Cerebral perfusion during sleep-disordered breathing

Snoring, a leading symptom of the sleep apnoea syndrome (SAS), has been reported to be one of the risk factors for sleep-related cerebral strokes. Episodes of apnoea are accompanied by hypoxaemia as well as hypercapnia. As CO2 constitute a major regulatory factor controlling cerebral blood flow, it is likely that changes in cerebral perfusion are to be found in patients with SAS, which may be related to nocturnal stroke. A computer-assisted pulsed (2 mHz) Doppler ultrasonography system has been modified for continuous long-term and on-line recording of cerebral haemodynamics together with simultaneous polysomnography, continuous blood pressure recordings, and measurement of the end-expiratory CO2. The dynamics of cerebral blood flow velocity (CBFV) during sleep were measured in the right middle cerebral artery in 10 SAS patients. CBFV showed a characteristic nocturnal pattern with decreases during non-rapid eye movement (NREM) sleep and increases during REM sleep. Changes in sleep stage patterns as well as awakenings from NREM sleep were not regularly accompanied by corresponding changes in CBFV. Dramatic increases in CBFV could be observed during apnoeic episodes, with maximum increases during REM sleep. CO2 reactivity and changes in CBFV related to apnoea duration were markedly increased during sleep compared with the waking state in SAS patients. The dynamic feature of CBFV in relation to sleep patterns reflects quantitative uncoupling between cerebral electrical activity and cerebral perfusion during sleep in SAS patients as has been previously reported for normal subjects (Hajak et al. 1994). It supports a dissociation in the activity of central regulatory mechanisms during human sleep which might cause abnormal cerebral perfusion under certain circumstances. The increased CO2 reactivity during sleep in SAS suggests a 'hypersensitivity' of intracranial vasoactive receptors and/or disturbances in the central autonomic control of cerebrovascular functions. It may be concluded that, under certain conditions, the interaction of decreased cerebral perfusion in SAS patients with sleep-related cerebral perfusion patterns and haemodynamic changes during apnoeic episodes might lead to a critical reduction in cerebral perfusion.

Dynamics of cerebral blood flow velocities during normal human sleep

Bilateral flow patterns of the middle cerebral artery (MCA) were recorded continuously throughout the night in 18 healthy male subjects (mean age 27.4 years) by a computer-assisted pulsed Doppler (2 MHz) system together with simultaneous polysomnography. After inception of sleep, mean flow velocity (MFV) decreased steadily during deepening sleep stages reaching -15.0 +/- 3.6% (p < 0.001) in the right MCA and -16.2 +/- 3.4% in the left MCA (p < 0.001) in stage 4 of the first sleep cycle compared to the waking state. Lowest MFV values were found in stage 2 preceding the last REM period (right MCA: -19.2 +/- 4.1%: left MCA: -19.7 +/- 5.1%). Changing from non-REM into REM sleep, a sudden rise of MFV, which varied from 8.9% (first sleep cycle, left MCA) to 18% (last sleep cycle, right MCA), could be consistently detected indicating a coupling of cerebral electrical activity and cerebral perfusion in REM sleep. During non-REM sleep this concomitant change of MFV and EEG activity was only found in the first sleep cycle, whereas no parallel changes could be observed in later sleep cycles. These results indicate a decoupling of EEG measured cerebral electrical activity and perfusion and suggest that factors other than metabolic mechanisms contribute to the regulation of cerebral perfusion during human non-REM sleep.

Cerebrovascular reactivity to acetazolamide in (senile) dementia of Alzheimer's type: relationship to disease severity

Neuropathological reports about denervation and amyloid angiopathy in dementia of Alzheimer's type (DAT) as well as signs of selective incomplete white matter infarctions point to a vascular involvement within the degenerative process. In order to investigate potential alterations of cerebrovascular function we performed cerebral blood flow measurements before and after intravenous injection of 1 g acetazolamide using technetium-99m hexamethylpropyleneamine oxime and single photon emission tomography in 12 patients (6 female, 6 male; mean age 70.8 +/- 9.6 years) with probable (senile) dementia of Alzheimer's type (SDAT) and 9 controls (7 female, 2 male; mean age 71.2 +/- 8.6 years). SDAT patients revealed significantly reduced cerebrovascular reactivity with lower values with increasing cognitive impairment. We discuss possible underlying mechanisms.

