Plasma dexamethasone levels in children given the dexamethasone suppression test.

To determine whether children who demonstrate dexamethasone suppression test (DST) nonsuppression have lower plasma dexamethasone levels than DST suppressors, we administered the DST to 73 patients ranging in age from 5-14 years. Plasma dexamethasone levels and postdexamethasone cortisol levels were measured at 4:00 PM on day 2. We found: (1) DST nonsuppressors had significantly lower plasma dexamethasone levels (p less than 0.03) than suppressors; similar trends were observed when the population was divided into depressed and nondepressed patients; (2) mg/m2 dose of dexamethasone was directly correlated with plasma dexamethasone (p less than 0.003) and inversely correlated with postdexamethasone plasma cortisol levels (p less than 0.04); and (3) a statistically significant inverse correlation between plasma dexamethasone levels and postdexamethasone cortisol levels (p less than 0.04). Our findings show that plasma dexamethasone levels are important in evaluating DST results in psychiatrically disturbed children and suggest that dexamethasone dosage for use in the DST in children might be better calculated in terms of body surface area.

Narcolepsy associated with lesions of the diencephalon.

Although symptomatic narcolepsy, or narcolepsy due to identifiable brain lesions, was once thought to be common, there are few well-documented reported cases since the discovery of the association of REM sleep abnormalities with narcolepsy. Even fewer such reports have been accompanied by human leukocyte antigen (HLA) testing. We report 3 patients who fulfill criteria for symptomatic narcolepsy, 1 with a craniopharyngioma, the 2nd with a hypothalamic syndrome of unknown etiology, and the 3rd with obstructive hydrocephalus and a sarcoid granuloma in the region of the 3rd ventricle. The first 2 were positive for HLA-DR2 while the 3rd was negative for the HLA-DR2 and HLA-DQwl antigens. These findings suggest that diencephalic lesions can be associated with signs and symptoms of narcolepsy that are clinically indistinguishable from those of idiopathic narcolepsy, and that the HLA-DR2 antigen is not required in all cases of symptomatic narcolepsy.

Pseudoarylsulfatase A deficiency in a psychiatrically disturbed adolescent.

A case of pseudoarylsulfatase A deficiency in an adolescent boy presenting with affective lability, impulsivity, aggression, inattention, and academic difficulties is described. Genetically related to metachromatic leukodystrophy, pseudoarylsulfatase A deficiency has generally been felt to be a benign disorder. Pseudodeficiency of arylsulfatase A has, however, been associated with serious psychiatric morbidity in recent studies. Possible explanations for this association are suggested. To the best of the authors' knowledge, this is the first case report of pseudoarylsulfatase A deficiency in a psychiatrically disturbed adolescent.

Mania associated with fluoxetine treatment in adolescents.

Fluoxetine, a selective serotonin reuptake inhibitor, is gaining increased acceptance in the treatment of adolescent depression. Generally safe and well tolerated by adults, fluoxetine has been reported to induce mania. The cases of five depressed adolescents, 14-16 years of age, who developed mania during pharmacotherapy with fluoxetine, are reported here. Apparent risk factors for the development of mania or hypomania during fluoxetine pharmacotherapy in this population were the combination of attention-deficit hyperactivity disorder and affective instability; major depression with psychotic features; a family history of affective disorder, especially bipolar disorder; and a diagnosis of bipolar disorder. Further study is needed to determine the optimal dosage and to identify risk factors that increase individual vulnerability to fluoxetine induced mania in adolescents.

Language disorders and learning disabilities in school-refusing adolescents.

