[Catatonia in autism spectrum disorders: review and case-report]. / Katatonie bij autismespectrumstoornis; overzicht en gevalsbeschrijving.

BACKGROUND: Catatonia develops in children, adolescents, and adults with autism spectrum disorders. AIM: To review catatonia in autism spectrum disorders. METHOD: A case-report is presented and discussed. RESULTS: Catatonia is a comorbid syndrome occurring in 12-17% of selected groups of adolescents and young adults with autism spectrum disorders who have been referred for specialised care or admitted to hospital. Clinical experience and case-reports indicate that benzodiazepines and electroconvulsive therapy can be used safely and effectively in both the treatment in acute cases and maintenance treatments for catatonia patients with autism spectrum disorders. CONCLUSION: Catatonia is a recognisable and treatable syndrome in children and adolescents with autism spectrum disorders.

[Mechanisms of catatonia]. / Mechanismen van katatonie.

BACKGROUND: Catatonia is being increasingly viewed as a unique syndrome consisting of specific motor signs that respond characteristically and uniformly to benzodiazepines and electroconvulsive therapy. This interpretation is also reflected in changes in the classification of catatonia in DSM-5. An all-embracing pathogenesis of catatonia remains elusive. AIM: To review the mechanisms of catatonia. METHOD: We reviewed the literature. RESULTS: Certain aspects of catatonia can be explained by a number of different mechanisms. We present a new, more comprehensive model involving the vagal nerve. CONCLUSION: Further research into the underlying mechanisms of catatonia is needed in order to to find new therapies.

[Anti-NMDA-receptor encephalitis: a new axis-III disorder in the differential diagnosis of childhood disintegrative disorder, early onset schizophrenia and late onset autism]. / Anti-NMDA-receptorencefalitis: een nieuwe as III-stoornis in de differentiaaldiagnose van desintegratiestoornis van de kinderleeftijd, vroeg optredende schizofrenie en laat optredend autisme.

Childhood disintegrative disorder (CDD), early onset schizophrenia (EOS), and late onset autism (LOA) often follow a similar course: initially, development is normal, then there is a sudden neuropsychiatric deterioration of social interaction and communication skills, which is combined with a decline in intelligence and reduction in daily activities. A 9-year-old boy was admitted to the paediatric ward with acute onset of secondary epileptic seizures. It was not long until the boy's symptoms resembled that of patients with cdd, eos and loa. Intensive tests led to the diagnosis of anti-NMDA-receptor encephalitis. Anti-NMDA-receptor encephalitis should be regarded as a possible organic cause underlying the syndromal presentation of CDD, EOS and LOA.

The role of deprivation, abuse, and trauma in pediatric catatonia without a clear medical cause.

OBJECTIVE: Catatonia is considered a unique syndrome of motor signs, at times life-threatening when aggravated by autonomic dysfunction and fever, but eminently treatable with specific medical treatments, if recognized early. Catatonia commonly occurs in children and adolescents with a wide range of associated disorders. The role of deprivation, abuse, or trauma in the development of pediatric catatonia is examined. METHOD: Reports considering deprivation, abuse, or trauma as precipitants of catatonia in pediatric cases are culled from the classic writings on catatonia and from a selective review of modern contributions. RESULTS: Kahlbaum gave trauma a central role in catatonia in many young adult cases. Kanner described children with psychogenic catalepsy. Anaclitic depression, a condition found by Spitz in deprived institutionalized children, strongly resembles stuporous catatonia. Leonhard considered lack of communication with the mother or substitute mother as an important risk factor for childhood catatonia. Children including those with autism who experience emotional and physical trauma sometimes develop catatonia. The clinical descriptions of children with classic catatonic syndromes and those of contemporary refugee children with a syndrome labeled Pervasive Refusal Syndrome are similar. CONCLUSION: The literature supports the view that deprivation, abuse, and trauma can precipitate catatonia in children and adolescents.

[Autism and catatonia: successful treatment using lorazepam. A case study]. / Autisme en katatonie. Een succesvolle behandeling met lorazepam.

A 24-year-old man who was mentally retarded and had an autistic disorder, developed mutism and motor symptoms. He was diagnosed with catatonia and was treated successfully with lorazepam. Additionally, we review the literature about the diagnosis and treatment of catatonia in patients with autism; in such cases accurate diagnosis is vital but is complicated by overlapping symptoms.