99mTc-HMPAO-SPECT in the diagnosis of senile dementia of Alzheimer's type--a study under clinical routine conditions

This study was designed to evaluate, whether investigations of cerebral blood flow can be a helpful diagnostic tool in the differential diagnosis between (senile) dementia of Alzheimer's type [(S)DAT] and geriatric depression with cognitive impairment. Under clinical routine conditions we performed Single Photon Emission Computed Tomography (SPECT) using 99mTc-Hexamethylpropyleneamine Oxime (HMPAO) in 23 patients with (S)DAT (14f, 9m; mean age 68.9 y), 17 patients with geriatric depression (9 f, 8 m; mean age 66.4 y) and 12 age-matched controls (9 f, 3 m; mean age 69.2 y). Semiquantitative analysis (corticocerebellar ratios) of eight different regions of interest (ROI) revealed a significantly (p < 0.05) reduced perfusion in the (S)DAT patients compared to the control group. The depression group exhibited perfusion values between the (S)DAT and control group. The difference between the depression and (S)DAT group was most prominent in the left parieto-occipital ROI (p = 0.008). We discuss the data with extensive regard to the literature and conclude that 99mTc-HMPAO SPECT is a valuable additional tool in the differential diagnosis of depression and dementia in the elderly.

Single photon emission tomography (SPET) imaging of dopamine D2 receptors in the course of dopamine replacement therapy in patients with nocturnal myoclonus syndrome (NMS)

Single photon emission tomography (SPET) permits the in vivo measurements of regional cerebral radioactivity in the human brain following the administration of compounds labeled with photon-emitting isotopes. According to our SPET findings of a reduced binding of [123I]labeled (S)-2-hydroxy-3-iodo-6-methoxy-([1-ethyl-2-pyrrolidinyl]methyl) benzamide (IBZM) (a highly selective CNS D2 dopamine receptor ligand) to D2 dopamine receptors in striatal structures in untreated patients with nocturnal myoclonus syndrome (NMS) it seemed to be of interest to investigate whether there are changes in D2 receptor binding under dopamine replacement therapy or not. We studied the uptake and distribution of [123I]IBZM before and in the course of dopamine replacement therapy in four patients with severe insomnia caused by a nocturnal myoclonus syndrome (NMS). We found an increase of the IBZM binding to D2 receptors in the course of treatment, which was associated with an improvement of sleep quality. Reasons for this are discussed. The [123I]IBZM SPET technique in conclusion offers an intersting tool for in vivo investigations of functional changes in the dopaminergic neurotransmitter system in longitudinal studies.

What treatments do patients with panic disorder and agoraphobia get?

In a retrospective study 100 patients with DSM-III-R/ICD-10 panic disorder and agoraphobia (PDA) were interviewed about the psychopharmacological, psychological and 'alternative' treatments they had received in the course of their illness. Patients gave global statements about how satisfied they were with the various treatments they had experienced. Many patients received treatments that have never been investigated under controlled conditions. The most common drug treatments, in descending order, were: 48% benzodiazepines, 42% tricyclic antidepressants, 32% herbal preparations, 29% neuroleptics, 7% selective serotonin reuptake inhibitors and 6% beta blockers. Of the drug prescriptions, 63% were according to international standards. Of the neuroleptics, two-thirds (63.3%) were prescribed by nonpsychiatric physicians, and only one-third by psychiatrists (33.3%). Tricyclic antidepressants were prescribed more often by psychiatrists (64.7%) than by non-psychiatrists (31.4%). Among psychological treatments, autogenic training (43% of the patients) and psychodynamic therapy (33%) were used far more frequently than behavioural/cognitive therapy (20%). These results confirm the underutilisation of available effective treatments for panic disorder (e.g. tricyclic antidepressants or behavioural therapy) and the overutilisation of treatments without proven efficacy (e.g. herbal preparations or autogenic training). Patients were most satisfied with treatments that have been proven effective in controlled studies. Among drug treatments, benzodiazepines, selective serotonin inhibitors and tricyclic antidepressants were favoured (mean on a 0-4 scale indicating effectiveness: 2.6, 2.6 and 2.4). Neuroleptics (1.4), beta-blockers (1.0) and herbal preparations (0.9) were not rated highly effective by the patients. Among psychological treatments, patients were more satisfied with behavioural/cognitive therapy (2.6) than with psychodynamic therapies (1.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Nocturnal myoclonus syndrome (periodic movements in sleep) related to central dopamine D2-receptor alteration