OBJECTIVE: We undertook this study to test the hypothesis that school-refusing adolescents hospitalized on an inpatient psychiatric unit have more language and learning disabilities than diagnosis-, age-, and sex-matched psychiatric controls. METHOD: The Woodcock-Johnson Tests of Achievement-Revised (WJTA-R), the WISC-R, the Adolescent Language Screening Test, the Clinical Evaluation of Language Fundamentals-Revised, and the Test of Language Competence (TLC) were given to a group of well-characterized, primarily depressed school refusers and matched psychiatric controls. RESULTS: We found that school-refusing adolescents had significantly lower WISC-R verbal intelligence scores, lower Math and Written Language subscale scores on the WJTA-R, and lower scores on the TLC than nonrefusers. School refusers were found to have a significantly higher incidence of both language impairments and learning disabilities than controls. CONCLUSIONS: We infer that academic and communicative frustration and the adolescent's resulting inability to meet the academic and social demands in the school environment may play a role in the etiology of school refusal.

Update on lithium carbonate therapy in children and adolescents.

The use of lithium to treat child and adolescent psychiatric disorders is becoming more common. Since the publication of the report of The Committee on Biological Aspects of Child Psychiatry of the American Academy of Child Psychiatry in 1978, a considerable body of literature has accumulated on the efficacy of lithium in treating adolescent bipolar disorders, childhood aggression, and behavioral disorders associated with mental retardation and developmental disorders. Efforts to understand lithium's mechanism(s) and refinements in psychiatric diagnosis have contributed to its growing use.

Capgras syndrome in adolescence.

Capgras syndrome, the delusion of substitution, has rarely been reported in adolescents. The etiology is unknown, and intense controversy surrounds the debate over the relative importance of biological versus psychological factors. Presented here are two cases of Capgras syndrome in adolescents and a review of the relevant biological, neuropsychological, and psychodynamic literature. The authors suggest that the psychological processes underlying the Capgras delusion are mediated by neuroanatomical connections between various brain areas and hypothesize that the fundamental lesion in Capgras syndrome may be the patient's inability or failure to acknowledge the authenticity of a person they clearly recognize.

Global self-worth, specific self-perceptions of competence, and depression in adolescents.

OBJECTIVE: The purpose of this research was (1) to study adolescent depression severity in relation to global self-worth and specific self-perceptions of competence, and (2) to determine whether improvement in depression during hospitalization is accompanied by improvement in global self-worth and specific self-perceptions. METHOD: A within-subject longitudinal design with cross-sectional control subjects was used. Thirty depressed adolescent inpatients participated in assessments of depression severity (Hamilton Rating Scale for Depression) and self-perceptions of global self-worth and domain-specific competencies (Self-Perception Profile for Adolescents) at hospital admission and discharge (mean hospitalization: 59 days). A demographically similar group of 30 normal comparison subjects participated in the baseline assessment. RESULTS: Global self-worth was negatively associated with inpatients' depression severity and differentiated inpatients from normal comparison subjects. Self-perceptions of specific competencies were differentially related to depression severity, with perceived social acceptance being most clearly related to depression severity. Among the subgroup of inpatients showing clear and significant improvement in depression across hospitalization, increases in global self-worth and perceived social acceptance were also evident. CONCLUSIONS: Findings underscore the importance of considering global self-worth and self-perceptions of specific competencies in developmentally significant areas when assessing and treating adolescents.

Sleep deprivation in depressed adolescents and psychiatric controls.

Up to 70% of depressed adults have an antidepressant response to sleep deprivation. To study the effects of sleep deprivation on depression severity and level of arousal in psychiatrically disturbed adolescents, we deprived 17 patients of sleep for 36 hours. Severity of depression and subjective arousal were assessed at baseline, during sleep deprivation, and after 1 night's recovery sleep. We found that severely depressed adolescents showed a significant decrease in depression severity, whereas depressed patients in remission and psychiatric controls worsened after sleep deprivation. Patients with depression in remission showed a significant decrease in subjective arousal after sleep deprivation. In contrast to findings in depressed adults, the effects of sleep deprivation persisted after 1 night of recovery sleep, and diurnal variation of mood did not predict response to sleep deprivation. These findings are consistent with those reported in the adult literature, and suggest a common psychophysiology between adult and adolescent depression.

