The treatment of the restless leg syndrome with or without periodic leg movements in sleep.

There are presently three main treatments for restless leg syndrome-periodic leg movements in sleep (RLS-PLMS). The benzodiazepines (especially clonazepam) are considered by most clinicians to be the treatment of choice in mild cases, especially in young subjects. In our experience, however, L-dopa and bromocriptine are more effective treatments, although no controlled studies have ever been conducted to compare their therapeutic benefits and the side effects of benzodiazepines and dopaminergic drugs. The use of opioids should be restricted to patients who have severe symptoms and who fail to respond to benzodiazepines or L-dopa. Propoxyphene was found less effective than L-dopa in decreasing PLMS, but some patients resistant to L-dopa may exhibit a masked therapeutic response to opioids. However, there is currently no method to predict the response to any treatment modality.

Periodic limb movements and sleep apnoea.

This study investigated the relationship of Periodic Leg Movements (PLMs) to the severity of Obstructive Sleep Apnoea (OSA) in 52 patients. In addition the prevalence of PLMs in OSA was compared with two other patient populations: narcolepsy and idiopathic PLM disorder (n = 38). All patients were between 20 and 50 years in age and were compared with a control group of 88 asymptotic paid volunteers aged between 20 and 50. PLMs were scored when tibialis anterior EMG activity lasted 0.5-5.0 s with an amplitude of at least half that of pre-sleep voluntary ankle dorsiflexion and when they were part of 4 or more consecutive events separated by 20-90 s. The prevalence of PLMs in OSA was 27.6%, which was similar to the prevalence in our normal controls of 20.5%. However, in the OSA group the majority of the PLMs occurred in the mild OSA patients (40.7%). This was similar to the prevalence of PLMs in narcoleptics (50%). The prevalence of PLMs in moderate OSA, was 24.5%; similar to that of normal controls. In severe OSA, PLMs were also low (12.5%). There is an inverse relationship between PLMs and the severity of OSA. The greater number of arousals and awakenings associated with respiratory irregularities seen in the severe OSA group produced an equivocal manifestation of PLMs.

Somnambulistic-like behaviour in patients attending a lithium clinic.

The prevalence of somnambulistic-like behaviour related to treatment with lithium alone or in combination with other psychotropic medications was evaluated in patients attending a lithium clinic. A written questionnaire on somnambulistic-like behaviour was completed by 389 patients. Information was provided on the time of occurrence, frequency and severity of the episodes, the presence of childhood somnambulism, and the temporal relationship between psychiatric treatment and somnambulistic-like behaviour. Twenty-seven (27) patients (6.9%) presented sleepwalking behaviour related to the onset of treatment with lithium alone or in combination with other psychotropic drugs. Forty-five patients (11.6%) reported childhood somnambulism and 12 of them (27%) had their childhood somnambulism reactivated by the medication. Most patients had a diagnosis of bipolar affective disorder but somnambulistic-like behaviour also occurred in patients with other axis 1 diagnosis. Sleep-related violence was seldomly reported. Therefore, lithium alone or in combination with other psychotropic drugs may induce somnambulistic-like behaviour. A history of childhood somnambulism may increase the risk of developing sleepwalking behaviour while under psychotropic drugs treatment.

Alexithymia and impoverished dream recall in asthmatic patients: evidence from self-report measures.

Early clinical impressions that alexithymia is associated with diminished dream recall have been supported by more recent research. The present study was designed to examine this association using self-report measures and a carefully screened clinical population. Thirty-three male and 43 female asthmatics from an outpatient clinic were administered the Toronto Alexithymia Scale, the Eysenck Personality Questionnaire, and a questionnaire concerning retrospective recall of dreams and nightmares. Multiple regression analyses revealed that, among men, dream recall was negatively related to alexithymia, especially to the TAS analytical mode of thinking subscale, independent of age and neuroticism. Among women, dream and nightmare recall were positively correlated with neuroticism. These results are consistent with early clinical observations of pensée opératoire, with some research findings, and with the notion that dream recall may be differentially associated with components of alexithymia in men and women patients.

The termination phase of psychoanalysis in a narcissistic personality.

