The problem with parsimony: mania and hyperthyroidism.

A patient is described who developed mania during an episode of hyperthyroidism and later presented again with mania following correction of the thyroid disturbance. Although there are prominent connections between endocrine and mood disorders, clinicians are advised to recall basic medical principles and not assume that an etiological relationship exists in the individual patient until it is proven.

Toward a profile of medically ill psychiatric patients.

We reviewed 564 consecutive psychiatric inpatient admissions. In support of previous studies, we found 51.9% to have significant medical disorders, nearly half of them "new" or previously unsuspected. Women, the elderly, substance abusers, and patients with nonschizophrenic functional psychoses had a higher prevalence of medical disorders. Using this information as a starting point, further work should be done to define a profile of the psychiatric patients at highest risk for medical illnesses.

Abnormalities of one-carbon metabolism in psychiatric disorders: study of methionine adenosyltransferase kinetics and lipid composition of erythrocyte membranes.

Two independent lines of inquiry have implicated some disturbance of one-carbon cycle metabolism in affective disorders. Folic acid deficiency commonly leads to depression, and S-adenosylmethionine has been reported to have antidepressant properties. Methionine adenosyltransferase has been reported to be underactive in depression and schizophrenia and overactive in mania. This study reports the effects on erythrocyte methionine adenosyltransferase (MAT) kinetics (Vmax) of a 2-week treatment in a population of patients housed on a psychiatric research ward. The drug-free schizophrenic patients and depressives had, upon admission, low Vmax values, and the drug-free manic patients had high Vmax values on admission. After 2 weeks of appropriate treatment, the values for all three patient samples showed significant normalization (i.e., the levels rose in schizophrenics and depressives and fell in manics). We have further shown that pretreatment low levels of erythrocyte membrane phosphatidylcholine in depressives and high levels in manics show statistically significant normalization following 2 weeks of pharmacotherapy. The significance of these results is discussed.

Medication effects on one-carbon metabolism in schizophrenia, mania, and major depression.

Erythrocyte methionine adenosyltransferase (MAT) activity (Vmax) and phosphatidylcholine (PC) levels previously have been found increased in manic patients and decreased in depressive and schizophrenic patients. To evaluate whether these abnormalities were the result of medication effects, erythrocyte MAT activity (Vmax) was assayed for paired samples from 29 schizophrenic, 16 manic, and 12 depressive patients, an erythrocyte PC levels were obtained for paired samples from 13 schizophrenic, seven manic, and seven depressive patients. Patients were medication free for at least 3 weeks. Vmax was significantly increased in schizophrenic and depressive patients (p less than 0.01; p less than 0.01) and significantly decreased (p less than 0.01) in manic patients after 2 weeks of psychotropic medication. Similar trends were found in PC levels. The findings of those one-carbon metabolism tests following medication are generally opposite to those reported to be related to specific disorders and tend toward normalization. Moreover, in vitro preincubation of erythrocytes of three normal subjects with the most commonly used neuroleptics had no consistent effects of MAT Vmax. These findings confirm previous studies that showed similarities in one-carbon metabolism of schizophrenic and depressed patients as opposed to manic patients and suggest that medications tend to correct or minimize rather than induce such abnormalities.

Lithium treatment of hyperthyroidism and mania.

A case of a man who was admitted to the hospital with both mania and hyperthyroidism is presented to illustrate the interactions between affective disorder and thyroid function. In addition, the methods in which lithium carbonate affects thyroid function, thus making diagnosis more difficult, are discussed. The authors suggest guidelines for evaluation and management of similar patients.

Monosymptomatic hypochondriacal psychosis manifesting as delusions of infestation: case studies of treatment with haloperidol.

Pimozide has been successfully used in the treatment of delusions of infestation; however, it is not widely available in the United States. Similarities in both chemical structure and degree of potency suggest that haloperidol may be an alternative treatment for this syndrome. Three cases of delusions of infestation successfully treated with haloperidol are described. In all three the symptoms were relieved acutely; in two the improvement was maintained.

Effects of bipolar affective disorder and lithium administration on the cholinergic system in human blood.

