Psychocutaneous disorders.

Dermatologic conditions are commonly associated with psychiatric sequella, eg, urticaria, alopecia, psoriasis, or acne. Moreover, the onset and course of dermatologic disorders may be significantly influenced by stress, emotional disturbances, or psychiatric disorder. Compulsions involving the skin, excoriations, or hair pulling (trichotillomania) are the more frequently encountered problems. In some cases, skin conditions are self-induced or reflect signs or symptoms of an underlying psychiatric disorder, including psychosis or obsessive-compulsive disorder. Additionally, skin lesions have been frequently described in case reports of factitious dermatitis. Finally, adverse effects of psychotropic drugs may cause dermatologic side effects, mostly idiosyncratic skin eruptions. These problems are discussed with emphasis on clinical features, comorbidity, and psychiatric management.

Disagreement in the reporting of depressive symptoms between patients with dementia of the Alzheimer type and their collateral sources.

The authors investigated sources of disagreement on the Geriatric Depression Scale (GDS) between patients and their collateral sources (CSs). There were 198 subjects with possible or probable Alzheimer's disease (DAT) and 64 cognitively intact subjects evaluated at an outpatient geriatric assessment center. The 30-item GDS was completed by the patient and the CS version of the GDS by the CS. A sizable discrepancy was found in the reporting of depressive symptoms by the subjects vs. the CSs. Multiple-regression analyses revealed that both level of insight and level of physical illness in the subjects with DAT significantly influenced the discrepancy. An increased sense of burden in the CSs was associated with a larger symptom gap in both DAT and control subjects. CSs consistently perceived more depressive symptoms than subjects, especially subjects with DAT who had no insight into their cognitive impairment.

Effective use of anxiolytics in older adults.

This article reviews the current classification of anxiety disorders and the frequency of these disorders in older adults. General treatment principles are discussed, and an overview of anxiolytic medications is presented. Use of these anxiolytic agents in specific disorders is then discussed, followed by a brief review of non-pharmacologic treatment approaches to anxiety disorders.

Psychotherapeutic agents in older adults. Sedative hypnotics and sleep.

Complaints about sleep are prominent among geriatric patients. Insomnia is a prominent feature of many psychiatric and general medical conditions. The physiologic effects of aging and primary sleep disorders also contribute to insomnia, sleep pattern changes, daytime sleepiness, and dozing. The clinical approach to insomnia requires a thorough diagnostic assessment as well as study of sleep habits and hygiene. Hypnotic agents may be useful in providing short-term relief. Pharmacologic intervention is best combined with nonpharmacologic approaches that improve the efficiency of sleep.

The use of selective serotonin reuptake inhibitors for depression and psychosis complicating dementia.

This retrospective chart review examines the impact of selective serotonin reuptake inhibitors on 20 patients with both depression and psychosis complicating dementia of the Alzheimer type (DAT) and other dementias. Fifteen of the 20 patients had moderate to marked improvement in depressive and psychotic symptoms. Eleven of 12 patients with DAT had moderate to marked improvement compared to only four of eight patients with dementia from other causes. The drugs were effective in diminishing or eliminating psychotic symptoms in six patients who had previously not responded to a trial of a neuroleptic. The selective serotonin reuptake inhibitors may have an important role to play in patients with DAT who have coexisting depression and psychosis. These drugs are very well tolerated and may have a place as first-line agents in non-emergent settings where a clinician might otherwise think of instituting a neuroleptic or as a second-line agent when a neuroleptic has proven ineffective.

Anxiety disorders and insomnia in geriatric patients.

Anxiety and insomnia are among the more frequently encountered problems in geriatric cases. The effective clinical approach identifies underlying diagnostic syndromes or general medical conditions. An integrated approach to management combines pharmacotherapy and behavioral interventions as appropriate. Overall the prognosis for most patients is excellent.

Challenges and opportunities for consultation-liaison psychiatry in the managed care environment.

While the evolving managed care revolution is dramatically changing the clinical, educational, and economic systems in which consultation-liaison (C-L) psychiatrists must operate, this revolution also present several important opportunities for those in C-L psychiatry. The authors, who are academic department chairs and formerly directed C-L divisions, discuss C-L psychiatry's potential involvement and suggest approaches to effectively address key aspects of these changes.

Measures of psychiatric symptoms in Alzheimer patients: a review.

This review of instruments for the identification and quantification of psychiatric symptoms in Alzheimer disease (AD) is intended as a reference source for clinicians and researchers concerned with evaluating, quantifying, and managing psychiatric symptoms in AD. We review 16 clinician- and caregiver-rated scales selected from >30 scales on the basis of their face validity, their psychometric properties, the frequency of their use, and their promise as assessment instruments. Instruments are described in terms of the population on which they were developed, the symptoms assessed, informant, by whom administered, time to administer, time interval covered, number of items, measurement of frequency and severity, assessment of impact on caregiver, reliability, validity, and scoring. Recommendations are made concerning the best use of each scale. We summarize in table form the sources of information for instruments, characteristics of the instruments by domain, and potential use of instruments for quantification or management of symptoms and for estimation of caregiver burden. There are a number of reliable and valid scales for the assessment of psychiatric symptoms in AD, each with specific assets and liabilities. Knowledge of the specifics of these scales will enable clinicians and researchers to select the best instruments for their particular needs and to design more effective instruments.

Predicting response to fluoxetine in geriatric patients with major depression.