Parents' marital functioning and adolescent psychopathology.

Parents' marital functioning and adolescent psychopathology were investigated in 2 studies. The first study compared parents' marital satisfaction, conflict over childrearing, affective communication, and traditional role orientation in matched samples of psychiatric inpatient and control-group adolescents. The second study examined associations between specific dimensions of marital functioning and adolescent depression severity, suicidal ideation, and social adjustment in a larger sample of adolescent inpatients. In Study 1, parents of inpatients reported less marital satisfaction and more conflicts over childrearing than parents of control-group adolescents. In Study 2, marital conflicts over childrearing were associated with a less active or involved father-adolescent relationship and more severe school behavior and spare time problems. Marital functioning was not associated with depression severity or suicidal ideation.

Electroconvulsive treatment in adolescents with pharmacotherapy-refractory depression.

The effectiveness and safety of ECT in pharmacotherapy-refractory depression was examined in 11 hospitalized adolescents (ages 16.3 +/- 1.7 years, 10 females) with a primary DSM-III-R diagnosis of mood disorder, which had failed to respond to three or more adequate trials of antidepressant pharmacotherapy. After a thorough diagnostic evaluation, patients received a course of ECT involving 11.2 +/- 2.0 (range 8-15) administrations. ECT was commenced with bilateral treatment in 2 adolescents and nondominant right electrode placement in 9 patients; 5 of the 9 patients were subsequently changed to bilateral treatment. All 11 patients improved to a clinically significant degree. Significant improvements were noted in scores on the Children Depression Rating Scale-Revised (CDSR-R) and the Global Assessment of Functioning Scale (GAF) (p < 0.05). Euthymia, defined as CDRS-R score < or = 40, was achieved by 64% (7/11) of patients. The Mini-Mental State Examination showed no significant decline in cognitive functioning. Neuropsychological testing completed in 5 subjects both before ECT and 1-5 days after the last treatment, indicated a significant decline in attention, concentration, and long-term memory search. Minor side effects, experienced within the first 12 hours of treatment, were headache (80% of patients) and nausea/vomiting (64%). The potentially serious complication of tardive seizure (after full recovery of consciousness) occurred in 1 adolescent. Prolonged seizures (> 2.5 minutes) were noted in 7 of the 11 patients (9.6% of the 135 ECT administrations). Pending further research on ECT in youth, it is recommended that ECT should only be administered to youth in hospital settings, that all regularly administered psychotropic medications (including antidepressants) be discontinued before ECT and restarted after the final administration of ECT, and that physicians be aware that 12 treatments are usually sufficient, but that 15 treatments may occasionally be necessary for treating depressed adolescents. With the understanding that scientific evaluation of ECT in youth is lacking, it appears that ECT can be an effective and relatively safe treatment for depressed adolescents who have failed to respond to antidepressant pharmacotherapy.

Psychosocial functioning of severely disturbed adolescents after short-term hospitalization.

Forty-two severely emotionally disturbed adolescents discharged after a brief hospitalization for an acute psychiatric episode were assigned to two groups--one for whom clinicians recommended continued intensive treatment in an inpatient, residential, or day treatment setting, even though such services were not available, and the other for whom clinicians recommended only outpatient treatment. The two groups were compared on rates of rehospitalization, self-harmful actions, and suicide attempts and on severity of problems with peers during the six months after discharge. The two groups showed significant differences only in the extent of their problems with peers.

Suicide contagion among adolescents during acute psychiatric hospitalization.

