A Brief History of Psychiatry: Millennia Past and Present—Part II

Institutional treatment of psychiatric disorders dates back at least to the time of Hippocrates, when there were efforts to improve patients' general health in pleasant surroundings. Institutions for the mentally ill and for abusers of addicting substances have varied through the centuries from squalid conditions to surroundings meant to improve psychological and social well being. In the eighteenth-century, Pinel, Rush, and others assumed that environmental changes could affect psychological states and alter behavior. Twentieth century debate has been concerned with whether or not patients are better treated in hospitals or in the community. Currently, the focus on minimizing health care costs has emphasized often-valuable intensive and not so intensive outpatient programs, almost to the exclusion of sometimes-necessary inpatient hospitalization. Contemporary social and political trends inside and outside the mental health professions include attempts to modify this emphasis and to focus on the specific needs of individual patients.     

Neurostimulation—Past,Present, and Beyond

Neurostimulation as a treatment for epilepsy has been around for almost 20 years in the form of vagus nerve stimulation. Newer types of neurostimulation are being developed and stand on the brink of approval for use. The two newest therapies, not yet approved in the United States, are deep brain stimulation and the Responsive Neurostimulator System . In fact, in Europe, approval has already been given for deep brain stimulation and newer forms of vagus nerve stimulation. Efficacy is similar between these therapies, and side effects are moderate, so what will be the future? The challenge will be to learn how to use these therapies correctly and offer the right treatment for the right patient.Despite the development of new antiepileptic drugs (AEDs), of which there are now 24 in total available in the United States, there are still many patients suffering from continued seizures. Patients with refractory epilepsy should initially be evaluated for resective epilepsy surgery. Neurostimulation is not a replacement for resective surgical options. Unfortunately, not all patients can be cured of their seizures by epilepsy surgery, therefore other methodologies have to be developed as well. Of the nonpharmacologic therapies available, vagus nerve stimulation (VNS) has been the procedure that has been the most accessible and best studied. The therapy has been approved since 1997 in the United States, and in Europe since 1994. Efficacy can be compared with that of a newer AED (1). Deep brain stimulation (DBS) has been studied in different forms, but only a double-blind study of bilateral stimulation of the anterior nucleus of the thalamus (2) has been accepted by the European Medicinal Agency as showing efficacy and is now approved as a therapy for epilepsy in Europe. DBS for epilepsy has not been approved in the United States. The closed-loop system (the Responsive Neurostimulator System, RNS) is also under development, and a double-blind study has also been completed (3), but approval for use in refractory focal onset epilepsy patients is pending.     

Uncommon and/or bizarre features of dementia: Part III

Clinical neurologists have long recognized that dementia can present as atypical or variant syndromes/symptoms. This study aimed at describing uncommon or bizarre symptoms/syndromes observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published before 2018. Search terms used included compulsion, dementia, extracampine hallucination, disordered gambling, humour, and obsession. Publications found through this indexed search were reviewed for further relevant references. The uncommon/bizarre feature of dementia was described as case reports and there were no systematic investigations.     

Evolution of the Neurotic Present from the Traumatic Past†

THE course of scientific development, as with all human endeavor, is distinguished by two constantly interacting and interrelated movements; the collection of facts and the creation of theories to explain these facts is the process of relating them to one another and of provoking the search for new ones. The collection of facts without recourse to theory, the spinning of theories that contradict facts, is not science. Inevitably the advance of each is dependent upon the other, and in this growth facts remain constant but cumulative, while theories like old cells, having served their function, are replaced by new ones. When, however, such old theories are accepted as facts and worshipped as immutable images, then not merely the old theory but the science also dies. Psychoanalysis and the firmly established Libido Theory exemplify this statement; the latter may be preserved intact, but only at the expense of the former. The price is too high for those who utilize both science and psychoanalysis.     