Psychoactive substances in suicides. Comparison of toxicologic findings in two samples.

The goal in this study was to assess if there is any constancy in detections of psychoactive substances in consecutive suicides. Toxicologic findings in 179 suicides in San Diego County, California, between 1981 and 1982, and 333 suicides in Mobile County, Alabama, between 1990 and 1998, were compared. Alcohol was detected in about 30% of suicides in both samples. Abusable prescription psychoactive substances, i.e., benzodiazepines and opiates, were detected in one fifth of cases in both locations. Nonabusable prescription psychoactive substances, mainly antidepressants, were found in more suicides in Mobile than in San Diego. Detection rates of different classes of psychoactive substances have not changed much in the past decade. Detection of alcohol, cocaine, or cannabis in about 40% of suicides supports the clinical practice of discouraging consumption of these substances in depressed patients. Another challenge is the low rate of detection of antidepressants in suicide, which suggests undertreatment of depression in suicides. Continued reporting of routine, comprehensive, toxicologic findings in suicides is useful to monitor patterns of use of psychoactive substances in this group and to guide suicide prevention in clinical practice and public health policy.

Patterns of psychoactive substance detection from routine toxicology of suicides in Mobile, Alabama, between 1990 and 1998.

BACKGROUND: Postmortem toxicology can be useful for reconstructing some clinically important events occurring before a suicide. Its utility may be improved by examining patterns of detected substances in a population over time. METHODS: Toxicology was performed for 333 (96%) of the 346 suicides occurring in Mobile County, Alabama, between October 1990 and September 1998. Detected psychoactive substances were grouped in three categories: alcohol, cocaine, and cannabis; abusable prescription medications; and non-abused psychotropic medications. The overlap between these three categories was assessed. RESULTS: Psychoactive substances were detected in 227 (68%) of 333 suicides. Of the cases positive for any prescription psychoactive medication, 2/3 were positive for an abusable medication. An abusable substance was found in 56% of cases positive for non-abused psychotropic medication. Alcohol, cocaine and/or cannabis were found in 34% of cases with abusable prescription medications and in 33% with non-abused psychotropics. LIMITATIONS: Clinicians must be aware of a number of methodological realities when interpreting routine postmortem toxicology results. CONCLUSIONS: Routine surveillance of psychoactive substances among suicides can provide useful data for directing and monitoring strategies for suicide prevention in clinical practice.

A retrospective study of general hospital patients who commit suicide shortly after being discharged from the hospital.

OBJECTIVE: To assess the scope of diagnostic screening for suicide prevention in general hospital patients. METHODS: Retrospective medical record review of general hospital patients who committed suicide and matched-control subjects who did not commit suicide shortly after being discharged from the hospital. RESULTS: The suicide rate was 32 per 100 000 patient-years. Eight (73%) of 11 patients who committed suicide were diagnosed with depression, substance use disorder, or both at their last hospital admission compared with 11 (33%) of the controls (P<.05). Only 1 of 44 patients (both cases and controls) was referred for psychiatric consultation. CONCLUSIONS: The suicide rate in general hospital patients was almost 3-fold higher than in the general population. Depression and/or substance use disorders were risk factors for suicide. Screening for those disorders may be beneficial for suicide prevention in the general hospital population, but will likely benefit more patients who will not commit suicide.

The association of suicide attempts and comorbid depression and substance abuse in psychiatric consultation patients.

Substance abuse has been associated with attempted suicide and suicide. Few studies have examined the prevalence and associations of combined depression and substance abuse in suicide attempters. A chart review study of 1136 adult general hospital patients referred for psychiatric consultation between 1995 and 1998 was conducted to assess this further. Among 371 cases with self-harm, 311 (84%) attempted suicide. Suicide attempters were younger and diagnosed more often with comorbid substance abuse than patients without self-harm. Depressive disorders were found in 59% and substance abuse disorders in 46%. Comorbid depression and substance abuse was the most frequent category in suicide attempters, i.e., in 37%. Self-reported suicide intent was associated with increasing age, male gender, and comorbid depression and substance abuse. The suicide rate in suicide attempters was 322 per 100,000 patient-years, and 131 per 100,000 in consultation patients without self-harm. It is concluded that comorbid depression and substance abuse is associated with attempted suicide in psychiatric consultation patients. Suicide attempters should be thoroughly assessed for substance abuse. The increased suicide rate in psychiatric consultation patients with and without suicide attempts warrants further research.