This paper describes a patient whose termination phase of analysis activated an intense mourning reaction that helped to overcome the stalemate of therapy. After I attempted to demonstrate how her narcissistic armouring yielded when the termination of analysis was agreed upon, the psychological reenactment of a split off (disavowed) trauma of an early loss (her father) and the failure of essential attributes in maternal care became manifested behind her narcissistic defenses. The reconstruction of these events was possible during the process of mourning. At the termination phase she behaved as if she "had lost the war"; from the point of view of her masochism it was a Pyrrhic victory, "a victory through defeat". Contrary to mother, I let her go but then she refused to go, which created a situation that activated a profound mourning reaction leading to important structural changes. A review of the pertinent psychoanalytic literature on termination along with clinical material derived from the termination phase of a patient with a narcissistic personality is presented.

The dream specimen in psychosomatic medicine in the light of clinical observations.

The author attempts to demonstrate a relationship between dreams and symptom formation in the psychosomatic patient. The egos of many patients predisposed to psychosomatic illness have shown a deformation of a defensive nature because of early impingement of the protective shield (a maternal function) which caused a precocious development of a false-self in Winnicott's sense. In a series of dreams the failure of one or more dream functions became evident. Such failures are often found in patients with psychosomatic symptoms and depend on the severity of illness and preillness factors such as personality, body image and type of object relationships. The dream functions identified were the traumatolytic, the wish-fulfilling, the symbolizing and the integrating ones. The author further speculates on the relationship between the physical symptom, the failure of a particular dream function, the physiological correlates of the manifest versus the latent content of the dream, the breakdown of the process of symbolization and the activation of an archaic body image representation.

Alexithymia, clinical and therapeutic aspects.

The clinical observations on alexithymia which were initiated by Sifneos and Nemiah in the earlier 1970s have given rise to a host of studies with implications beyond the psychosomatic field of enquiry. Is alexithymia a pathology of affect or a character neurosis; is it primary or secondary; genetic or developmental? Is it an adaptational deformation related to social class and low psychological sophistication, a life style or a cerebral deficit? Is it global and consistent (trait) or partial and temporary (state)? Is it part of the necessary and sufficient condition for the development of a psychosomatic symptom or is it a nonspecific autoplastic alteration? It is quite possible that alexithymia is one of several mediating processes between stress and disease along with genetic susceptibility, developmental variables, context and reaction to untoward life events, coping dispositions, psychosocial support and sociocultural factors. Therapeutic approaches would depend on whether we are dealing with a primary affectless condition or a secondary one. A differential diagnosis is essential since self-numbing following psychic trauma or a pathological grief, masked and atypical depression are treatable. Blocking of affect may have dire effects on the psychosomatic economy and on the capacity for intimacy. Muscular and psychological rigidity, weariness, ennui and anhedonia may be the only clues to the presence of alexithymia. Since we may be dealing with a spectrum disorder, there is no single treatment modality. There are no controlled studies on the use of psychotropic drugs and psychoanalytic-oriented and behavioral approaches have been shown to be of some benefit.

An integrative model for the treatment of psychosomatic disorders. The place of sleep and dreams revisited.

The functions and dysfunctions of slow wave sleep and of REM sleep and its associated dreams have a tremendous significance in understanding the psychosomatic model of illness and in establishing preventive strategies. Ten patients suffering from a variety of psychosomatic illnessess spent 3-4 nights sleeping at the Dream Laboratory. A psychiatric evaluation was carried out and those suffering from schizophrenia, severe depression, acute stage of physical illness and organic deficits were not accepted for the study. It was postulated that increased psychosomatic 'penetrance' as measured by poverty of fantasy life, feelings of helplessness, absence of dream reports, vacant and contrived emotional expression and poor psychological mindedness would be correlated with psychological test results (IPAT anxiety Scale and Zung Depression Rating Scale), manifest dream content analysis and particular REM and stage 4 deficit. The higher psychosomatic 'penetrance' in our study was not found in all patients with a psychosomatic diagnosis but rather in those patients suffering from ulcerative colitis. The degree of 'penetrance' was related to specific physiological, psychological and interpersonal parameters. Based on these findings a spectrum of clinical and physiological criteria of selection for particular therapeutic intervention was presented.