No consensus exists regarding whether early response to an antidepressant strongly predicts a good outcome, what is the criterion for early response, or when to measure it. We hypothesized that early response (> or = 20% decrease in HAM-d21) after any of weeks 1, 2, or 3 of fluoxetine treatment of major depression in geriatric outpatients would predict a favorable outcome by week 6 or an earlier endpoint accurately enough for clinical use. We also hypothesized that the week 1, 2, and 3 percent changes in 21-item Hamilton Rating Scale for Depression (HAM-D21) would predict the percent change at week 6 (or endpoint) accurately enough for clinical use. We enrolled 671 elderly outpatients with unipolar DSM-III-R major depression in a double-blind, placebo-controlled trial of fluoxetine, 20 mg/day. For analysis, fluoxetine-treated patients were randomly divided into a development set (N = 154) for a preliminary test of our criteria and a validation set (N = 181) to validate the development data set's results. Early responders at weeks 1, 2, and 3 were statistically significantly more likely to experience marked improvement or remission than those lacking early response. However, at week 3, this criterion correctly classified only about three-fourths of patients with regard to marked improvement and only about two-thirds with regard to remission. Moreover, about one-third of patients predicted to experience marked improvement and about three-fifths of those predicted to remit did not. The continuous variable, percent change in HAM-D21, did not produce predictive results of any greater clinical utility. We believe that the sensitivity, specificity, false-positive rate, false-negative rate, and kappa of outcome predictions all should be reported in future studies. Without a full set of descriptive statistics, clinicians can be misled by statistically significant results.

Munchausen's syndrome and other factitious disorders.

Factitious disorders including Munchausen's syndrome are likely encountered by all clinicians during their career. Neurologic presentations are common, especially with Munchausen's syndrome by proxy. An appropriate index of suspicion and nonjudgemental confrontation and psychiatric consultation facilitate a successful clinical approach. Redefining the factitious illness as psychiatric with continued involvement of a primary physician and family support are also keys to successful management. Underlying psychiatric syndromes need to be assiduously evaluated and steadfastly treated. Prognosis is best for patients who do not meet criteria for Munchausen's syndrome or who have psychosocial supports and less severe personality pathology.

Psychiatric education improves internists' knowledge: a three-year randomized, controlled evaluation.

Trainees were randomized into four groups: (1) control; (2) consult; (3) liaison; or (4) consult-plus-liaison to evaluate the psychiatric knowledge gained after two different training programs for primary care residents. Consult was a 1-month rotation on the Psychiatry Consultation Service. Liaison consisted of 31-hour workshops over 1 year. Consult-plus-Liaison refers to both training programs, experienced in consecutive years. An oral examination was administered before and after training. The analysis of variance and tests of simple effects revealed significant training effects for both groups. The effect size of training was greater for residents exposed to both programs, compared with either one alone. The two different training programs were both effective in improving the psychiatric knowledge of primary care residents and exposure to both programs proved superior to either one alone.

Pharmacokinetics and psychopharmacology: application to the geropsychiatric patient.

Understanding pharmacokinetics is an important step in the confident administration of psychotropic drugs. Changes in pharmacokinetics have particular implications for the geropsychiatric patient who will experience a variety of physiological changes that could potentially affect the intensity and duration of drug effects.

Culture as a variable in drug therapy.

Few studies exist on culture as a variable in psychopharmacological intervention and response. Differences exist, but are they genetic? environmental? social?

The role of psychological factors in gastrointestinal conditions. A review pertinent to DSM-IV.

The authors reviewed the literature to assess the relationship between psychological factors and gastrointestinal conditions. The conditions that were found to be more relevant and worthy of future investigation were nonulcerative dyspepsia, inflammatory bowel disease (regional enteritis), and irritable bowel syndrome. The pertinent findings suggest that an important link exists between psychological factors and gastroenterological disorders, which supports the need for modification of the DSM-III-R's diagnostic category, "Psychological Factors Affecting Physical Condition." In concert with a subcommittee addressing other organ systems and psychological factors, the authors conclude that a diagnostic approach with greater utility would be useful for both researchers and clinicians. A conceptual framework as proposed in DSM-IV could also advance knowledge of psychological factors and their contribution or role in the etiology, perpetuation, and exacerbation of certain gastrointestinal conditions.

The role of psychological factors in dermatologic conditions.

Knowledge about the psychiatric factors affecting dermatologic illness is far from conclusive. Studies in the past decade have strengthened concepts regarding associated psychological factors. Many dermatologic conditions are now considered in the context of genetic predisposition, personality, and biopsychosocial factors. Several psychotropic medications have been observed to affect dermatologic conditions. This article reviews the research and clinical reports of the past decade that address nosologic and diagnostic aspects of psychological factors affecting dermatologic conditions. This article is a result of the efforts of a work group to propose revisions to the DSM-III-R diagnostic category of psychological factors affecting physical condition and supports the need for a systematic, nosologic schema that would potentially increase our knowledge and improve our understanding of this important psychosomatic domain.

The relationship of high-intensity signals on magnetic resonance images to cognitive and psychiatric state in Alzheimer's disease.

In Alzheimer's disease (AD), the relationship between white-matter changes on magnetic resonance images and behavior are unclear. Therefore, magnetic resonance images, cognition, and psychiatric state were assessed in patients with AD with depression (AD/DEP; n = 18) and without depression (AD; n = 45), older depressed patients (n = 12) and older normal individuals (n = 25). High-intensity signals in the cortex and subcortical regions were similar in number and proportions among all groups, even when hypertensive patients were excluded. No correlations to cognitive or psychiatric state were found. Periventricular signals were categorized using a 1- (absent) to 6- (thick, irregular caps and stripes) point scale. The categories were similar among groups except that patients with AD exhibited more category 5 changes than did normal subjects, neuropsychological performance was significantly worse in patients with AD who had category 5 and 6 changes when compared to those in category 1. These results suggest that periventricular changes may predict poor neuropsychological performance in patients with AD. However, neither deep white-matter lesions nor periventricular changes are useful for diagnostic purposes.