Selective mutism: more than social anxiety?

This study investigated the relationship between selective mutism (SM), social phobia (SP), oppositionality, and parenting styles. Twenty-one children with SP, 21 children with SM and SP, and 21 normal children ages 7-15, and the mother of each child, participated in an assessment of psychopathological factors potentially related to SM. Children with SM did not endorse higher levels of social anxiety than did children with SP, although clinicians gave higher severity ratings to those who had both disorders. In addition, although a dimensional measure of oppositionality (Eyberg Child Behavior Inventory) did not reveal group differences, there were significantly more diagnoses of oppositional defiant disorder among children with SM (29%) in comparison to children with SP alone (5%). With respect to parenting styles, there were no significant differences among parents of children with SM and the other groups, except that children with SP reported significantly less warmth/acceptance from parents than normal children. These data replicate previous findings that children with SM do not report greater social anxiety than other children with a SP diagnosis. Furthermore, they suggest that oppositional behaviors may be part of the clinical presentation of a subset of children with SM.     

Postherpetic neuralgia: Topical lidocaine is effective in nociceptor–deprived skin

Objectives Topical lidocaine is effective in postherpetic neuralgia (PHN). The aim of the present investigation was to classify patients according to their predominant peripheral nociceptor function and to compare these data with the results of a controlled study using dermal lidocaine patch.Methods Within the skin area of maximal pain QST (thermotest) and QCART (histamine iontophoresis and laser Doppler flowmetry) were performed prospectively in 18 PHN patients. A controlled study using cutaneous lidocaine (lidocaine 5% patch, IBSA) followed.Results Six patients (group I, sensitised nociceptors) had no sensory loss. Heat pain thresholds were equal or lower than on the contralateral side. Histamine–induced flare and axon reflex vasodilatation were not different on both sides. Histamine evoked pain increased. In 12 patients (group II, nociceptor impairment) heat pain thresholds were higher than contralateral. Histamine–induced flare was impaired or abolished. Histamine did not induce any sensation. Lidocaine was efficacious in the entire group of patients. Subgroup analysis revealed that patients with impairment of nociceptor function had significantly greater pain reduction under lidocaine vs placebo. Patients with preserved and sensitised nociceptors demonstrated no significant pain relief.Conclusions PHN patients differ concerning their cutaneous nociceptor function: In the group I pain is caused by pathologically sensitised nociceptors. In subset II there is a loss of function of cutaneous C–nociceptors within the allodynic skin. Patients responded well to topical lidocaine even if the skin was completely deprived of nociceptors. Different underlying mechanims of lidocaine action in nociceptor–deprived skin are discussed.     

Progressive multicystic encephalopathy: is there more than hypoxia-ischemia?

Progressive multicystic encephalopathy following prenatal or perinatal hypoxia-ischemia is a well-described phenomenon in the literature. The authors report on a term infant with a devastating encephalopathy and severe neuronal dysfunction immediately after delivery without a known antecedent of prenatal or perinatal hypoxia or distress. Clinical and paraclinical findings in the patient are compared with those described in the literature. The authors focus on the specific results guiding to the final diagnosis of progressive multicystic encephalopathy and the timing of morphologic changes. As in this case, if the criteria of an acute hypoxic event sufficient to cause neonatal encephalopathy are not met, then factors other than hypoxia-ischemia may be leading to progressive multicystic encephalopathy.     

Subjective evaluation: is there more than one criterion?

Previous cross-sectional investigations have shown that subjective evaluation criteria (criteria that are used in psychiatric research for evaluating care based on patients' statements) do overlap and that there exists a single general factor underlying all these criteria. In this study, we tested longitudinally and in two different samples of schizophrenia patients the distinctness and covariation at baseline and at followup of three common subjective evaluation criteria (subjective quality of life, self-rated needs, and self-reported symptoms). Scores were intercorrelated at both baseline and followup and showed some intercorrelations over time, suggesting temporal covariation. One stable subjective appraisal factor was identified at both baseline and followup, summarizing a negative subjective quality of life and more symptoms and needs. This factor explained 50 percent to 69 percent of the variance. It was found to be strongly associated with observer-rated mood and was mainly predicted by reporting dark thoughts and being dissatisfied with life as a whole. In subjective evaluation, there appears to be a need to distinguish between a general appraisal factor and specific aspects of different criteria. Therefore, future research needs to focus on how the general factor can be assessed more directly and to identify how the specific variance of different criteria independent of that factor can be maximized.     