International trends of therapy and research in psychosomatic medicine.

Against the background of the holistic concept of illness trends of psychosomatic therapy and research are identified in major countries. Different countries tend to concentrate on different aspects of research or praxis based largely on their compatibility with cultural or social assumptions of illness. The psychotherapies, behavioral medicine, social therapies and biological approaches are underscored in a given country and even within the same country competing therapies strive for hegemony. Problems and limitations of the reductionistic versus the holistic approaches in psychosomatic research are highlighted.

Oral contraceptives and depression.

PIP: Studies of depression associated with oral contraceptive use present conflicting results. Individual susceptibility may affect psychiatric symptoms more than biochemical composition of the pill. In the authors' study 40 women without previous histories of depression were assigned to 4 regimens: 1) mestranol 80 mcg, norethisterone 1.0 mg; 2) pill 1 and pyridoxine; 3) mestranol 5 mcg, norethisterone 1.0 mg; and 4) pill 3 and pyridoxine. Alcohol and other chemicals were avoided. The 40 subjects completed self-reporting ratings on depression and a libido rating. 24 hour urine samples were collected on day 14 and 21 of the menstrual cycle. A brief psychiatric interview was conducted monthly. Adrenaline, noradrenaline, and 5 HIAA were measured throughout the year long study. 10 women completed 3 cycles. 20 of 10 complained of lethargy, loss of libido, irritability, and moodiness. The study concludes that biochemical and pharmacological effects affect a minority of women. A psychologic and negative placebogenic effect is possible. Depending on the composition of the contraceptive, a differential effect may occur. Sequential pills caused less depression than combination types.^ieng

The mind-body problem from a medical perspective.

Classical philosophical ideas on the mind-body problem were interpreted in the light of contemporary theories. There are two mind-body theories that are suspect for a natural scientist, namely, parallelism and panpsychism. There are three further theories that are considered radical and not supported by current research: epiphenomenalism, central-state materialism and behaviorism. That leaves us with the two most prevalent theories, namely, interactionism and neural identity. The authors discuss the evidence for and against each theory.

The clinical features of migraine as a manifestation of allergic disease.

Patients with a clinical history of migraine were evaluated psychiatrically, and by electroencephalography. They were challenged with food antigens by skin-prick test, and abdominal symptoms were evaluated following oral ingestion of food allergens. A significant correlation was found between challenge with specific food allergens and the development of migraine headaches, the appearance of abdominal symptoms and the occurrence of positive skin reactions. Psychiatric abnormalities and EEG alterations were associated with the occurrence of headaches and allergic clinical features. It is suggested that the clinical features of migraine can be explained as a result of release of chemical mediators following antigen-antibody reactions in the brain and other tissues where specific antibodies are localized. The continuous ingestion of the responsible food allergens would account for the raised tissue concentrations of noradrenaline, histamine and other mediators to which the clinical features of migraine are attributed.

Interrater reliability of the multiple sleep latency test.

The purpose of this study was to evaluate interrater reliability in the interpretation of the multiple sleep latency test (MSLT). We prospectively analyzed MSLTs performed on 21 patients with excessive daytime sleepiness. MSLTs were recorded on Grass Model 78 polygraphs with EEG, electro-oculogram, and chin EMG. Each test was performed simultaneously at paper speeds of 10 and 30 mm/sec and was scored blindly by 3 readers using standard criteria. For the quantitative variable (sleep latency), a LISREL model was used. For the binary variable (REM present or not), a kappa coefficient was used. Interrater reliability of sleep latency was 0.850 at speed 10, and 0.884 at speed 30. There was no significant difference between speed 10 and 30. Interrater reliability for the presence or absence of REM was 0.515-0.563 at speed 10, and 0.447-0.525 at speed 30. On the MSLT, the estimation of sleep latency showed excellent consistency between different readers. The determination of the presence or absence of REM only showed fair to good agreement among observers. There was no significant difference between a paper speed of 10 vs. 30 mm/sec.