Creativity and psychosis. An examination of conceptual style.

The performance of creative writers on the Goldstein-Sheerer Object-Sorting Test was compared with that of admitted manic and schizophrenic patients. Writers and manics tended to show more behavioral and conceptual overinclusion, but the writers showed substantially more richness and the manics more idiosyncratic thinking. Schizophrenics tended to be underinclusive rather than overinclusive and showed less richness and bizarreness than the writers and manics. These data imply that the conceptual style of writers may resemble mania more than schizophrenia and that, if overinclusiveness is an index of thought disorder, manics may have a more florid thought disorder than schizophrenics.

Weight loss and the heart. Effects of anorexia nervosa and starvation.

Anorexia nervosa is a common psychiatric disorder predominantly affecting young women, associated with significant morbidity and mortality, much involving the cardiovascular system. In contrast, protein-calorie malnutrition, while not strictly analogous to the protein-sparing characteristics often noted in anorexia nervosa, is a problem of global stature. Physiologic consequences of anorexia nervosa include rhythm disturbances, mitral valve prolapse, plus both systolic and diastolic ventricular dysfunction. Diminished exercise capacity occurs in both states, with marked blunting of the heart rate and blood pressure response. Congestive heart failure may appear, especially during refeeding. In addition to the myofibrillar destruction associated with protein-calorie malnutrition, hypophosphatemia, particularly when exacerbated by unrestricted glucose-rich refeedings or hyperalimentation, may be one additional cause of ventricular dysfunction. A high level of suspicion for cardiovascular complications is, therefore, warranted in the evaluation and therapy of weight loss conditions such as starvation and anorexia nervosa.

Heart failure during treatment of anorexia nervosa.

The author presents data on three anorectic patients who developed heart failure during the nutritional rehabilitation phase of their treatment. After discussing possible reasons for the patients' cardiac decompensation, she suggests procedures for the prevention and early detection of heart failure in anorectic patients during the recovery phase.

Psychosis, thought disorder, and regression.

Focusing on the definition, scope, and role of psychiatry today, the author discusses whether psychiatry is primarily medical, whether it is overstepping its boundaries in attempting to treat problems of living, and whether it is too involved with social questions. On the basis of an examination of the current scientific base of psychiatry, he predicts that psychiatry will continue to grow in size and diversity, that it will refocus substantially on biological issues, that it will become more humble about what it can do with regard to social problems, and that it will continue to yield new therapeutic measures and techniques.

Perceptual and cognitive abnormalities in bulimia.

The authors compared 55 bulimic subjects and 55 normal control subjects using the Beck Depression Inventory, a new scale designed to detect cognitive distortions (the Bulimia Cognitive Distortion Scale), and several perceptual and attitudinal measures of body image. There were significant differences between the bulimic and control groups on all measures except estimates of face width. These findings are discussed in terms of a multifactorial theory of the psychopathogenesis of bulimia.

Neuroleptic malignant syndrome associated with clozapine use.

Clozapine, an atypical antipsychotic drug, is indicated for severely ill schizophrenic patients refractory to treatment with conventional neuroleptics. One advertised advantage of clozapine is the absence of associated neuroleptic malignant syndrome (NMS). On the basis of a clinical case, the authors question this claim. They are concerned that this potentially fatal condition may be misdiagnosed if physicians are not aware of possible NMS associated with the use of clozapine.

Anorexia nervosa and diabetes mellitus.

Four patients who developed anorexia nervosa after the onset of diabetes mellitus are described. It is postulated that the co-occurrence of the two conditions was not coincidental, but that each contributed to the development of the other. The nature and treatment of diabetes offer numerous opportunities for the anorexic patient to lose weight by a variety of dangerous maneuvers, including adjustment of the insulin dose, failure to inject insulin, secret vomiting, and failure to provide urine samples. Treatment of patients with both conditions is a therapeutic challenge to the psychiatrist and diabetologist. A behavior management program combined with psychotherapy is most often effective.

Outcome of gastric restriction procedures: weight, psychiatric diagnoses, and satisfaction.