Characterizing selective mutism: Is it more than social anxiety?

Selective mutism (SM) occurs when a child persistently lacks speech in some social situations but not in others, despite the ability to use and comprehend language. While considered to be related to anxiety, SM is poorly understood and studies of SM children are often based on parent reports. This study developed a unique, non-verbally based assessment protocol for SM children in order to better characterize their clinical profile, language abilities, and learning abilities. A comparison was done with a group of children of similar age, with social phobia (SP) but no SM, to search for characteristics that might distinguish SM from other anxiety disorders. Twenty-three children participated in the study (14 SM and 9 SP). The assessment protocol included standardized anxiety rating scales, cognitive and academic tests, and a speech and language assessment. SM and SP groups showed similar levels of anxiety and academic ability, but the SM group showed some language impairments relative to the SP group. Though requiring replication with a larger sample and nonclinical comparison group, the results suggest that SM children can be assessed by non-verbal means and that their disorder is characterized by anxiety and subtle language impairments.     

Remission in depressed outpatients: more than just symptom resolution?

OBJECTIVE: In treatment studies of depression remission is defined according to scores on symptom severity scales. Normalization of functioning has often been mentioned as an important component of the definition of remission, though it is not used to identify remitted patients in studies of treatment efficacy. Conceptually, the return of normal functioning should be as fundamental to the concept of remission as is symptom resolution because the presence of both symptoms and impaired functioning are core constructs in the diagnosis of mental disorders. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the independent and additive association between level of severity of depressive symptoms and functional impairment in predicting depressed patients' subjective evaluation of their remission status. METHODS: Five hundred and fourteen depressed psychiatric outpatients filled out a questionnaire on which they rated the severity of the symptoms of depression, the level of impairment due to depression, and their quality of life. RESULTS: Symptom severity, functional impairment from depression, and quality of life were significantly and highly intercorrelated, and each was significantly associated with remission status. The results of a logistic regression analysis indicated that each of the three variables was a significant, independent, predictor of remission status. DISCUSSION: In treatment studies of depression remission is narrowly defined in terms of symptom resolution. Our results support broadening the concept of remission beyond symptom levels to include assessments of functioning and quality of life.     

Do juveniles bully more than young offenders?

This study compares bullying behaviour among juvenile and young offenders and incorporates two different methods to measure bullying. Ninety-five male juvenile and 196 male young offenders completed two questionnaires, one that measured bullying directly and one that measured behaviours indicative of "being bullied" or of "bullying others". Juveniles perceived a higher extent of bullying than young offenders. Juveniles reported significantly more physical, psychological or verbal and overall direct forms of bullying behaviour than young offenders. A number of differences were found between juveniles and young offenders with regard to the types of prisoners likely to become victims, who they would advise a victim to speak to and how bullying could be prevented. The results are discussed in relation to developmental theories of aggression and how bullying behaviour can be defined and measured among prisoners.     

EEG changes reflecting pain: is alpha suppression better than gamma enhancement?

