Psychiatric issues in pulmonary disease.

This article has attempted to provide an overview of the clinical literature regarding the psychological issues facing patients with pulmonary disease, depending on when the illness begins in the life span, because different developmental tasks are disrupted. Patients must contend with side effects of medication that may mimic or exacerbate psychiatric disorders. The main drug interactions for psychiatrists to be aware of in this patient population occur between rifampin, or theophylline and psychotropic medications. In lung transplant recipients on cyclosporine therapy, the antidepressant drug nefazadone may cause increased cyclosporine levels. Psychiatrists must be aware of the risks, benefits, and survival statistics; educate patients; and ascertain whether the patient is competent to make medical decisions regarding treatment procedures.     

Psychiatric considerations in premature birth.

Five percent to ten percent of all live births are premature. Modern neonatology has dramatically improved survival rates. Morbidity rates, however, are as high as 60%, according to some studies. In this paper, outcome and intervention findings are described. Experiential, familial and socioeconomic factors interact synergistically with preterm birth and biological vulnerability to create cognitive, behavioural and interpersonal disorders. Principles of intervention are suggested, based on promoting organization within the infant and a responsive, active approach in the caregivers.     

Psychiatric emergency services: policy considerations.

Funding for PES occurs through a variety of public and private sources. Potential difficulties associated with providing emergency psychiatric care in a free-market economy are discussed.     

Psychiatric services in general hospitals. Rational and irrational considerations

The structure of a psychiatric service in an urban general hospital is complex. Varied intrainstitutional and extrainstitutional relationships create stress, which can lead to rational and irrational reactions, often in combination. Psychologic mechanisms that exist in individuals also occur as shared defense mechanisms in an institutional setting, serving to reduce anxiety and stress but often at the expense of accurate reality perception. Good communication can play a vital role in reducing reality distortions but is itself often blocked or impaired by the same defense mechanisms that led to the distortions. An awareness of how these mechanisms operate in an institutional setting can aid the psychiatric administrator in correcting distortions and maintaining good channels of communication.     

Psychiatric phenomenology in Cushing's disease.

We evaluated 20 patients with Cushing's disease (i.e., Cushing's syndrome due to ACTH-secreting pituitary microadenoma) and 20 patients with Major Depressive Disorder (MDD) using the Structured Clinical Interview for DSM-III-R (SCID) and Research Diagnostic Criteria. The diagnosis of Generalized Anxiety Disorder (GAD) was most common in Cushing's disease (79%), followed by MDD (68%), and Panic Disorder (PD) including subthreshold PD (53%). The combination of MDD and GAD and/or PD was also common in Cushing's disease (63%). Behavioral symptoms, if present, usually first occurred at or after the onset of the first physical symptoms. However, the onset of PD was associated with more chronic stages of Cushing's disease. In both Cushing's disease and MDD, more female than male relatives suffered from MDD, whereas more male than female relatives suffered from substance abuse. The data demonstrate a syndrome of anxious depression in patients with active Cushing's disease; such comorbidility has not been previously noted. The data also point to intriguing epidemiological, clinical, and biological associations between Cushing's disease, MDD and substance abuse.     

Psychiatric complications in Parkinson disease.

Although Parkinson disease (PD) is primarily considered a movement disorder, the high prevalence of psychiatric complications suggests that it is more accurately conceptualized as a neuropsychiatric disease. Affective disorders, cognitive impairment, and psychosis are particularly common in PD and are associated with excess disability, worse quality of life, poorer outcomes, and caregiver distress. Yet, in spite of this and their frequent occurrence, there is incomplete understanding of the epidemiology, phenomenology, risk factors, neuropathophysiology, and optimal treatment strategies for these disorders. Psychiatric complications are typically comorbid, and there is great intra- and inter-individual variability in presentation. The hallmark neuropathophysiological changes that occur in PD plus the association between exposure to dopaminergic medications and certain psychiatric disorders suggest a neurobiological basis for most psychiatric symptoms, although psychological factors are probably involved in the development of affective disorders. Although antidepressants, antipsychotics, and cognition-enhancing agents are commonly prescribed in PD, controlled studies demonstrating efficacy and tolerability of these drugs are virtually nonexistent. Because of the high prevalence and complexity of psychiatric complications in PD, geriatric psychiatrists are in a position to offer valuable consultation and clinical care to this population. This article provides an overview of the epidemiology, pathophysiology, clinical presentation, and management of the most common psychiatric complications in PD.     

Psychiatric comorbidity in eating disorders: Psychopathological considerations

Abstract The psychiatric comorbidity was examined in patients who met ICD-10 criteria for eating disorders. The most frequent comorbid diagnoses were mood disorders, followed by personality disorders and neurotic disorders. Non-attendance at school was also seen. Eating disorders did not directly cause mood disorders, but rather indirectly brought them about by a devaluation of self-esteem. Features of personality disorders occurred independently of eating disorders, appearing or disappearing relative to the major object or transitional object. Neurotic disorders served as non-verbal communication, a function originally included in eating disorders. It is important to take note of the devaluation of self-esteem and the meanings of symptoms as communication within eating disorders.     