OBJECTIVE: The study investigated whether exposure to other suicidal adolescents led to suicide contagion among patients hospitalized on an acute adolescent psychiatry unit. It also examined whether some adolescents express more suicidality during hospitalization than before admission. METHODS: Fifty-seven adolescents with a range of diagnoses admitted to a university-based psychiatric inpatient unit were assessed for suicidality at hospital admission and discharge using the Spectrum of Suicide Behavior scale and the Suicidal Ideation Questionnaire-Jr. Suicidal intent or behavior was the primary reason for admission of 58 percent of the patients. RESULTS: Despite many patients' severe suicide risk at hospital admission, 94 percent expressed no active suicidal intent and engaged in no behavior that could be considered suicidal during hospitalization. Four patients engaged in possibly suicidal, self-cutting behaviors; however, these incidents did not cluster in time. Fourteen patients (26 percent) expressed a significant increase in suicidal ideation during hospitalization, but the increase was not associated with study measures of exposure to other suicidal adolescents. CONCLUSIONS: Contagion of suicidal behaviors may not be a frequent or significant problem on acute adolescent inpatient units, although the phenomenon of increased suicidal ideation among some inpatients warrants further study.

Suicidal adolescents' perceptions of their family environment.

This study examined the extent to which adolescents' perceptions of their family environments were associated with suicidal behavior. Fifteen suicidal adolescents, 14 psychiatric controls, and 14 normal controls rated their families on cohesiveness, adaptability, parent-adolescent communication, parental caring, and parental over-protectiveness. Suicidal adolescents rated their families as the least cohesive and most rigid of the 3 groups, suggesting that adolescent suicidal behavior may occur when isolation is experienced within an inflexible family system. Suicidal and psychiatric control adolescents rated their families as similarly dysfunctional along the remaining variables, and as more dysfunctional than families of normal control adolescents. The implications of these findings are discussed, and it is suggested that several characteristics commonly attributed to families of suicidal adolescents may actually be general risk factors for adolescent psychopathology, rather than for suicidal behavior specifically.

A prospective study of adolescent suicidal behavior following hospitalization.

Identification of factors associated with adolescent suicidal behavior following psychiatric hospitalization would facilitate development of effective aftercare interventions. This prospective study identified specific predictors of suicidal behavior in 100 adolescents during a 6-month follow-up period. Standardized baseline assessments and structured follow-up telephone interviews were conducted with adolescents and their guardians. Eighteen percent of adolescents reported suicidal behavior during the follow-up period, primarily of low medical lethality and minimal or ambivalent suicidal intent. This behavior was associated with suicidal thoughts, family dysfunction, and dysthymia. It was not associated with initial posthospitalization treatment compliance. Implications of these findings are discussed.

Safety assessment of the neomycin phosphotransferase II (NPTII) protein.

Two approaches were used to assess the safety of the NPTII protein for human consumption using purified E. coli produced NPTII protein that was shown to be chemically and functionally equivalent to the NPTII protein produced in genetically engineered cotton seed, potato tubers and tomato fruit. The NPTII protein was shown, as expected, to degrade rapidly under simulated mammalian digestive conditions. An acute mouse gavage study confirmed that the NPTII protein caused no deleterious effects when administered by gavage at a cumulative target dosage of up to 5000 mg/kg of body weight. This dosage correlates to at least a million fold safety factor relative to the average daily consumption of potato or tomato, assuming all the potatoes or tomatoes consumed contained the NPTII protein. These results, along with previously published information, confirm that ingestion of genetically engineered plants expressing the NPTII protein poses no safety concerns.

Myoclonic seizures after abrupt withdrawal from phenelzine and alprazolam.

Monoamine oxidase inhibitors (MAOIs) are being used more frequently in the treatment of various psychiatric and neurological disorders. Although adverse effects of MAOI treatment are widely known, withdrawal symptoms are less well known. They include nausea, sweating, palpitations, nightmares, and psychosis. Withdrawal reactions from combination therapy with an MAOI and another agent are seldom described. Reported here is the occurrence of myoclonic seizures after the abrupt discontinuation of phenelzine and alprazolam. Alterations in the GABA and serotonin neurotransmitter systems as a result of withdrawal of the MAOI and the benzodiazepine may account for the seizures.