BACKGROUND: Weight losses following bariatric surgery have varied widely, depending on length of follow-up and various pre-surgical characteristics of patients undergoing surgery. METHODS: One hundred thirty one patients had a detailed presurgical psychiatric evaluation. Patients were assessed clinically for 2 years after surgery and at follow-up a mean of 5.7 years after surgery. RESULTS: Mean presurgical body mass index (BMI) was 52.9 kg/m2; therefore, many patients had 'super obesity'. Two-thirds of the patients were located a mean of 5.7 years after surgery. The mean change in BMI at follow-up was 25% and the mean weight loss was 27%. One-third had excellent or good weight outcomes using the Griffen criteria. Five patients had died by follow-up. There was no relationship between age, gender, or fat content presurgically and weight loss at follow-up, although presurgical weight was associated with greater weight loss at follow-up. Weight regain began 2 years after surgery. There was no relationship between the presence or absence of a presurgical psychiatric diagnosis and weight loss at follow-up. There was also no relationship between the presence of a presurgical psychiatric diagnosis and various mental health parameters at follow-up. Satisfaction with the surgery was marginally associated with weight loss but significantly associated with improved mental and physical health. CONCLUSIONS: Mean weight losses were less than have been previously reported with gastric restriction procedures but the follow-up was longer than usually reported and many patients had 'super obesity' prior to surgery. The implications of 'super obesity' for weight loss are discussed.

Bariatric surgery and multiple personality disorder: complexities and nuances of care.

BACKGROUND: Multiple personality disorder (MPD) can occur in patients with morbid obesity in need of bariatric surgery, though few reports noting this association exist in the literature. Herein we address MPD in morbid obesity, in the context of a patient presenting to us seeking surgical treatment of her morbid obesity. METHODS: A 31-year-old morbidly obese (BMI 49 kg/m2) Hispanic female presented in early 1994 requesting bariatric surgery. She had been a victim of violent sexual abuse as a young girl. Subsequently, she developed at least three personalities, including one male personality. RESULTS: Although she has lost nearly 45 kg after gastroplasty, her care has been complicated by her named multiple personalities. While MPD are infrequent and unfamiliar to most care providers, successful outcomes can be promoted with a proper approach. CONCLUSIONS: This patient's care illustrates that: (1) all personalities must agree to proposed operative intervention; (2) consent must be obtained from the 'true' patient; and (3) postoperative care and follow-up must address all personalities for an optimal outcome.

Initial assessment and early treatment options for anorexia nervosa and bulimia nervosa.

This article presents the essential aspects of assessment of patients with anorexia nervosa or bulimia nervosa. The evaluation of the athlete with a suspected eating disorder is described. The choice of appropriate type and site of treatment is discussed. Throughout the article there is an emphasis on methods that can be useful in assisting the patient to acknowledge his or her illness and participate in treatment. The need to focus simultaneously on psychological and relationship issues and nutritional status is stressed.

Untreated anorexia nervosa. A case study of the medical consequences.

This case demonstrates the devastating physical sequelae of 30 years of untreated anorexia nervosa. A full array of these consequences occur in this one patient and include the following: malnutrition and hypoproteinemia, electrolyte disturbances, cortical atrophy with hydrocephalus ex vacuo, tricuspid and mitral valvular dysfunction, anemia, impaired lower gastrointestinal motility, delayed gastric emptying, disturbances in the hypothalamic pituitary target organ axes, severe osteoporosis, marked edema, and extreme muscle wasting. Other possible physical sequelae of her anorexia nervosa are discussed. Psychiatrists, as well as other physicians, should be vigilant in diagnosing this illness and treating it as early as possible. This particular patient was in the medical system for numerous admissions and workups over three decades before the correct diagnosis of anorexia nervosa was made.

A vision-based technique for objective assessment of burn scars.

In this paper a method for the objective assessment of burn scars is proposed. The quantitative measures developed in this research provide an objective way to calculate elastic properties of burn scars relative to the surrounding areas. The approach combines range data and the mechanics and motion dynamics of human tissues. Active contours are employed to locate regions of interest and to find displacements of feature points using automatically established correspondences. Changes in strain distribution over time are evaluated. Given images at two time instances and their corresponding features, the finite element method is used to synthesize strain distributions of the underlying tissues. This results in a physically based framework for motion and strain analysis. Relative elasticity of the burn scar is then recovered using iterative descent search for the best nonlinear finite element model that approximates stretching behavior of the region containing the burn scar. The results from the skin elasticity experiments illustrate the ability to objectively detect differences in elasticity between normal and abnormal tissue. These estimated differences in elasticity are correlated against the subjective judgments of physicians that are presently the practice.

Osteoporosis and eating disorders.

Osteoporosis is a common complication of anorexia nervosa. Multiple factors increase risk, including decreased body weight and fat content, elevated cortisol levels, inadequate vitamin D and calcium intake, and amenorrhea and hypoestrogenemia. There is both decreased bone formation and increased bone resorption in the osteoporosis of anorexia nervosa. Treatment includes weight normalization and supplemental calcium and vitamin D. Unlike postmenopausal osteoporosis, estrogen replacement does not prevent or correct the osteoporosis that occurs in anorexia nervosa. Patients with bulimia nervosa or an eating disorder not otherwise specified may also be at risk of osteoporosis, especially if they have had a prior episode of anorexia nervosa.