Primary Progressive Aphasia and Alzheimer’s Disease: Brief History, Recent Evidence

Primary progressive aphasia (PPA) has been recognized as a syndrome distinct from the usual pattern of language deterioration in Alzheimer??s disease and typically more related to the pathology of frontotemporal dementia (FTD). In recent years, however, the syndromes of primary progressive aphasia have become more complex, divided into the three subtypes of progressive nonfluent aphasia (PNFA), semantic dementia (SD), and logopenic/phonological progressive aphasia (LPA). These syndromes have not only made the linguistic analysis more complex, but the associated pathologies have also become more variable. In particular, PNFA is usually, but not always, associated with FTD pathology and often evidence of a tau mutation, but rarely AD; SD is usually associated with FTD of the ubiquitin staining or progranulin (TAR-DNA) mutation type, but, again, occasionally AD; LPA is typically associated with AD pathology. Patterns of atrophy on magnetic resonance imaging (MRI) generally conform to these subtypes, with PNFA associated with left frontal and insular atophy, SD associated with bilateral temporal atrophy, and LPA associated with L superior-posterior temporal and parietal atrophy. These patterns can also be seen on positron emission (PET) scanning with fluorodeoxyglucose. The newer amyloid binding ligand PET technologies are less useful for detecting regional atrophy patterns but more useful for indication of the underlying pathology. We can thus speak of syndromes of PPA or underlying pathological bases of PPA.     

Psychiatry in Jamaica—Growth and Development

The history of psychiatry in the Caribbean island of Jamaica is presented based on ethnohistoriographic accounts of large group meetings of patients and staff of the Bellevue State Mental Hospital in the late 1970s. The development of psychiatric services is described from pre-colonial days of the indigenous Arawak Indians. The existing mental hospital was established in 1862 by the British Colonial Government, and the Mental Hospital Act of 1873 created the system whereby the mentally ill were arrested for lunacy and incarcerated in the mental hospital by Magistrates order. The development of a Community Psychiatric Service and the establishment of a deinstitutionalization programme for the mental Hospital in the decade of the 1960s and 70s is described, and a review of the private and public community services presently existing in the island is also described. A brief review of the existing literature on Jamaican psychopathology is presented, including a discussion on schizophrenia in Afro-Caribbeans, other common psychiatric conditions, developments in psychotherapy in Jamaicans, and psychodynamic issues of cultural identity.     

European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part III: pharmacological treatment

In 2011, the European Society for the Study of Tourette Syndrome (ESSTS) published the first European guidelines for Tourette Syndrome (TS). We now present an update of the part on pharmacological treatment, based on a review of new literature with special attention to other evidence-based guidelines, meta-analyses, and randomized double-blinded studies. Moreover, our revision took into consideration results of a recent survey on treatment preferences conducted among ESSTS experts. The first preference should be given to psychoeducation and to behavioral approaches, as it strengthens the patients’ self-regulatory control and thus his/her autonomy. Because behavioral approaches are not effective, available, or feasible in all patients, in a substantial number of patients pharmacological treatment is indicated, alone or in combination with behavioral therapy. The largest amount of evidence supports the use of dopamine blocking agents, preferably aripiprazole because of a more favorable profile of adverse events than first- and second-generation antipsychotics. Other agents that can be considered include tiapride, risperidone, and especially in case of co-existing attention deficit hyperactivity disorder (ADHD), clonidine and guanfacine. This view is supported by the results of our survey on medication preference among members of ESSTS, in which aripiprazole was indicated as the drug of first choice both in children and adults. In treatment resistant cases, treatment with agents with either a limited evidence base or risk of extrapyramidal adverse effects might be considered, including pimozide, haloperidol, topiramate, cannabis-based agents, and botulinum toxin injections. Overall, treatment of TS should be individualized, and decisions based on the patient’s needs and preferences, presence of co-existing conditions, latest scientific findings as well as on the physician’s preferences, experience, and local regulatory requirements.

     

The Evolution of a Community-Based Telepsychiatry Program in Rural Alabama: Lessons Learned—A Brief Report

The purpose of this paper is to describe the partnership between a community-based rural mental health clinic and an academic health center to provide telepsychiatry services in rural Alabama. The partnership was developed to meet the needs of a clinic that serves an underserved rural population with limited psychiatric services. This paper offers valuable lessons learned for mental health practitioners who may be considering the benefits and challenges of forming community-based partnerships in use of telepsychiatry to build capacity to deliver clinical mental health services to rural mental health shortage areas.