Clinical characteristics of older psychiatric inpatients with borderline personality disorder.

This case study investigation considers typical and potentially unique characteristics of older (> 50 years) Borderline Personality Disorder (BPD) patients and describes their impact on an inpatient psychiatric unit encompassing a therapeutic milieu setting and multidisciplinary treatment teams. The somatization of symptoms, in particular, and the associated therapeutic, medical, and psychopharmacological interventions, result in prolonged and elaborate treatments that undermine clinical and personal boundaries, clash with managed care directives, and engender frustrating and elusive transferential and countertransferential reactions. Moreover, the guilt-inducing nature of somatization and physical frailty in older individuals, combined with the well-documented ability of BPD patients, regardless of age, to incite stormy and 'split' relationships, are linked characteristics that may describe a diagnostic subtype of BPD. Rather than suggesting a diminution of psychopathology as BPD patients age, the results of this investigation indicate that their persistent difficulties may only be altering in content and in pathological adaptation to changing needs.

Cultural sensitivity training in mental health: treatment of Orthodox Jewish psychiatric inpatients.

We describe some of the cultural/religious issues which arose in the treatment of major psychiatric disorders among Orthodox Jewish inpatients at SUNY Health Science Center's University Hospital (SUH) in Brooklyn, New York. The distinct ways in which cultural and religious factors impacted on presentation, therapeutic interventions, and transference-countertransference reactions are noted. Specific reference is made to the use of religion by patients and families as a means of defense, rationalization or power-brokering. Via case vignettes, we explore ways of distinguishing between culturally appropriate vs. maladaptive behaviors in the Orthodox population. Practical solutions are suggested for sensitive ways to surmount culture-based barriers to effective inpatient therapy in this group.

Treatment of obsessive-compulsive disorder using clomipramine in a very old patient.

OBJECTIVE: To describe the effect of the tricyclic drug clomipramine in a very old patient with obsessive-compulsive disorder and Alzheimer dementia. CASE SUMMARY: A 93-year-old woman had a history of obsessive-compulsive disorder since early adulthood. The obsession consisted of remembering names of famous people and the compulsion consisted of excessive list making. With the onset of memory loss secondary to Alzheimer disease, she became increasingly anxious and compulsive as a result of a failure to remember. After nine weeks on fluoxetine she became jittery and more confused. After a two-week wash-out period, she was given a nine-week course of clomipramine that was carefully titrated up to a therapeutic concentration. RESULTS: At the completion of clomipramine treatment, the patient no longer felt driven to recall the names of famous people. Her score from the Yale-Brown Obsessive-Compulsive Scale dropped from 29 to 3. Her Folstein Mini-Mental State Examination score increased from 21 to 23. CONCLUSIONS: Clomipramine appeared much more effective and better tolerated than fluoxetine in this very old patient despite its potential anticholinergic effect and the coexistence of Alzheimer disease.

Fluvoxamine for stereotypic behavior in patients with dementia.

OBJECTIVE: To describe the effects of treatment with the selective serotonin reuptake inhibitor fluvoxamine on three patients with advanced dementia who developed a stereotypic movement disorder. CASE SUMMARY: Three patients in a skilled nursing facility were referred by their primary physicians for psychiatric consultation to assist with the management of stereotypic behaviors. The patients received a standard medical, neurologic, and psychiatric workup for dementia. Two of the patients were diagnosed with dementia of the Alzheimer type and the other patient was diagnosed with vascular dementia. All three patients were started on fluvoxamine 25 mg/d; behaviors were monitored daily by the nursing staff and their primary care physicians and weekly by their psychiatrist using the Abnormal Involuntary Movement Scales. The dosage was titrated upward weekly to a maximum dosage of 150 mg/d. RESULTS: Two patients showed complete resolution of their stereotypic behaviors by week 6. The third patient showed noticeable improvement with some residual movements after 8 weeks of treatment. CONCLUSIONS: Fluvoxamine appeared effective in the control of stereotypic behaviors in three patients with advanced dementia.

Risperidone-induced neuroleptic malignant syndrome.

