The classification of conversion disorder (functional neurologic symptom disorder) in ICD and DSM.

The name given to functional neurologic symptoms has evolved over time in the different editions of the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM), reflecting a gradual move away from an etiologic conception rooted in hysterical conversion to an empiric phenomenologic one, emphasizing the central role of the neurologic examination and testing in demonstrating that the symptoms are incompatible with recognized neurologic disease pathophysiology, or are internally inconsistent.

Neuroleptic malignant syndrome.

Neuroleptic malignant syndrome is a rare but serious adverse effect of antipsychotic medication. The author describes three new cases and reviews 50 others published in the past 5 years. Demographic and clinical features, diagnosis, treatment, outcome, and pathophysiology are critically reviewed, and a new set of diagnostic criteria, incorporating physical signs and routine laboratory tests, is proposed.

Relation of psychopathology in general medical inpatients to use and cost of services.

The authors investigated the relation between psychopathology in medically ill inpatients and use and cost of medical care services. Of 455 medical inpatients, the Medical Inpatient Screening Test identified 27.9% as very depressed, 27.5% as very anxious, 20.2% as having cognitive dysfunction, and 8.6% as having high pain levels. Overall, the test identified 51% of the patients as having high levels of psychopathology or pain. These subjects had a 40% longer median length of hospital stay and 35% greater mean hospital costs than those with low levels of psychopathology or pain. Patients with greater psychopathology also had higher hospital charges, more procedures during hospitalization, and more discharge diagnoses but did not differ from the other patients in sex, race, age, diagnosis-related group (DRG) major diagnostic category, or DRG weight.

A randomized controlled study of psychiatric consultation guided by screening in general medical inpatients.

OBJECTIVE: The purpose of the study was to test the hypothesis that psychiatric consultation would reduce health care utilization during and after medical hospitalization. METHOD: A randomized, double-controlled clinical trial of psychiatric consultation was conducted on the general medical inpatient services of a university hospital. After meeting inclusion criteria, 1,541 patients were screened for depression, anxiety, confusion, and pain over a period of 21 months. The 741 patients with high levels of psychopathology or pain were subdivided into baseline control subjects (N = 232), contemporaneous control subjects (N = 253), and an experimental consultation group (N = 256). The major outcome measures were length of hospital stay and hospital costs. Secondary outcome measures were posthospital health status, rehospitalization rates, and use of outpatient medical care. RESULTS: This study did not demonstrate an effect of experimental psychiatric consultation on hospital resource use or posthospital medical care utilization after adjustment was made for disease severity. Hospital resource use decreased in the entire sample over the 21-month duration of the study. CONCLUSIONS: The brief, efficient screen for anxiety, depression, confusion, and pain identified a group of patients who also used more hospital resources, but a single experimental psychiatric consultation did not reduce costs. The double-controlled nature of the design proved essential to avoid being misled by background changes in hospital resource use.

Long-term outcome after neuroleptic malignant syndrome.

Little information is available on long-term outcome after neuroleptic malignant syndrome (NMS). Four patients are described who had survived episodes of NMS 2 to 11 years earlier. Some were safely re-treated with neuroleptics, and all safely received general anesthesia. No major sequelae were identified. Recommendations for management of patients after NMS are provided.

Psychosocial evaluation of heart transplant candidates: an international survey of process, criteria, and outcomes.

Heart transplant programs were surveyed regarding psychosocial evaluation process, criteria, and outcomes. There was considerable disagreement among programs when a patient is rejected on psychosocial grounds with regard to the use of second opinions and how often patients are informed of the reasons. Wide discrepancies in criteria used and rates of patients refused on psychosocial grounds were discovered. More than 70% of all programs excluded patients for transplantation on the grounds of dementia, active schizophrenia, current suicidal ideation, history of multiple suicide attempts, severe mental retardation, current heavy alcohol use, and current use of addictive drugs. Lack of consensus was found for some exclusion criteria (cigarette smoking, obesity, noncompliance, recent alcohol or drug abuse, criminality, personality disorder, mild mental retardation, controlled schizophrenia, and affective disorder). The proportion of patients rejected for transplantation on psychosocial grounds ranged from 0% to 37%, with an average rate of 5.6% in the United States and 2.5% in non-U.S. programs. This survey thus supports the need for research on the validity and reliability of psychosocial selection criteria.