ObjectiveSuppression of alpha and enhancement of gamma electroencephalographic (EEG) power have both been suggested as objective indicators of cortical pain processing. While gamma activity has been emphasized as the best potential marker, its spectral overlap with pain-related muscular responses is a potential drawback. Since muscle contractions are almost universal concomitants of physical pain, here we investigated alpha and gamma scalp-recorded activities during either tonic pain or voluntary facial grimaces mimicking those triggered by pain.MethodsHigh-density EEG (128 electrodes) was recorded while 14 healthy participants either underwent a cold pressor test (painful hand immersion in 10 °C water) or produced stereotyped facial/nuchal contractions (grimaces) mimicking those evoked by pain. The scalp distribution of spectral EEG changes was quantified via vector-transformation of maps and compared between the pain and grimacing conditions by calculating the cosine of the angle between the two corresponding topographies.ResultsPainful stimuli significantly enhanced gamma power bilaterally in fronto-temporal regions and decreased alpha power in the contralateral central scalp. Sustained cervico-facial contractions (grimaces) gave also rise to significant gamma power increase in fronto-temporal regions but did not decrease central scalp alpha. While changes in alpha topography significantly differed between the pain and grimace situations, the scalp topography of gamma power was statistically indistinguishable from that occurring during grimaces.ConclusionGamma power induced by painful stimuli or voluntary facial-cervical muscle contractions had overlapping topography. Pain-related alpha decrease in contralateral central scalp was less disturbed by muscle activity and may therefore prove more discriminant as an ancillary pain biomarker.     

Is life stress more traumatic than traumatic stress?

This study explored the definition of a traumatic stressor, as it currently stands in the DSM-IV-TR, and the relationship between this definition and psychological symptomatology. Four hundred and fifty-four college undergraduates completed measures assessing psychopathology and exposure to trauma. Individuals were then divided into two groups, those who reported a traumatic event that was consistent with the DSM Criterion A1 definition and those who reported a traumatic event that was inconsistent with the definition. Surprisingly, the latter group reported significantly greater severity of PTSD symptomatology than those who reported a Criterion A1 PTSD event. In addition, significantly more people in the DSM trauma-incongruent group met criteria for PTSD than those in the DSM trauma-congruent group. Nearly two-thirds of the DSM trauma-incongruent group identified the death or illness of a loved one as their traumatic experience. The results are discussed within the context of the ongoing controversy over PTSD Criterion A1.     

Treating psychosis: is there more to early intervention than intervening early?

While the possibility of early intervention following the initial onset of psychotic disorders such as schizophrenia is an exciting development, a closer examination of the nature and content, as well as the timing, of treatment is required for this new approach to be successful. Modification and integration of diverse treatments need to be empirically investigated for their potentially greater effectiveness in patients who are, in general, much younger, naive to the mental health system, and possibly capable of full integration into society. Reducing delay in treatment initiation may be complex, may involve adopting early identification strategies, and may pose significant systemic and conceptual challenges. The 2 aspects of early intervention--integration of phase-specific treatments and early case identification--need to go hand in hand to ensure that another opportunity will not be missed in our efforts to improve the outcomes of these most serious of all mental disorders.     

Autism following a history of newborn encephalopathy: more than a coincidence?

Between June 1993 and December 1996, 276 term newborn infants with encephalopathy and 564 randomly selected term controls were enrolled in a population-based study of moderate and severe term newborn encephalopathy (NE) in Western Australia. During comprehensive neurobehavioural and cognitive follow-up of all patients and controls at 3 years and again at 5 years of age we found an unexpected but strong association between NE and autism spectrum disorders (ASDs). A diagnosis of ASD by age 5 years was reached using criteria according of the Diagnostic Statistical Manual, 4th edition. Linking records to the Western Australian Disability Services Commission Register ensured that no child in the study with ASD was missed. By age 5 years, 37 (13.4%) infants with NE and one (0.2%) control had died. Among the 239 survivors of NE, 12 (5%) were diagnosed with an ASD. Of these, 10 (4.2%) met the full criteria for autism, one had pervasive developmental disorder-not otherwise specified, and one had Asperger syndrome. Among the 563 surviving controls, five (0.8%) were diagnosed with an ASD: three with autism, one with autism/possible Asperger syndrome, and one with Asperger syndrome. Compared with the controls, the children who had experienced NE were 5.9 times (95% confidence interval 2.0-16.9) more likely to have been diagnosed with an ASD.