied by risk factors, may contribute to cardiac arrhythmias including torsade de pointes.

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.

Nefazodone and depression.

Nefazodone is a fourth-generation antidepressant with novel serotonergic actions. It is a potent antagonist of synaptic 5-HT(2) receptors and a moderate blocker of synaptic 5-HT reuptake. Its mild synaptic blockade of norepinephrine is of little clinical importance. Besides its effectiveness in depression, nefazodone is effective in depression-related anxiety. Of all the antidepressants, nefazodone is least likely to induce sexual dysfunction. This drug increases sleep efficiency and reduces the number of nighttime awakenings. Nefazodone, compared with many other antidepressants, is unlikely to induce a withdrawal syndrome if abruptly stopped.

The Charles Bonnet syndrome: a review.

The Charles Bonnet syndrome (CBS) derives from complex visual hallucinations. Neurologists, ophthalmologists, and psychiatrists have studied this entity for many years. Despite interest in CBS recently in contemporary American medical literature, investigators have not agreed upon a universal definition of this entity. This article reviews the current literature on CBS and related phenomena, offers specific criteria to define this syndrome, and suggests future work in this area.

Polydipsia-hyponatraemia syndrome : epidemiology, clinical features and treatment.

The polydipsia-hyponatraemia syndrome (PHS) occurs in about 5 to 10% of institutionalised, chronically psychotic patients, 80% of whom have schizophrenia. Major clinical features are polydipsia and dilutional hyponatraemia. Complications of PHS include delirium, generalised seizures, coma and death.Nonpharmacological interventions are fluid restriction, diurnal bodyweight monitoring, behavioural approaches, and supplemental oral sodium chloride administration. These interventions require an experienced and dedicated multidisciplinary staff.A number of pharmacological treatments have been assessed for PHS including the combination of lithium and phenytoin, demeclocycline, propranolol, ACE inhibitors, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors, typical antipsychotic drugs, clozapine and risperidone. Of these agents, the most promising are the combination of lithium and phenytoin, and clozapine.Integrated treatment requires a highly informed multidisciplinary staff, meticulous monitoring of diurnal weight gain and serum sodium level, and careful record keeping. Acute interventions of observation by trained staff, fluid restriction, water-free areas and supplemental sodium chloride administration are based on diurnal weight gain employing a monthly weight chart and a base weight method. Intravenous hypertonic saline is used briefly and administered in a highly controlled manner when patients with PHS present with generalised seizures and coma. Long term strategies include behavioural interventions and the combination of lithium and phenytoin, and clozapine.

Measuring and estimating daily urine volume in psychiatric patients: strengths and weaknesses.

We collected daily urine volumes (DUV) from 24 nonpolydipsic psychiatric patients and eight polydipsic schizophrenic patients. At 7 AM and 4 PM, we collected spot urine samples and measured urine creatinine concentration (UCr). Using morning weight and the UCr measurements, we compared actual DUV with estimated DUV using 3 methods to estimate DUV currently available in the literature. Each method of estimating DUV was superior among the polydipsic patients compared with the nonpolydipsic patients. We discuss the strengths and weaknesses of trying to estimate DUV in psychiatric patients. One method was simple but less accurate. The two remaining methods gave similar results but one method was substantially easier to use than the other.

Increased disorderliness and amplified basal and pulsatile aldosterone secretion in patients with primary aldosteronism.

