Self-injurious behavior: pathophysiology and implications for treatment.

BACKGROUND: Self-injurious behavior (SIB) is a common clinical problem that affects a diverse group of patients and populations. Little is known about the underlying pathophysiology and pharmacologic treatment of SIB. METHOD: The authors selectively reviewed the clinical literature on SIB and related aggressive/impulsive behaviors, with the aim of formulating provisional guidelines for pharmacotherapy. RESULTS: The serotonergic system is most directly implicated in the pathophysiology of SIB and related behaviors. While there is no well-established "drug of choice" for SIB, the identification of specific subgroups of SIB patients and associated symptoms such as psychosis permits the rational selection of medication. Serotonin selective reuptake inhibitors, other serotonergic agents, antipsychotics, beta-blockers, and opiate antagonists all play a role in the treatment of SIB. CONCLUSION: SIB is not a single entity and may have different pharmacologic treatments, depending on the associated symptoms and target population. Medications that act on the serotonergic system appear to be the most promising.

Factitious disorders with psychological symptoms.

BACKGROUND: Factitious disorders with psychological symptoms have been underdiagnosed and hence undertreated. Historically, the literature has focused on factitious disorder with physical symptoms, particularly Munchausen's syndrome. METHOD: The authors report three cases of factitious disorder with psychological symptoms that had diverse clinical presentations. RESULTS: Two of the patients had features of a psychiatric Munchausen's syndrome--being middle-aged, aggressive men who falsified their symptoms, treatments, and backgrounds. The third patient was a younger woman with comorbid substance abuse, dysthymia, and borderline personality disorder. CONCLUSION: The authors feel that there is a need for refinement of diagnostic criteria, greater awareness, and evaluation of treatment approaches for this condition.

Clozapine and associated diabetes mellitus.

BACKGROUND: Clozapine is an effective therapy for the treatment of refractory psychosis. Clozapine-associated adverse effects include sedation, weight gain, sialorrhea, palpitations, seizures, and hematologic changes such as agranulocytosis. METHOD: We present a four-case series in which clozapine use was associated with either a de novo onset or severe exacerbation of preexisting diabetes mellitus. RESULTS: The change in glycemic control was not significantly related to weight gain. Three of the patients have been able to continue on clozapine therapy and have experienced a reduction in psychotic symptoms. CONCLUSION: Patients with a family history of diabetes mellitus or with preexisting diabetes mellitus may need to have blood sugar monitored closely during initiation of clozapine treatment.

Occurrence of seizures related to psychotropic medication among psychiatric inpatients.

OBJECTIVE: Seizures associated with psychotropic medication are serious and reportable adverse drug reactions. This study examined the occurrence of seizures associated with psychotropic medication during psychiatric hospitalization. METHODS: Among 10,994 admissions to a psychiatric teaching hospital over a 30-month period between 1990 and 1993, 29 patients were identified by a specially trained quality assurance nurse as having seizures that were probably related to psychotropic medication. These cases were verified by a clinical pharmacist and a psychopharmacologist. Two patients were excluded, and the records of 27 patients were reviewed in detail. RESULTS: Nineteen of the 27 patients (70 percent) whose seizures were related to psychotropic medication had a preexisting seizure disorder, and eight had new-onset seizures. Psychotropic medications were primarily implicated as being associated with seizures in the cases of three of the 19 patients with preexisting seizure disorders (15.8 percent) and five of the eight patients with new-onset seizures (62.5 percent). In the group with preexisting seizure disorders, six patients (32 percent) had subtherapeutic blood levels of antiseizure medication, and four (21 percent) experienced pseudoseizures. CONCLUSIONS: Seizures among inpatients on psychotropic medication were infrequent (.3 percent of psychiatric admissions); the majority (70 percent) occurred in patients with preexisting seizure disorders. Seizures were directly attributed to psychotropic medications in less than .1 percent of admissions.

Sertraline and psychotic symptoms: a case series.

Sertraline and other SSRIs have a relatively favorable side-effect profile and are widely prescribed. We report the emergence of psychotic symptoms during treatment with sertraline in four patients. Three of these patients had a history of psychotic illness and were on antipsychotic medication, when sertraline was added. The psychotic symptoms emerged within 3 days-7 weeks of starting sertraline and resolved on its discontinuation. We wish to alert clinicians to the possibility that sertraline may provoke or exacerbate positive psychotic symptoms, particularly in patients on neuroleptics, with a previous history of psychosis.

Sleepwalking.

Sleepwalking is one of the parasomnias, a group of disorders that also includes night terrors, nocturnal enuresis and nightmares. This disorder of arousal is much more common in children than in adults, and it is commonly associated with other parasomnias. Sleepwalking typically occurs during the first three hours of sleep, when sleep stages 3 and 4 (non-rapid-eye-movement sleep) are most prevalent. The episodes usually last 30 seconds to 30 minutes. The differential diagnosis of sleepwalking includes partial complex seizures occurring during sleep, rapid-eye-movement behavior disorder, night terrors, malingering, dissociative phenomena and medication effects. The treatment of sleepwalking in children includes providing a regular sleep-wake schedule, ensuring that the child has sufficient sleep and reassuring the parents. Medications and psychotherapy may be indicated in some adult patients.

Transfer of psychiatric inpatients to a general hospital due to adverse drug reactions.

The authors review their experience with transfers of hospitalized psychiatric inpatients to general hospitals because of adverse drug reactions (ADRs). A total of 29 medical transfers related to ADRs were found in a review of 10,994 psychiatric inpatient admissions that occurred in a 30-month period between 1990 and 1993 (0.264%). Most cases involved neurological syndromes (76%), particularly delirium (31%). Low-potency antipsychotic agents were most frequently implicated (31%). Most ADRs were of moderate severity, but 8 cases required medical hospitalization (0.07% incidence). These findings indicate that ADRs leading to transfer of hospitalized psychiatric patients to a general medical facility were infrequent (< 0.3% of psychiatric admissions) and rarely led to medical hospitalization (< 0.1%).

Bupropion and anticonvulsant drug interactions.

The use of bupropion (BUP) involves a higher seizure risk than the use of other antidepressants, limiting its dose and widespread use. The two reported cases document anticonvulsant-BUP drug interactions through plasma levels. Carbamazepine appeared to decrease the plasma BUP to nondetectable levels, while hydroxybupropion was found at very high levels. Data presented suggest that BUP may increase sodium valproate levels. Conclusions from these case reports are tentative, pending further study. Monitering of BUP and its metabolites may ultimately prove useful in guiding clinicians dosing decisions, especially when mood stabilizers are combined with other psychotropic drugs in refractory bipolar patients.

Is there a relationship between clozapine and obsessive-compulsive disorder?: a retrospective chart review.

The emergence of obsessive-compulsive symptoms during clozapine treatment has been reported in recent case studies, yet the incidence and significance of this finding is still unclear pending reliable data from a larger sample of patients. Hospital records of 142 randomly selected inpatients started on clozapine treatment at McLean Hospital before July 1, 1992, were reviewed retrospectively. Based on a limited retrospective chart review, there were no definitive cases of patients who developed obsessive-compulsive disorder (OCD) or whose OCD worsened as a result of clozapine treatment. Although some fluctuation of OCD symptoms may have occurred in two cases, it is unclear whether those symptoms were related to treatment with clozapine (or other psychotropic drugs) or to undulations in the natural history of OCD. No definitive relationship between OCD symptoms and clozapine treatment could be established in this limited study. Further clarification of this matter awaits outcome research using prospective methodologies.