Posttraumatic stress disorder as a risk factor for obesity among male military veterans.

OBJECTIVE: Obesity is a significant public health problem in the United States, particularly among military veterans with multiple risk factors. Heretofore, posttraumatic stress disorder (PTSD) has not clearly been identified as a risk factor for this condition. METHOD: We accessed both a national and local database of PTSD veterans. RESULTS: Body mass index (BMI) was greater (P < 0.0001) among male military veterans (n = 1819) with PTSD (29.28 +/- 6.09 kg/m(2)) than those veterans (n = 44 959) without PTSD (27.61 +/- 5.99 kg/m(2)) in a sample of randomly selected veterans from the national database. In the local database of male military veterans with PTSD, mean BMI was in the obese range (30.00 +/- 5.65) and did not vary by decade of life (P = 0.242). CONCLUSION: Posttraumatic stress disorder may be a risk factor for overweight and obesity among male military veterans.

Naloxone fails to prolong seizure length in ECT.

Electroconvulsive shock (ECS) in animals has been shown to enhance endogenous opiate systems. The anticonvulsant effects of ECS are also partially blocked by the opiate receptor antagonist naloxone, leading some investigators to postulate that the anticonvulsant effects of ECS are mediated by activation of endogenous opiates. If such a phenomenon occurs in humans, then naloxone might prolong seizure length in electroconvulsive therapy (ECT). In the present study, nine patients were given 2.0 mg intravenous (i.v.) naloxone 2 minutes prior to one-half of their ECT treatments. Motor seizure length was measured via the cuff technique. EEG tracings were read by an investigator blind to naloxone status. There was no difference between the two groups in either EEG or nonblindly evaluated motor seizure length. It is concluded that a dose of 2 mg naloxone does not effectively increase seizure length in ECT.

Is bipolar disorder still underdiagnosed? Are antidepressants overutilized?

BACKGROUND: Previous studies have suggested that bipolar disorder may be underdiagnosed, and that antidepressants may be over-utilized in its treatment. METHODS: Consecutively admitted patients (n =48) diagnosed with DSM-IV bipolar disorder, type I, (n = 44) or schizoaffective disorder, bipolar type, (n = 4) were interviewed systematically and their charts were reviewed to confirm diagnosis before admission. They were then treated according to systematic structured interview diagnoses. These data reflect the changes in diagnoses and treatment. RESULTS: 40% (19/48) were identified with previously undiagnosed bipolar disorder, all previously diagnosed with unipolar major depressive disorder. A period of 7.5+/-9.8 years elapsed in this group before bipolar diagnosis was made. Antidepressant use was high on admission (38%) and was reduced with acceptable treatment response rates. The adjunctive use of risperidone appeared to be a good treatment alternative. LIMITATIONS: While diagnoses were made prospectively, treatment response was assessed retrospectively, and was based on non-randomized, naturalistic therapy. CONCLUSIONS: Systematic application of DSM-IV criteria identified previously undiagnosed bipolar disorder in 40% of a referred population of patients with mood disorders, all previously misdiagnosed as unipolar major depressive disorder. Antidepressants appeared overutilized and risperidone was an effective alternative adjunctive therapy agent.

Neuroleptic malignant syndrome: a review.

OBJECTIVE: Neuroleptic malignant syndrome is an uncommon side effect of antipsychotic medications characterized by severe rigidity, tremor, fever, altered mental status, autonomic dysfunction, and elevated serum creatinine phosphokinase and white blood cell count. This paper presents a concise and comprehensive review of neuroleptic malignant syndrome, written with the practitioner in mind, to provide information that will be useful in actual clinical settings. METHODS: MEDLINE was searched from 1966 to 1997 for key reviews, reports on series of cases of neuroleptic malignant syndrome, individual case reports, and other clinically and theoretically important information. RESULTS AND CONCLUSIONS: Virtually all neuroleptics are capable of inducing the syndrome, including the newer atypical antipsychotics. The standard of care for the recognition of neuroleptic malignant syndrome has shifted considerably over the past 15 years. Neuroleptic malignant syndrome belongs in the differential diagnosis of any patient receiving a neuroleptic who develops a high fever or severe rigidity. In addition to measurement of creatinine phosphokinase and white blood cell count, important tests to rule out other etiologies include urinalysis to measure electrolytes, including calcium and magnesium; kidney, liver, and thyroid function tests; lumbar puncture; an electroencephalogram; and a computed tomography or magnetic resonance imaging scan of the head. Although specific treatment remains controversial, supportive treatment such as antipyretics, a cooling blanket, and intravenous fluids to correct dehydration and electrolyte abnormalities is critical and widely supported by consensus. Most patients recover from neuroleptic malignant syndrome in two to 14 days without any cognitive impairment, and new dysfunction usually is attributable to very high fever, hypoxia, or other complications, rather than neuroleptic malignant syndrome per se.

Bilateral ulnar nerve paralysis: an unreported complication of drug-induced extrapyramidal rigidity.