Several processes relating to the cholinergic system that are present in human blood were measured in samples obtained from patients with bipolar affective disorder, both before and during treatment with lithium, and from controls. The biochemical measurements include RBC and plasma choline concentrations, the kinetics of RBC choline uptake, plasma non-specific cholinesterase and RBC and plasma acetylcholinesterase. The RBC choline level is increased and the Vmax of the RBC choline uptake system is decreased in samples from lithium-free bipolar patients during manic episodes. There are no differences from control in the plasma choline levels or in the acetylcholinesterase enzyme activities in blood samples from the lithium-free or lithium-treated patients. Plasma non-specific cholinesterase is below control levels in all patients. Lithium treatment increases the RBC choline concentration to more than ten-times control levels and reduces the Vmax and the affinity for choline of the RBC choline transport system. In vitro addition of lithium does not replicate the effects of in vivo administration of lithium. Possible mechanisms for these effects of lithium are discussed.

Interactions between depression and borderline personality disorder. A pilot study.

Although many nosologists advocate the autonomy of borderline personality disorder (BPD), its heterogeneity led to demands that it be absorbed into the affective disorder spectrum. This study attempted to determine if (a) BPD and affective disorders overlapped and (b) if BPD characteristics were differentially associated with specific Axis I, DSM-III diagnoses. Forty-three BPD inpatients were rated retrospectively on 29 variables, including BPD characteristics from Gunderson's diagnostic interview for borderlines (DIB). chi 2 analyses were performed for each of 28 variables in 56 contingency tables whose independent variables were dysthymia/other Axis I diagnoses or depression/no depression. BPD inpatients with dysthymia had more impaired occupational functioning and greater use of splitting. Also, depressed BPDs were in general more dependent, empty and bored, and suicidal.

Self-mutilation by tooth extraction.

We have described a schizophrenic patient who mutilated himself by extracting two teeth. We reviewed the existing literature on self-mutilation and the psychoanalytic significance of teeth as body parts.

Cholinergic processes in blood samples from patients with major psychiatric disorders.

Cholinergic processes were measured in plasma and red blood cells (RBC) obtained from patients with mania, depression, and schizophrenia. RBC choline levels were elevated in manic patients, and lithium treatment led to a further increase. RBC choline transport was below normal in manic patients, and lithium treatment further reduced choline transport in addition to reducing the apparent affinity for choline. RBC acetylcholinesterase was low in depressed and schizophrenic patients, but not in manic patients, whereas plasma acetylcholinesterase was reduced only in depressed patients. Plasma nonspecific cholinesterase was below normal in all groups of patients. These results indicate unique patterns of differences from controls in the cholinergic system in blood samples from patients with different psychiatric illnesses.

One-carbon metabolism disturbances in affective disorders. A preliminary report.

Methionine adenosyltransferase (MAT) activity (Vmax) and the relative amount of phosphatidylcholine (% PC) were measured in erythrocytes of up to 30 DSM-III diagnosed manic, 17 unipolar depressed patients, and 28 normal controls. Manic subjects had significantly higher and depressed subjects significantly lower MAT Vmax than normals. The relative amount of PC was in the low range for the depressives, and in the high range for the manics. Depressive patients present, in these tests, similar abnormalities to those seen previously in schizophrenic patients. Clinical and diagnostic implications of these findings are discussed.

Inappropriate admissions to psychiatric wards.

Our seven clinical vignettes illustrate different mechanisms of inappropriate admissions to psychiatric wards and the circumstances and outcome of such admissions, with emphasis on the shared responsibility of psychiatric and nonpsychiatric physicians, the financial consequences, and the implications of such admissions on the profession's public image. Inappropriate admissions create undue tensions and demands on an already overworked psychiatric staff, and raise legitimate issues of quality of care, the need for clinical and administrative guidelines for consultation and transfer, the degree of communication between psychiatry and other specialties, and a host of psychodynamic considerations, somehow overlooked in recent years. The main issue in most cases is the level of communication between the psychiatric and nonpsychiatric camps. Clinical, epidemiologic, and actuarial studies are needed in this area.

Toxic psychosis: a complication of antimalarial therapy.

A case is reported of toxic psychosis in a patient with a diagnosis of discoid lupus erythematosus treated with hydroxychloroquine. The dose slightly exceeded the maximum recommended dose for 10 days because of a pharmacy error. Since more antimalarials are being used for various diseases, attention is called to this possible complication with a subtle onset.