To investigate the pathophysiology of altered aldosterone secretion in patients with primary aldosteronism, the pulsatile mode of in vivo aldosterone and cortisol release was examined by quantitative deconvolution analysis in 5 normal subjects (controls) and 10 patients with aldosterone-producing adenomas (APA) under conditions of sodium (150 meq/day) balance. Episodic release of aldosterone and cortisol was assessed by sampling blood at 10-min intervals for 24 h. A waveform-independent deconvolution algorithm was used to calculate endogenous aldosterone and cortisol secretion rates on a sample by sample basis in each subject. There were no differences in the number of aldosterone or cortisol secretory bursts per day or their mean interpulse intervals between normal subjects and patients with primary aldosteronism. A 24-h rhythmicity in serum aldosterone concentrations was maintained in APA patients. Patients with primary aldosteronism had significantly higher (P < 0.01) aldosterone mean secretory rates, mean mass of aldosterone secreted per burst, maximal aldosterone secretion rates attained within each burst, and mean basal (nadir) aldosterone secretion rates. A recently introduced regularity statistic, approximate entropy (ApEn), was used to test for orderliness (small ApEn) vs. randomness (large ApEn) in the aldosterone time series. ApEn was significantly larger for the APA patients (1.433 +/- 0.148) than for normal subjects (0.306 +/- 0.098; P < 0.001), with complete group segmentation yielding 100% sensitivity and specificity. In contrast, a scale-invariant form of this measure, normalized ApEn, showed no significant distinction between tumoral and normal aldosterone release patterns. These ApEn findings taken together are consistent with the deconvolution results from an entirely distinct perspective, reinforcing an amplitude difference, but no frequency difference, between normal subjects and APA patients. Unexpectedly, patients with APA had significantly lower mean cortisol secretory rates, reduced cortisol secretory burst mass, and attenuated maximal cortisol secretory rates than normal subjects (P < 0.01). Plasma cortisol and aldosterone concentrations in patients remained positively correlated over short time lags. In summary, the present findings demonstrate that in normal subjects and patients with APA, both aldosterone and cortisol are secreted in a burst-like mode. The presence of substantial basal aldosterone release and increased irregularity of serial aldosterone concentrations distinguishes APA from normal subjects.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment strategies in the polydipsia-hyponatremia syndrome.

The clinician must first identify the patient at risk of developing water intoxication and its complications including seizures, coma, and death. In the polydipsic patient, behavioral approaches correcting or limiting polydipsia may prevent progression to dilutional hyponatremia. Drugs that oppose the central release or renal action of antidiuretic hormone will usually normalize morning serum sodium concentration in patients with the polydipsia-hyponatremia syndrome. The clinician can monitor such patients by observing diurnal changes in body weight. Specific interventions derive from specific weight changes. For the symptomatic patient suffering from water intoxication, intravenous administration of saline raising the serum sodium concentration to the 120-mmol/L range, followed by fluid restriction to further correct hyponatremia, will almost always successfully correct hyponatremia and protect against central pontine myelinolysis.

Temporal pattern of renin and aldosterone secretion in men: effects of sodium balance.

To investigate the pulsatile nature of basal and stimulated renin and aldosterone secretion, we sampled blood for plasma renin activity (PRA) and plasma aldosterone concentration at 10-min intervals for 24 h in nine normal supine human male subjects after equilibration in high- and low-sodium balance states. We evaluated serial hormonal measures by a quantitative waveform-independent deconvolution technique designed to compute the number, amplitude, and mass of underlying secretory bursts and simultaneously to estimate the presence and extent of basal secretion. For both PRA and aldosterone: 1) burstlike release accounted for greater than or equal to 60% of total secretion and tonic release for less than 40%; 2) there was an 80- to 85-min interpulse interval unchanged by sodium intake; 3) sodium restriction engendered an increase in plasma hormone concentrations by increasing the amount and maximal rate of hormone secreted per burst; 4) low dietary sodium also induced increases in basal hormone secretory rates, suggesting that there may be two regulatory processes driving renin and aldosterone secretion; and 5) PRA was significantly coupled to plasma aldosterone concentration by a 0-, 10-, or 20-min aldosterone lag time in both high- and low-sodium balance. We conclude that both renin and aldosterone are released via a predominantly burstlike mode of secretion; PRA and plasma aldosterone concentrations are positively coupled by a short time lag (0-20 min); and sodium restriction achieves an increase in mean PRA and plasma aldosterone concentration by selective amplitude enhancement of individual hormone secretory bursts and by increased tonic (interburst) basal secretory rates.

Risk-taking behavior of college students and social forces.

We surveyed 1,900 first-year students at the University of Virginia 1 month after arrival. We looked at drinking and driving practices. Men drank more and they drank more often than women. Our data suggest that in defining frequent heavy drinkers, one should consider body weight. We now define frequent heavy drinking as five or more drinks in a row at least weekly for men, and for women we use three to four drinks or more in a row at least weekly. Frequent heavy drinkers and dangerous drivers appeared disproportionately among students planning to join fraternities and sororities. We believe correction of alcohol abuse and addiction by college students must focus, at least in part, on social organizations, especially fraternities and sororities. Also, we must attend to characterologic features that predispose to alcohol abuse and dependence and dangerous driving practices.