Psychiatric presentation of Jakob-Creutzfeldt disease.

A case of presenile dementia, which on a post-mortem examination proved to be due to Jakob-Creutzfeldt Disease, is described. The most dramatic early clinical feature was that of hysterical aphonia, temporarily removable by hypnotic suggestion. Anxiety symptoms and irritability also occurred early on, followed by a transient hallucinatory psychosis. The hysterical features persisted throughout. In view of the lack of dementing features or neurological signs, a psychogenic diagnosis was repeatedly made by several neurologists. This case illustrates the fact that primary hysterical neurotic features almost never occur for the first time in mid-life.     

Wilson's disease. Psychiatric symptoms in 195 cases

A series of 195 cases of Wilson's disease were assessed retrospectively on a range of variables, including psychiatric, neurologic, and hepatic symptoms, and biochemical data as recorded at first admission to a specialist clinic. Ninety-nine patients (51%) were rated as displaying some evidence of psychopathologic features, and 39 (20%) had seen a psychiatrist before the diagnosis of Wilson's disease. The most common psychiatric features were abnormal behavior and personality change, although depression and cognitive impairment were also rated frequently. Schizophrenialike psychoses were rare, apparently occurring at no more than chance frequency. Psychiatric symptoms were related to neurologic rather than hepatic symptoms, and certain symptoms (incongruous behavior, irritability, and personality change) had a particularly significant relationship with bulbar and dystonic disorders but not with tremor. Psychiatric manifestations are important in Wilson's disease, and many of the psychopathologic features seem to have an organic basis.     

Cocaine abuse during pregnancy: Psychiatric considerations

Cocaine abuse is an increasing problem in the obstetric population. It not only poses a health risk to the pregnant woman, but can precipitate premature labor and abruptio placentae, and has been associated with a number of physical and behavioral problems in the newborn. Evaluation and management of the pregnant cocaine abuser is similar in most respects to that of nonpregnant adults, but diagnosis, psychotherapy, and pharmacotherapy is strongly influenced by the pregnancy. This article describes the risks of cocaine use during pregnancy and outlines the evaluation and management of the pregnant cocaine abuser.     

Early Alzheimer's disease. Diagnostic considerations

An 82-year-old cognitively healthy man was assessed longitudinally until very mild senile dementia of the Alzheimer type was diagnosed by clinical research criteria and documented by psychometric testing at age 85 years. Four months after diagnosis, Alzheimer's disease was confirmed neuropathologically. The diagnostic difficulties involved in distinguishing early senile dementia of the Alzheimer type-Alzheimer's disease from normal aging are examined and clinical and pathologic features useful for their discrimination are discussed.     

Psychiatric complications in Parkinson's disease

Parkinson's disease (PD) is caused by an abnormal degeneration of the dopamine (DA) producing cells in the substantia nigra (SN) and ventral tegmentum area (VTA) in combination with a varying decay of the noradrenergic (locus coeruleus), cholinergic forebrain (nucleus basalis of Meynert) and serotoninergic (dorsal raphe nuclei) systems, leading to a multitude of motor and non-motor behavioral disturbances, known as parkinsonism. Normally, main dopamine depletion is restricted to the SN region with manifest (non)motor behavioral abnormalities caused by the inability to spontaneously switch between intern-cued cortical behavioral programmes. Clinical symptoms comprise motoric abnormalities, though subtle cognitive disturbances as well as psychological dysfunction with loss of mental flexibility and reactive depressive symptoms might be seen. These symptoms might be compensated in part by externally-cued behavior.     

Psychiatric syndromes in Huntington's disease

Thirty patients with Huntington's disease, a genetically transmitted neuropsychiatric disorder that can be diagnosed reliably, were evaluated systematically for psychopathology, followed for extended periods, and treated with psychopharmacological medications when necessary. DSM-III criteria were used for establishing syndromic diagnoses. Twenty-four individuals demonstrated substantial behavioral abnormalities, including affective and schizophrenic syndromes, changes of personality, and disorders that could not be classified adequately. Pharmacotherapy was modestly beneficial in some cases. Consideration of the array of behavioral disturbances encountered in this pathogenetically unified disorder suggests that a dimensional approach to symptom classification might prove more useful heuristically than present typological methods.     

Psychiatric symptoms in Parkinson's disease

Aside from the well-known triad of resting tremor, postural instability, and bradykinesia, Parkinson’s disease (PD) patients may also develop psychiatric illness as a part of their disease. The psychiatric symptoms may be as disabling as the movement disorder, but are often amenable to treatment. We review the most recent investigations of mood disorders, anxiety disorders, and hallucinations/ psychosis in PD. We then highlight new treatment studies for hallucinations/ psychosis in PD.     

Psychiatric symptoms in cases of clinically diagnosed Alzheimer's disease.