OBJECTIVE: To describe a patient with neuroleptic malignant syndrome (NMS) induced by risperidone, an atypical antipsychotic, and to review the available literature related to risperidone-associated NMS. DATA SOURCE: Case report information was obtained from the resident physician and medical records. MEDLINE and Index Medicus were searched to obtain literature published between 1960 and 1995. DATA SYNTHESIS: We report an adolescent boy who developed NMS after treatment with risperidone. Risperidone therapy was started after unsuccessful treatment and development of extrapyramidal adverse effects with haloperidol. The patient demonstrated the classic tetrad of fever, generalized skeletal muscle rigidity, altered mental status, and autonomic dysfunction. Risperidone was discontinued and the patient recovered after a prolonged hospital course with supportive management. CONCLUSIONS: Clinicians are cautioned about the possibility of NMS with risperidone.

Death on a psychiatric inpatient unit. Effect on a subgroup of schizophrenic patients.

This study documents the effect of an untimely death on a group of patients in a psychiatric inpatient unit. The large community meeting was used as a forum to characterize unique bereavement patterns in a subgroup of schizophrenic patients. Nonschizophrenic patients tended to reach out to obtain comfort and support, but schizophrenic patients showed a heightened sense of vulnerability and expressed distrust and blame toward the staff. We document the interventions that were attempted in neutralizing regression and restoring adaptive coping mechanisms during and after the community meeting.

Posttraumatic stress disorder in survivors of the Brooklyn Bridge shooting.

OBJECTIVE: The authors documented the frequency of posttraumatic stress disorder (PTSD) in civilian victims of urban terrorism. METHOD: A recent shooting attack on a van of Hasidic students provided a unique opportunity to document responses of survivors in this targeted group. Eleven of 14 survivors were compared with age-matched subjects on a variety of questionnaires and clinical evaluations. RESULTS: Of the 11 survivors, four were diagnosed with PTSD (all of whom also had concurrent major depressive disorder), one with major depressive disorder, and two with adjustment disorder. CONCLUSIONS: Findings are interpreted in the context of unique factors contributing to the heightened vulnerability of this group.

Treatment of Hassidic Jewish patients in a general hospital medical-psychiatric unit.

A combined medical-psychiatric inpatient unit at a general medical center in Brooklyn, New York, provides inpatient psychiatric treatment to members of the Orthodox Jewish sect of the Lubavitcher Hassidim, who are generally reluctant to accept treatment in traditional psychiatric inpatient settings. The unit's biological treatment model, which emphasizes long-term maintenance on psychotropic medication, monthly postdischarge pharmacotherapeutic visits, lowered expectations, and minimal use of expressive psychotherapy, is compatible with the Hassidic community's view of mental illness. A practicing Orthodox Jewish psychiatrist on the unit staff sensitizes other staff members to religious and cultural issues in treating Hassidic patients.

Psychosocial adjustment among returnees to Judaism.

Two groups of returnees to Orthodox Judaism who were among Lubavitcher Hasidim attending an outpatient mental health center were studied to investigate a relief effect upon returning. One group manifested lifelong serious psychopathology, and the members of the comparison group, who had undergone similar religious transition, had sought help for adjustment-type problems. The psychopathology manifested prior to religious change persisted for those who had exhibited a lifelong history of pathology, even after the radical transition. The lack of a relief effect and the lifestyles possibly unique to Lubavitcher Hasidim are discussed.

Alzheimer's disease in a patient on long-term hemodialysis: a case report.

This case report describes a progressive dementia in a 49-year-old black male on long-term hemodialysis. The initial presentation simulated depression. The dementia persisted after an unsuccessful cadaver homograft transplant. The character of the dementia was nonspecific but typical features of dialysis dementia were lacking. Autopsy revealed a ruptured cerebral aneurysm, polycystic kidneys, moderately severe atherosclerosis, miliary tuberculosis, and neurofibrillary degeneration of the hippocampus. The significance of a possible relationship between end-stage renal disease (ESRD), hemodialysis, and Alzheimer's disease in this case is discussed.

Behçet's syndrome: a family study and the elucidation of a genetic role.

A family with features of the mucocutaneous ocular syndrome is described. A 4-generation study reveals that the condition has been inherited as an autosomal dominant trait with variable expressivity. Psychiatric symptoms and myalgia have been prominent features peculiar to our patients.

Haemodynamics and treatment of right ventricular infarction.

In this article 2 cases of myocardial infarction with haemodynamically dominant right ventricular infarction are reported. The incidence and significance of the condition are discussed. The use of haemodynamic monitoring in diagnosis and management is stressed and the response to fluid therapy, either alone or together with inotropic drugs, is discussed.