The nocturnal myoclonus syndrome (NMS) consists of stereotyped, repetitive jerks of the lower limbs that occur during sleep or wakefulness. NMS is often related with restless-legs syndrome (RLS) and can cause severe sleep disturbances and daytime sleepiness. The efficacy of dopamine agonists in the treatment points to a dopaminergic dysfunction in NMS. We investigated the central dopamine D2-receptor occupancy with [123I] labeled (S)-2-hydroxy-3-iodo-6-methoxy-([1-ethyl-2-pyrrolidinyl]methyl) benzamide (IBZM) (a highly selective CNS D2 dopamine receptor ligand) ([123I]IBZM) and single photon emission tomography (SPET) in 20 patients with NMS and in 10 healthy controls. In most of the patients with NMS there was a lower [123I]IBZM binding in the striatal structures compared to controls. The results indicate that NMS is related to a decrease of central D2-receptor occupancy.

[Ambulatory treatment of sleep disorders in the aged]

An enquiry into the handling by medical practitioners of sleeping problems among elderly patients was conducted in southern Lower Saxony by personal interview, combined with a standard questionnaire. A typical case report had been drafted concerning a 70-year-old, previously healthy widow: her complaints were "nonspecific" and could be classified as an example of either depression, of the onset of senile dementia or as within normal limits for age. This case report was presented by two interviewers to 145 general practitioners (GPs) and 14 neurologists in private practice (response rate of 83.2%) who were asked how they would have treated the patient's sleeping disorder. 30.3% of the GPs and 14.3% of the neurologists would initially not have prescribed medication. Only GPs (19.5%) mentioned possible herbal medication. Sedative neuroleptics were preferred by 57.1% of neurologists and 26.2% of GPs, while benzodiazepines would have been given by 14% of both groups. Antidepressive drugs and chloral hydrate were chosen less often (5.7% and 2.5%, respectively). These data support the finding of a high frequency of neuroleptic prescriptions given to the elderly. They also make clear that the possibility of treatment without drugs is usually not sufficiently explored.

Effects of clozapine on CSF homovanillic acid in spasmodic torticollis

We studied the effect of the atypical neuroleptic clozapine (CLO) on homovanillic acid (HVA) in cerebrospinal fluid (CSF) in five patients with spasmocid torticollis. Lumbar puncture was performed before and on the seventh day of CLO treatment. Although an HVA elevation was to be expected because of the antidopaminergic action of CLO, statistical analysis failed to reveal any significant increase of HVA under CLO treatment. Thus significance of CSF HVA may be less important for the description of antidopaminergic action of neuroleptics than previously assumed.

Eosinophilia-myalgia syndrome in Germany: an epidemiologic review

OBJECTIVE

To review the epidemiologic features of eosinophilia-myalgia syndrome (EMS) in Germany.

DESIGN

We determined the incidence of EMS in Germany through May 1992 and analyzed the dose of L-tryptophan used, the duration of intake, and the concurrent medications.

MATERIAL AND METHODS

All patients receiving L-tryptophan preparations in Germany were already under medical supervision before the onset of the disease; thus, information on patient history and other potential risk factors was readily available. Because of the drug status of L-tryptophan preparations, brands could be accurately traced back to suppliers of raw materials. Statistical differences in age and gender of patients, dose of L-tryptophan, eosinophil count, and skin involvement were sought between patients with and those without concurrent medications.