OBJECTIVE: This case report describes a very unusual consequence of drug-induced extrapyramidal side effects. CLINICAL PICTURE: The patient developed bilateral ulnar nerve paralysis. TREATMENT: The treatment consisted of anticholinergic medication and physiotherapy. OUTCOME: The patient made a complete recovery over a period of 8 months. CONCLUSIONS: There is a need to ensure compliance with anticholinergic medication when using depot neuroleptic medication.

Diversity in schizophrenia: toward a richer biopsychosocial understanding for social work practice.

By incorporating information from the neurosciences, the study discussed in this article supports the view that schizophrenia is a diverse and biopsychosocial phenomenon. Forty-two people with schizophrenia were placed in one of two groups: people with a larger ventricle-to-brain ratio (VBR) or cortical atrophy (CA) or both and people without these conditions. The authors hypothesized that the former would have lower levels of psychosocial adaptation, higher levels of stress, and lower levels of self-esteem and would have a different course of illness than people without these two conditions. The study found few differences between the two groups, but there were significant differences between women and men and between African American and white participants. Implications for social work practice in the area of serious mental illness are discussed.

Racial differences in the diagnosis of psychosis.

In clinical populations, it has been reported that African-American patients are more likely to receive a diagnosis of schizophrenia than similar Caucasian patients. Factors contributing to this racial discrepancy are poorly defined. The authors examined the hypothesis that racial differences in severity of first-rank symptoms of schizophrenia contribute to this diagnostic difference. Patients were recruited as part of the DSM-IV Field Trial for Schizophrenia and Other Psychotic Disorders, and evaluated using a structured rating instrument. Symptom and diagnostic comparisons were performed between black and white patients. Black patients were significantly more likely than white patients to be diagnosed with schizophrenia and less likely with psychotic depression. Racial differences in symptom profiles were observed with black patients demonstrating more severe psychotic symptoms, in general, and first-rank symptoms, specifically. There were no racial differences in rates of affective syndromes or severity of affective symptoms. Racial disparity in diagnosis of psychotic patients may be in part secondary to more severe first-rank symptoms in black patients, causing clinicians to stray from DSM-III-R criteria.

Mixture analysis of smooth pursuit eye movements in schizophrenia.

The goal of this study was to replicate and extend previous findings indicating that the eye movement data of schizophrenic patients is best represented by the mixture of two groups, one of which has distinctly poor performance. Forty-nine schizophrenic patients and 32 normal controls had their smooth pursuit eye movements quantified by calculating the root mean square (RMS) deviation between the target and eye waveforms. Based on the finding of mixture in the distribution of RMS error, the patients were divided into low (better tracking) and high (worse tracking) RMS error subgroups. The high RMS error patients had abnormally decreased gain. Both patient subgroups had abnormally increased frequency of catch-up saccades and increased phase lag. Distinguishing between these two subgroups may be useful in clarifying the pathophysiology of abnormal pursuit and its relationship to heterogeneity in schizophrenia.

Tardive dyskinesia in non-western countries: a review.

Tardive dyskinesia (TD) is a well-described adverse effect of treatment with neuroleptics. Studies from non-western countries are sparse and those that exist are not well publicized. We analyzed prevalence data on TD, published in English or French, and carried out in countries in Africa and Asia through December 1993. The estimated prevalence of TD among African subjects was 24% and among Asian subjects 17.2091. Both rates are in the middle range when compared with the western prevalence rates of 10-50%. Long-term hospitalization and older age were risk factors associated with TD. Female gender did not emerge as a risk factor. Also, several Asian studies showed that subjects with TD were taking lower doses of neuroleptics than subjects without TD. Prospective and controlled cross-cultural studies of TD are recommended for better understanding of associated risk factors and primary prevention.

Comment: the neglect of culture in psychiatric nosology: the case of culture bound syndromes.

Descriptive psychopathology and clinical phenomenology inform contemporary psychiatric diagnosis and nosology. The process of psychiatric diagnosis and classification is intricate and subject to continuous revision. This paper attempts to illustrate the effect of culture on psychopathology, with special emphasis on the diagnosis and classification of culture bound syndromes. There is a need for more clarity and specificity about the diagnosis and classification of culture bound syndromes. The paper suggests some questions that need to be addressed for the better integration of these syndromes into the main body of international classificatory systems. It is presumed that answers to these questions will provide a better nosological framework for culture bound syndromes.

Sustained attention and positive formal thought disorder in schizophrenia.

Deficits in sustained attention and formal thought disorder (FTD) are two characteristics of schizophrenia that might be expressions of a common pathology. This study examined whether a measure of enduring (post-treatment, stabilized) deficits in sustained attention, the Continuous Performance Test (CPT) could predict FTD. In addition, a comparison was made of CPT performance between subjects with schizophrenia (n = 41) and healthy controls (n = 28). Results replicated previous findings of significantly poorer performance by individuals with schizophrenia compared to normal controls. Within the schizophrenia group, significant correlations were found between FTD and CPT measures. In order to assess predictability of FTD, a hierarchical multiple regression analysis was used. CPT errors and gender both significantly predicted FTD. The most robust prediction was of residual FTD (post-treatment, stabilized) by CPT commission errors. These results lend support to the proposition that a subsyndrome within schizophrenia exists that is characterized by deficits in sustained attention and positive formal thought disorder. Furthermore, this subsyndrome might be more common in males than females.

