The Hillside journal of clinical psychiatry最新文献

The association between depressive symptomatology and failure of cortisol suppression following dexamethasone administration is explored in a preschool age tertiary care psychiatric population. Clinical research investigation of 16 preschoolers, including 13 inpatients and three outpatients, indicates that a broad range of DSM-III depressive symptomatology can be identified in this population. Seven patients had a serum cortisol value greater than 5 micrograms/dl following 1 mg dexamethasone and six of these had diagnoses within the depressive spectrum. The appropriateness of DSM-III criteria in this age group is discussed and the usefulness of the Preschool Depression Scale as an interview guide is reviewed. Difficulties in interpreting the biological findings are also reviewed, in addition to possible genetic or environmental influences from the family psychiatric history.

One hundred fifty-two inpatient major depressives fulfilled the Research Diagnostic Criteria for unipolar (N = 111) or bipolar (N = 41) affective disorder. After at least seven days drug-free, all patients had a thyrotropin releasing hormone stimulation test (TRHST), a dexamethasone suppression test (DST) and quantitative electroencephalography (QEEG). Multivariate analysis of variance was used to compare post-dexamethasone cortisol, delta TSH, six regional QEEG measures of interhemispheric symmetry and six focal measures of QEEG frequency. Age, sex and diagnosis were included in the analysis. Unipolar depressives were discriminated from bipolar depressives by age, delta TSH and QEEG fast wave abnormalities in the alpha and beta frequency bands. Unipolar depressives were significantly older, had lower mean delta TSH, showed excessive alpha activity and deficient beta activity. Bipolar depressives were younger, had higher mean delta TSH, showed a deficit of alpha activity and excessive beta activity. Unipolar might be discriminable from bipolar major depression by the use of two objective procedures--TRHST and QEEG. The two disorders appear to be biochemical and electrophysiological opposites. Treatment implications are discussed.

Trazodone has become a very popular second generation antidepressant. In our experience, trazodone levels are frequently obtained albeit interpretation/utility of these levels and purported normal ranges are in question. We analyzed 39 consecutive cases of major depressive disorder treated with trazodone in a primary care medical clinic. Thirty (79%) of subjects had a positive response. While a positive correlation existed between dosage and concentration of the parent drug, no dose-response correlation could be identified within this cohort. However, a minimum level of 250 ng/ml did appear necessary for a response. The overall utility/cost efficacy of second generation antidepressants, in the absence of well designed dose response studies, is questioned.

Multiple personality disorder (MPD) is being recognized with increasing frequency. A great imitator, it may be encountered among patients who appear to have a wide range of other diagnoses, and have been in treatment for years without the presence of MPD being discovered. Nine of 241 MPD patients interviewed by the author, 3.7%, had been accepted for psychoanalysis. In only one case had the diagnosis been appreciated by the analyst prior to his accepting the patient for analytic treatment. Four patients were profoundly resistant and or inaccessible to analysis for protracted periods. In one of these cases the diagnosis became clear and successful analysis was concluded, but three analyses ended unsuccessfully with the diagnosis still unknown. Two patients' analyses were interrupted due to abrupt regressive events initially perceived to indicate severe ego weakness incompatible with sustaining an analytic process, but later appreciated as signs of MPD. In three cases it appeared that the patients' being accepted for analysis triggered the emergence of the dissociative process, and either the patient or the analyst decided to pursue a different form of therapy. Unsuspected MPD appears to account for a small percentage of stalemates, failures, interruptions, and early flights from analysis.

Admission and mean 14-year follow-up Global Assessment Scale functioning were studied in 237 inpatients meeting DSM-III criteria for borderline (BPD) and schizotypal (SPD) personality disorders and compared to major affective disorder, schizophrenia and other diagnoses. BPD patients also meeting criteria for SPD functioned more poorly than other BPD or SPD patients at admission but improved their functioning at follow-up. Two BPD and SPD criteria which were associated with good follow-up functioning in BPD with SPD patients were found to predict poor admission functioning but good follow-up functioning in 18 of 237 former inpatients regardless of diagnosis.

A group of 19 geriatric bipolar lithium patients were interviewed in order to assess the incidence, bothersomeness and intensity of medication side effects. The role of subject variables was also examined. Most often reported side effects included excessive thirst, hand tremor, excessive urination and dry mouth. Although many side effects were experienced, these effects were generally tolerated with minimal intensity and bothersomeness. Results indicate that with proper precautions and monitoring, lithium can be safely administered to geriatric bipolar patients.

Amphetamine induced psychosis has for the past 30 years provided a useful model for the study of schizophrenia. The amphetamine model, however, has been shown to have a number of shortcomings including an inability to model the deficit symptoms of schizophrenia. PCP (phencyclidine) has been shown to be capable of inducing a schizophreniform psychosis consisting of both productive and defict symptomatology. PCP induced psychosis, therefore, may provide a useful model of schizophrenia. This paper reviews the literature concerning the PCP model of schizophrenia and provides some independent confirmation of the ability of PCP to modulate mesocortical dopaminergic activity. Since PCP appears to mediate its CNS effects via a subclass of glutamate receptors, a possible glutamate theory of schizophrenia is proposed.

Brain dysfunction has been noted Munchausen syndrome patients but rarely explored. We describe five Munchausen syndrome patients who all appeared intellectually intact because of their excellent verbal skills. However, formal neuropsychological assessment testing revealed deficits in conceptual organization, management of complex information, and judgement. We suggest that subtle but important neuropsychological impairment may contribute significantly to the aberrant behavior of Munchausen syndrome patients. Typical Munchausen behaviors such as irascibility, the desperate search for care, and pseudologia fantastica, may be understood as solutions to problems created by brain damage.