Psychiatric status, prevention, and outcome in patients with burns: a prospective study.

One hundred consecutive patients admitted to the Tampa Bay Regional Burn Center were assessed to determine cause of injury, preburn psychiatric status, and outcome (survival, length of stay in the hospital, and emergence of new psychiatric or physiologic disorders). Patients with psychiatric disorders were more likely to have injuries that were preventable, and there was a trend for this group to have more emergent psychiatric disorders and longer lengths of hospital stay. We suggest that the Burn Severity Index might be revised to include the presence of preburn psychiatric disorders and then be evaluated in a larger group with use of the Burn Registry.

Safety and efficacy of debridement under anesthesia in patients with burns.

Burn wound debridements requiring blunt or sharp manipulations are extremely painful even when large nonanesthetic doses of morphine are used. In this study we describe the use of debridement while the patient is under anesthesia (DUA) when manipulation of the wound is required. Seventy-one debridements were performed on 46 patients. One patient required additional fluids during the DUA, but no deaths, extensive blood losses, or significant changes in nutrition attributable to the DUA occurred. The mean number of required DUAs was 1.6 per patient compared with 6.0 per patient reported in a previous study from the same burn center that involved standard parenteral analgesic doses of morphine sulfate. Patients were completely anesthetized during the procedure. Therefore, they were free of pain and were amnestic for the experience. We conclude that DUA is a safe, efficacious procedure that permits full relief from the pain usually experienced during a manipulative burn wound debridement.

Posttraumatic stress disorder in patients with burns.

Among 39 patients with burns evaluated a mean of 12 months after hospital discharge, 38% met DSM-III-R criteria for post-traumatic stress disorder (PTSD) for at least 1 month. With proposed DSM-IV criteria, 43% met criteria for past or current PTSD. Analysis of specific symptom clusters of PTSD revealed that 74% of patients had been affected by a reexperience symptom for at least 1 month, but only 30% were currently experiencing flashbacks. No correlation was found between several clinical correlates (TBSA, length of hospitalization, and age) and development of PTSD. There was no correlation between presence of a DSM-III-R psychiatric diagnosis at the time of hospitalization and later development of PTSD and no correlation between whether or not a psychiatric diagnosis emerged during hospitalization and later development of PTSD. Finally, patients who had injuries that they could not prevent were no more likely to experience PTSD.

Self-inflicted burns: a ten-year retrospective study.

In this 10-year retrospective survey of 2216 admissions to a regional burn center, 15 patients (0.67%) had self-inflicted burn wounds. The burns were serious, with a mean abbreviated burn severity index of 11.2, and eight patients died of their injuries. Nine patients had a documented history of psychiatric problems, seven of whom had undergone a previous psychiatric hospitalization. A psychiatric assessment was obtained for 12 patients immediately after self-immolation, and all but one had a major psychiatric disorder. Seven patients had major depression and four had chronic paranoid schizophrenia. Motives were assessed, both by chart review and by interview of five available survivors and of relatives of nonsurvivors. Fewer than half actually intended to kill themselves; equally important was the theme of attempting to control internal psychotic states.

Alcohol disorders among patients with burns: crisis and opportunity.

A burn injury so severe that inpatient treatment is necessary is a crisis in any patient's life. For patients who also suffer from an alcohol use disorder, hospitalization may offer a unique opportunity to facilitate entry into appropriate treatment. In this study, 442 hospitalized patients with burns were evaluated, and 50 (11%) were diagnosed with an alcohol use disorder by DSM-III-R criteria. All but one of the injuries were deemed preventable. The average length of stay in hospital was 9 days longer for the alcohol group compared with the average stay in the burn center, resulting in additional costs of $337,500. Referral for treatment of the underlying alcohol disorder was recommended for fewer than half the patients. Thus, although the patients with alcohol use disorders had lengthy hospitalizations and were in circumstances that might permit the characteristic denial of alcoholism to be relinquished, the treatment team usually did not capitalize on this opportunity.

Scar assessment: current problems and future solutions.

Current problems in the assessment of scars are discussed. The concept of subjective and objective aspects of scar assessment is introduced. The patient's own view of the scar (the subjective component) can currently be assessed and may be very influential in determining the patient's quality of life, irrespective of the actual physical characteristics of the scar. The objective aspects of the scar, including size, shape, texture, and pliability, are currently difficult to measure. Although the Vancouver Scar Scale has been used as the standard for objective measurements, there are problems with both the validity and reliability of this instrument. Various imaging techniques may permit more reliable and accurate methods for measuring the quantitative aspects of scars.

Weight problems in adolescence.

Even the normal adolescent must incorporate into his body image radical changes in size, body proportions, and sexual characteristics. Obesity and anorexia, which are commonplace, may be sensitive problems to deal with.