Brain structure changes in schizophrenics with high serum titers of antibodies to herpes virus.

We compared five indices of brain structure between two groups of schizophrenics, namely, those with high and normal levels of antibody in the serum to herpes virus. Eleven 'immuno-positive' and 21 'immuno-normal' subjects obtained from a concomitant study of serum IgG antibody to viruses underwent magnetic resonance imaging (MRI) utilizing a 1 Tesla magnet and 8 mm thick slices. We measured ventricle-brain ratio (VBR), 3rd ventricle width, cortical atrophy, area of corpus callosum, and frontal lobe area. The differences between groups were assessed by t-test and chi-square analysis. Eight of 11 immuno-positives compared to 7 of 21 immuno-normals showed evidence of cortical atrophy (chi 2 = 4.49, p < 0.03). The immuno-positives had smaller left frontal area (mean + s.d = 125.69 + 21.30 versus 143.76 + 19.84, t = 2.07, p < 0.05) and larger 2nd quadrant of the corpus callosum (mean + s.d. = 1.58 + 0.39 versus 1.27 + 0.52, t = 2.68, p < 0.01). The right frontal area also was smaller in immuno-positives but not significant. VBR, 3rd ventricle and the 1st, 3rd and 4th callosal quadrants did not differ between the groups. We conclude that high antibody titers to herpes found in the sera of some schizophrenics might reflect an earlier pathogenetic process that affected brain development. Further studies of antibodies in CSF and brain structure in these or similar subjects and those suspected to be exposed to viral infections in utero should be vigorously pursued to obtain definitive evidence for this hypothesis.

Serum IgG antibody to herpes viruses in schizophrenia.

Immunoglobulin measurements have provided indirect evidence to suggest that viruses may play an etiologic role in schizophrenia. The authors review the conflicting studies and report their own measurements of serum antibody absorbance to five viral antigens using an ELISA technique in 38 schizophrenic patients and 22 matched controls. For herpes simplex virus, 12 subjects (32%) had antibody levels more than 2 SD above the control mean.

Autoantibodies to brain lipids in schizophrenia.

Serum IgG antibody to brain lipids was measured with an ELISA technique in 38 schizophrenic patients and 22 normal subjects. There were no significant differences between groups. The authors discuss methodological differences between this study and studies with positive findings.

Relation of serum molindone levels to serum prolactin levels and antipsychotic response.

The antipsychotic drug molindone is considered to be atypical in its mode of action and to have mild side effects. Currently no data are available on the range of serum levels of this drug during treatment. By means of a high performance liquid chromatographic technique, serum molindone levels were measured in 14 psychotic patients receiving a wide range of doses of this drug. Molindone levels as high as 350 ng/mL were obtained and were not associated with any toxic effects. Significant relations were noted between the serum level of the drug and both serum prolactin level and treatment response. The authors suggest that molindone may have a range of serum levels consistent with therapeutic benefit. Serum molindone and prolactin levels might help assess resistance to molindone treatment.

Amphetamine challenge test, response to treatment, and lateral ventricle size in schizophrenia.

The hypothesis of two independent pathologies in schizophrenia proposed by Crow (1980) were tested. Two dimensions of the dopamine variable, namely, the behavioral response during the Amphetamine Challenge Test (ACT) and the response to neuroleptic treatment, were studied in a cohort of 19 subjects with a research diagnosis of schizophrenia (n = 18) or schizoaffective disorder (n = 1) in an acute inpatient setting. The size of the lateral ventricle was assessed by mesauring the ventricle-brain ratio (VBR) on the computerized tomographic brain scan. Patients who had greater symptom reduction with the neuroleptic treatment worsened more in their positive psychotic symptoms during the ACT. Those with larger VBRs showed less treatment responsiveness and no worsening during the ACT. The findings are supportive of Crow's hypothesis. The ACT has the potential to be an index of both Type I and Type II pathologies.

Erratic eye tracking in schizophrenic patients as revealed by high-resolution techniques.

Using high-resolution infrared oculography with digital recording and analysis techniques, we tested several types of eye movements in 19 schizophrenic patients and 11 normal controls. Abnormal slow pursuit eye movements, seen in about half of the patients, were characterized by erratic inaccuracies in position, velocity, and phase. Tracking errors were quantitatively assessed by their root mean square (RMS) error. Position RMS errors fell into two clearly separated groups, with 10 of 19 patients clustering about the normal controls and the remaining 9 having much higher errors than normal. Although several of these poor trackers had an excess of saccades or low pursuit gain, these abnormalities were not primarily responsible for the large erratic tracking errors. Saccades in response to unpredictable target jumps had normal latencies (reaction times) and velocities, but were more hypometric and variable in accuracy than those of controls. These saccadic abnormalities did not correlate with the patients' position RMS errors during slow pursuit.