Suicidal behavior in psychiatric emergency room patients.

BACKGROUND: Psychiatric emergency room (ER) patients are thought to be at increased risk of suicide. The prevalence and characteristics of suicidal behavior in a recent sample of patients who came to the ER for psychiatric evaluation were examined. METHODS: Charts of 311 consecutive psychiatric ER patients were reviewed. Suicidal behavior was considered present if current suicidal ideation or attempts within 24 hours of or during the emergency evaluation were noted in the chart. RESULTS: Suicidal behavior was present in 38% of the psychiatric ER patients. Younger age, white race, affective disorders in female patients, and substance abuse disorders in male patients were features of the suicidal group. Sex of the patient was not associated with suicidal behavior. CONCLUSIONS: Suicidal behavior is prevalent in the psychiatric ER. Effective suicide prevention in this setting will hinge on finding more specific risk factors.

A review of postmortem alcohol detection as a diagnostic test for substance abuse disorders in suicides.

To assess the role of toxicologic detection of alcohol to diagnose substance abuse disorders in suicides, the author reviewed suicide studies with both comprehensive toxicologic and diagnostic data. The sensitivity of alcohol detection to diagnose alcohol and substance abuse disorders in suicides was low in all studies (range, 39%-42%), and the specificity was 80%-95%. A higher cutoff level for alcohol did not increase diagnostic performance. The author concludes that toxicologic detection of alcohol is not a reliable indicator of alcohol and substance abuse disorders in suicides because of the high rate of false-negatives. Most of the suicides with positive alcohol detection seem to suffer from chronic substance abuse problems. The role of intoxication is difficult to assess because of methodologic problems.

Aggression and recent substance abuse: absence of association in psychiatric emergency room patients.

Substance abuse has been linked to aggression in community and psychiatric samples. A retrospective chart review in 311 consecutive psychiatric emergency room patients was conducted to assess the association of substance abuse and aggression in an acute psychiatric setting. Various indices of substance abuse, including positive urine toxicology for alcohol, cocaine, and/or cannabis, were not associated with aggressive behavior. Patients with positive toxicology for cocaine were less frequently aggressive than cocaine-negative patients. Among aggressive patients, the presence of psychotic symptoms was the most important factor associated with admission. These findings suggest that aggression is not a common acute manifestation of recent substance abuse in psychiatric emergency room patients. Selection factors in this population and the specifics of an acute psychiatric setting may obscure the association, if any. Acute psychosis seems to have a more important role in this setting. Future studies should focus on the prevention and early treatment of aggression in psychotic emergency room patients.

Assessment and importance of personality disorders in medical patients: an update.

BACKGROUND: Personality disorders in medical patients have received less attention than depression, anxiety, or somatization. METHOD: We conducted a selective literature search to assess the role of personality disorders in medical patients. RESULTS: Review of recent studies suggests a high prevalence and morbidity of personality disorders in medical populations. Important correlates in selected groups are depression, somatization, noncompliance, sexual risk taking, and substance abuse. Difficulties in physician-patient relationships are also frequently reported. Psychiatric interventions are considered beneficial, though no single treatment of choice is available. CONCLUSIONS: We recommend that physicians consider the possibility of personality disorders in medical patients to choose appropriate treatments for selected symptoms. Training in interviewing skills may enhance recognition of personality disorders and management of associated psychiatric conditions.

Who brings patients to the psychiatric emergency room? Psychosocial and psychiatric correlates.