Dysosmia and dysgeusia presenting as depression.

Disorders of taste and smell are underrecognized and often misdiagnosed. Two cases are described in which patients mistakenly thought to suffer from depression actually had unnoticed drug-induced dysosmia and dysgeusia. Also reviewed are psychiatric, neurologic, and medical disorders and drugs that cause abnormalities of taste and smell, and some behavioral aspects of food aversions. Three groups, all of whom may superficially appear depressed, must be distinguished from each other: 1) patients with dysosmia or dysgeusia, 2) patients with primary neuropsychiatric illness with olfactory or gustatory hallucinations, and 3) patients with conditioned taste aversions.

Psychosocial interventions in chronic medical illness. An overview of outcome research.

Previous studies have shown that psychopathology is common in the medically ill, affects the course of medical illness, and is associated with increased health care costs. Recent controlled trials have demonstrated that psychosocial interventions in the medically ill can improve both psychosocial and medical outcomes. Although an important aim of current research is to assess the cost effectiveness of such interventions, the meaning and significance of "cost effectiveness," "cost benefit," and "cost offset" are frequently misunderstood. An overview of outcome research will be used to illuminate the promise and the limitations of such studies, with special attention to bias in research design.

The general hospital as a center of biopsychosocial training.

Utilization of general hospitals as training sites for undergraduate and graduate medical education provides special opportunities for integration of biologic, psychologic, and social factors in health care. For medical students, the general hospital environment ideally facilitates learning a core of psychiatric knowledge and the biopsychosocial approach to all illness while attracting some students to psychiatric careers. By spending much of their internship year in the general hospital, psychiatric residents integrate psychiatry into the rest of medicine and develop collegial relations with nonpsychiatrists. Residency training in the general hospital perpetuates this integrative experience and allows in-depth training in consultation-liaison psychiatry. Despite the multiple advantages of general hospitals in training students and residents, limitations of this setting also exist.

Psychopharmacology and neuropsychiatric syndromes in organ transplantation.

The physiological imbalances associated with organ insufficiency and the complexity of organ transplant surgery and postoperative care puts patients at risk for psychiatric disorders. The brain is susceptible to a variety of insults as a result of these complex processes, including those secondary to medications and infections. We review literature relevant to organ transplant patients and also include empirical knowledge based on clinical practice. We first describe the physiologic and psychiatric issues for each major organ that is commonly transplanted, including liver, kidney, heart, bone marrow, and pancreas, as well as multiple organ transplantation. We then discuss the pharmacologic treatment and neuropsychiatric side effects of rejection with various immunosuppressants, including cyclosporine, azathioprine, OKT3, FK506, and corticosteroids. Certain bacterial, fungal, viral, and protozoal infections occur more frequently in the transplant population; their relationship to neuropsychiatric dysfunction is discussed. We then present details of psychopharmacotherapy of delirium, other organic mental disorders, depression, mania, anxiety, and insomnia, with attention to drug interactions and differential diagnosis. Particularly cautious monitoring of medication doses and serum levels is recommended in these patients.

Psychopathology and pain in medical in-patients predict resource use during hospitalization but not rehospitalization.

The authors investigated the relationship between psychopathology and resource use in general medical in-patients during hospitalization and rehospitalization. Between 1 July 1987, and 30 April 1989, 1020 in-patients were prospectively screened for depression, anxiety, cognitive dysfunction, and pain. Overall, the screen identified 47% of patients as having high psychopathology or pain, including 25.7% depressed, 21.8% anxious, 17.6% with cognitive dysfunction, and 5.2% with high pain. There were no measured differences in demographics or disease severity between high and low psychopathology groups. High psychopathology patients had longer stays and higher costs during the index hospitalization but there were no differences during subsequent hospitalizations. Length of stay declined overall during the study period, but there were no changes over time in the association between high psychopathology or pain with increased resource use. The measured symptoms of psychopathology and pain we measured are associated with increased short-term utilization of health care resources, but the increase does not extend to subsequent hospitalizations. Outcome studies aiming to reduce psychopathology in medical in-patients should pay particular attention to short term costs.

Psychological factors predict symptoms of severe recurrent genital herpes infection.

In a group of patients with severe recurrent genital herpes infection, we measured symptoms (pain and itching), psychological factors (depression, anxiety, somatisation, interpersonal sensitivity, and life change) and objective indices of disease (number of recurrences in the previous year, total number of recurrences, duration of recurrences, number of lesions per recurrence). Psychological factors were more predictive of pain and itching than were somatic indices, even after correcting for sex.