All incident cases of clinically diagnosed Alzheimer's disease were identified through the unique record linkage system of the Mayo Clinic. Thirty-nine (32%) of the sample of 122 had a psychiatric history that preceded the onset of CDAD by at least 3 years. Twenty-five percent of the study population had had an episode of delirium within 2 years of the onset of CDAD. Eighty-four percent of the cases had psychiatric symptoms in the course of CDAD that were documented in their medical records. Specific symptom patterns included agitation, combativeness, confusion and disorientation, depression, psychosis, and wandering. These symptoms occurred more frequently in clusters than singularly.     

Psychiatric disorders in preclinical Huntington's disease

Background

Psychiatric symptoms are a common feature of Huntington''s disease (HD) and often precede the onset of motor and cognitive impairments. However, it remains unclear whether psychiatric changes in the preclinical period result from structural change, are a reaction to being at risk or simply a coincidental occurrence. Few studies have investigated the temporal course of psychiatric disorder across the preclinical period.

Objectives

To compare lifetime and current prevalence of psychiatric disorder in presymptomatic gene carriers and non‐carriers and to examine the relationship of psychiatric prevalence in gene carriers to temporal proximity of clinical onset.

Methods

Lifetime and current psychiatric histories of 204 at risk individuals (89 gene carriers and 115 non‐carriers) were obtained using a structured clinical interview, the Composite International Diagnostic Interview. Psychiatric disorders were classified using both standardised diagnostic criteria and a more subtle symptom based approach. Follow‐up of gene carriers (n = 51) enabled analysis of the role of temporal proximity to clinical onset.

Results

Gene carriers and non‐carriers did not differ in terms of the lifetime frequency of clinical psychiatric disorders or subclinical symptoms. However, gene carriers reported a significantly higher rate of current depressive symptoms. Moreover, the rate of depression increased as a function of proximity to clinical onset.

Conclusions

Affective disorder is an important feature of the prodromal stages of HD. The findings indicate that depression cannot be accounted for by natural concerns of being at risk. There is evidence of a window of several years in which preclinical symptoms are apparent.Huntington''s disease (HD) is an inherited neurodegenerative disorder, characterised by motor dysfunction, cognitive impairment and psychiatric disturbance. HD is associated with a wide range of psychiatric disturbances, including affective disorders,^1,2,3 irritability,^4,5,6 apathy^1,3,6 and psychosis.^4,7,8 Both major depression^1,2,4,9 and more subtle mood disturbances¹⁰ have been reported to predate clinical onset, conventionally defined by onset of motor symptoms. However, the basis for psychiatric symptoms remains unclear. Depression has been observed to occur up to 20 years before the onset of motor symptoms,^9,11 raising the possibility that psychiatric symptoms are an early indicator of HD and result from incipient neurodegenerative changes. However, the finding that psychiatric symptoms tend to cluster in certain HD families might indicate that psychiatric changes have a genetic basis and reflect a “switching on” of the HD gene early in life.^2,8 High rates of psychiatric disturbance have also been observed in HD family members who do not carry the genetic mutation,^9,10 raising the alternative possibility that affective changes arise in response to emotional stressors, such as being at risk, or the burden of growing up in a family with affected members. A more thorough understanding of the underlying basis of psychiatric changes in preclinical gene carriers is crucial, as future therapeutic strategies are most likely to target such individuals.Previous psychiatric studies of at risk individuals have yielded inconsistent results. Earlier studies reported high lifetime rates of psychiatric disorder in preclinical gene carriers (eg, 18% major affective disorder),² whereas more recent studies indicate little difference between rates for gene carrier and non‐carrier groups.^10,12,13,14 A number of factors may account for these discrepancies. The majority of earlier reports were limited to retrospective observation of affected individuals and therefore lacked appropriate controls.^4,5 The advent of predictive testing has enabled direct comparison of at risk individuals who have the HD mutation and those who do not, thereby controlling for social and environmental factors.^10,12,13,14 Whereas the majority of earlier studies lacked standardised assessment criteria,^4,7 more recent studies have utilised operational diagnostic criteria, although these have in turn been criticised for failing to detect the more subtle psychiatric disturbances that can occur in HD.^3,15Few studies have taken account of the temporal distance to onset of motor symptoms. It is now well established that the clinical onset of HD is typically preceded by a prodromal period of several months or years during which non‐specific mild neurological signs arise intermittently.¹⁶ The difficulty in establishing exact dates of onset for retrospective cases may have led to the inclusion in earlier studies of individuals who were already in the early stages of HD. Studies of presymptomatic individuals have typically recruited participants without motor signs, who may have been further from clinical onset.The present study is a double blind comparison of lifetime and current prevalence of psychiatric disorders in preclinical gene carriers and non‐carriers, using a combination of standardised psychiatric diagnostic criteria and a more subtle symptom based approach. Follow‐up of gene carriers has enabled analysis of the role of temporal proximity to clinical onset.