In a sample of 311 consecutive psychiatric emergency room patients, 133 (43%) were accompanied by relatives, friends, or others, 113 (36%) came with the police, and 65 (21%) came by themselves. There were more males in the group brought in by police or who came by themselves than in the group accompanied by family or others. Aggression was the presenting problem in about 40% of police referrals. Half the aggressive patients who were brought in by the police were diagnosed with psychotic disorders. Poor social functioning was found in patients who came with police and by themselves, this finding was more pronounced in males. High rates of substance abuse, as suggested by positive toxicology, were found in police referrals and patients who came by themselves. This was mostly due to alcohol in males and cocaine in females. Findings indicate that gender, diagnosis, and psychosocial status contribute independently to who brings patients to the psychiatric emergency room. It is suggested that this information is clinically useful for diagnostic assessment and management. Clinical and research implications are discussed.

A study on recidivism in the psychiatric emergency room.

Our goal in this retrospective study was to assess empirical risk factors for repeat visits to the psychiatric emergency room. This information may be useful for targeted prevention and cost-effective service planning. Over a 7-month period, 400 (18%) of 2212 patients were repeat visitors, accounting for 36% of all visits. A diagnosis of a psychotic disorder at the first visit was a risk factor for a repeat visit, especially in young patients. Substance abuse, as suggested by positive urine toxicology, decreased the likelihood of recidivism, but positive toxicology screens in young schizophrenic patients increased the chances of a repeat visit. In a 1-month consecutive sample of 311 patients, unemployment and homelessness were stronger correlates than a clinical diagnosis of schizophrenia. These findings support previous evidence that psychiatric emergency services are often used by underprivileged patients. We suggest that a rational preventive approach to reduce recidivism in psychiatric emergency services may include substance abuse treatment and case management for young schizophrenics and community outreach projects for socially disadvantaged patients. Compliance of recidivist patients poses a difficult task for case managers and community psychiatrists. More studies are needed to assess the efficacy of these interventions.

Diagnostic stability of schizophrenia in psychiatric emergency room patients.

Diagnoses obtained from the hospital computer system were compared at two consecutive visits in 286 psychiatric emergency room patients within a 7-month period. Diagnostic agreement of schizophrenia and changes from and to schizophrenia were examined. There was moderate stability for a schizophrenic diagnosis in patients at two consecutive visits (kappa 0.5). schizophrenia was a more stable diagnosis in males (kappa 0.6) than females (0.4). Underdiagnosis of schizophrenia in females may be due to initial diagnostic confusion with affective illnesses. Further studies are needed in other settings to assess if underdiagnosis is associated with undertreatment of schizophrenia in females.

Suicide methods and presence of intoxicating abusable substances: some clinical and public health implications.

Toxicological studies have reported the presence of alcohol in about a third of suicides. Some have suggested that the presence of alcohol might predispose suicidal people to use particular methods, e.g., guns, although, in general, this does not appear to be the case. More recently, comprehensive toxicological studies have provided data on the detection of all intoxicating abusable substances (IAS) among suicides. The purpose of this report is to examine the presence of two samples of suicides to see if any relationships between presence of IAS at post mortem toxicology and any specific suicide method. The samples included 179 suicides from San Diego, California (1981-1982), and 225 suicides from Mobile, Alabama (1990-1995) for which comprehensive toxicological examination had been conducted. Methods were grouped into more immediately fatal (MIF) and less immediately fatal (LIF) categories. The most common method in each category (guns and overdoses respectively) were examined separately as well. The same proportions of men (51%) and women (65%) were positive for any IAS in both locations. There were no significant differences in the proportions of suicides that were positive for IAS between the sample totals or by gender or age groups (under age 30 and age 30 and over) for any of the methods or categories examined. Significantly more of the Mobile suicides were by MIF methods than in San Diego for both genders, almost totally attributable to the use of guns. The use of guns for suicide in Mobile (and the state of Alabama) was also significantly higher than the rest of the U.S. in the early 1990's. Nonetheless, the suicide rates for men and women in Mobile (and Alabama) were no higher than for the overall U.S. rates. We conclude that potentially suicidal people should be advised to avoid intoxicating abusable substances of any kind. We also suggest that physicians should avoid prescribing such substances to depressed or suicidal patients.

Catatonia in an adolescent with Prader-Willi Syndrome.

Catatonia in children and adolescents has received little research attention. Treatment and course of catatonia in an adolescent patient with Prader-Willi Syndrome are presented. Clinical features of a small series of published case reports of catatonia in children and adolescents are reported. The association between catatonia, Prader-Willi Syndrome, and other neurodevelopmental disorders is discussed.