Abbreviated cognitive test for delirium.

The cognitive test for delirium (CTD) was recently developed to identify delirium in an intensive care unit (ICU) setting. Stepwise discriminant analyses using the original validation sample indicated that a total score formed by summing only two of the nine content scores (visual attention span and recognition memory for pictures) maintained good reliability (coefficient alpha = 0.79) and the ability to discriminate delirium from dementia, schizophrenia, and depression (p < 0.0001) and delirium from moderate to severe dementia (p < 0.0002). This abbreviated version of the CTD is more practical for use by ICU clinicians.

Biotin-responsive depression during hyperalimentation.

A patient with multiple enteric fistulae, after months of parenteral hyperalimentation, developed, severe depression accompanied by delirium, dermatitis, pallor, paresthesia, nausea, vomiting, anorexia, and headaches. His symptoms improved after treatment with parenteral biotin. Biotin-deficiency should be suspected in patients on hyperalimentation (without biotin supplementation) who develop similar symptoms.

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.

Controversial decisions regarding treatment and DNR: an algorithmic Guide for the Uncertain in Decision-Making Ethics (GUIDE).

We describe an algorithm to aid clinicians in making ethical decisions regarding interventions. Logically sequenced questions about competency, advance directives, treatment benefit, and patient and family preferences guide the decision maker to nine specific scenarios. Each scenario includes guidelines for action based on legal and ethical consensus.

Milieu reactions to ECT.

Electroconvulsive therapy (ECT) evokes strong emotional reactions and disagreements among mental health professionals, patients, and families. The indications for ECT, its efficacy and sequelae, theories of its mechanism of action, social and political debate, and the technique itself have all been sources of controversy. In the forty years since its advent, knowledge of these issues has evolved. The efficacy of ECT in major depressive illness is now well established, but at the same time we can eliminate most of the fifty theories that Gordon listed in 1948 to explain how ECT works. While the mechanism of action appears likely to be a neurochemical one, it is far from being clearly understood. But is is not just uncertainty about how ECT works that remains. Not only are there arguments among the lay public, but even knowledgeable mental health workers are sharply divided in their opinions of ECT (Frankel et el. 1978). We believe that even when ECT is administered in a humane manner with informed consent to appropriately selected patients who derived lasting benefit without major sequelae, it will continue to evoke strong emotional reactions in therapists, patients, and ward staff. In this paper, some of the continuing controversy surrounding ECT is examined through reactions to it in the therapeutic milieu among therapists, staff, and patients. We hypothesize that ECT can be especially upsetting because it often produces rapid improvement in patients who had previously not responded to treatment. This tends to create an inflated estimation of ECT. Devaluation of other therapeutic modalities, staff splitting, and disruptions in the therapeutic alliance may follow. We present two cases to exemplify aspects of how the milieu reacts to ECT, and conclude with recommendations to improve the delivery of treatment.

Psychosocial assessment of living organ donors: clinical and ethical considerations.

This article outlines psychosocial and ethical issues to be considered when evaluating potential living organ donors. Six types of living donors are described: genetically related, emotionally related, "Good Samaritan" (both directed and nondirected), vendors, and organ exchangers. The primary domains to be assessed in the psychosocial evaluation are informed consent, motivation for donating and the decision-making process, adequacy of support (financial and social), behavioral and psychological health, and the donor-recipient relationship. Obstacles to the evaluation process include impression management, overt deception, minimization of behavioral risk factors, and cultural and language differences between the donor and the evaluator. Ethical concerns, such as the right to donate, donor autonomy, freedom from coercion, nonmaleficence and beneficence in donor selection, conflicts of interest, "reasonable" risks to donors, and recipient decision making are also explored. To fully evaluate living organ donation, studying psychosocial as well as medical outcomes is crucial.

Dealing with the violent patient. Management strategies to avoid common errors.

Knowledge of the specific warning signs that may presage violence allows the physician to comprehensively evaluate the potentially dangerous patient and proceed carefully with appropriate intervention. The physician must strive not to suppress the natural reaction of fear, as most maladaptive responses derive from underestimating the risks involved or overestimating one's abilities to handle the situation. Research on the topic of patient violence has been neglected and is urgently needed.