RESULTS

On the basis of guidelines established by the Centers for Disease Control and Prevention, 105 patients fulfilled the criteria for EMS. No apparent correlation was found between the incidence of EMS and the dose of L-tryptophan or the duration of intake before onset of EMS. Assessment of the study group showed that 45% were taking various other medications, whereas 55% were taking L-tryptophan only. Analysis by type of pharmaceutical agent showed no preponderance of a specific concurrent drug (in particular, psychotropic drugs). Thus, concurrently used medications did not seem to be an important variable. All cases of EMS were associated with L-tryptophan from formulators that had used raw materials from the previously implicated source.

CONCLUSION

This study supports the pathophysiologic role of a contaminant in L-tryptophan in the occurrence of cases of EMS in Germany.

Clozapine treatment of spasmodic torticollis

We report a trial of clozapine (CLO) in patients with spasmodic torticollis (ST). In an open-design trial we treated five patients with adult-onset ST with CLO (300 mg/d) over 12 weeks and one patient over 3 weeks. We videotaped the patients three times (before and at the end of CLO treatment, and 2 weeks after CLO withdrawal) according to a standardized protocol. At the end of the treatment period, CLO plasma concentrations ranged from 67 to 371 ng/ml. In all six patients, analysis of the video ratings and patients' self-assessments failed to reveal any improvement of ST. These preliminary results fail to confirm any therapeutic benefit of CLO in the treatment of ST.

[Nightly myoclonus syndrome (NMS) and restless legs syndrome (RLS)--review and case report]

The paper gives a brief review of the existing literature concerning the nocturnal myoclonus syndrome (NMS). The clinical symptomatology, criteria for differential diagnosis and the relation to the restless legs syndrome (RLS) are discussed. Recently we investigated central dopamine receptor density with 123I-labeled 3'-iodo-6-methoxybenzamide (IBZM) (a highly selective CNS D2 dopamine receptor ligand) and single photon emission tomography (SPECT) in patients with NMS and found a reduced density of dopamine D2-receptors in the striatal structures, indicating a dopaminergic dysfunction in NMS and RLS. We present a report concerning a 58-year old female with NMS-associated insomnia and present IBZM SPECTs and hypnograms before and after a 3-month treatment with L-dopa and discuss the results with regard to pathophysiological theories.

[Intensive care treatment of psychiatric patients]

In a retrospective analysis we studied the frequency and cause of intensive care measures for psychiatric patients. All inpatients seen in the Department of Psychiatry, University of Göttingen, between 1985 and 1990 who either were treated in an intensive care unit (ICU) or died during treatment were included. 218 patients fulfilled these criteria, representing 2.4% of all psychiatric inpatients. In the sample as a whole, addiction (29%) and neurotic disorder (27%) were the largest diagnostic groups, followed by organic psychoses (15%). In comparison with other psychiatric diagnoses, addictive and organic disorders were overrepresented. The patients originally seen in the Department of Psychiatry (n = 70) were admitted to the ICU for various reasons (24% alcoholic delirium, 17% electrolyte disturbances and dehydration, 16% pneumonia, 11% suicide attempts, 7% thrombosis, etc.). Reasons for admission directly to the ICU (n = 138) with subsequent referral to the Department of Psychiatry were generally either suicide attempts (53%) or complications of addiction (32%). Thirty-six per cent of all patients required tracheal intubation. Patients with endogenous psychoses required mechanical ventilation more often than patients with other psychiatric diagnoses. Sixteen deaths occurred in this period of time, most often in patients with organic psychoses (n = 6). These results illustrate a high incidence of severe medical disorders in psychiatric inpatients. They emphasize the necessity of intensive collaboration between psychiatrists and intensive care physicians.

Relationship between cerebral blood flow velocities and cerebral electrical activity in sleep

The dynamics of cerebral blood flow velocity during sleep were measured in the right and left middle cerebral artery of 12 and 10 healthy male volunteers, respectively. A computer-assisted pulsed (2-MHz) Doppler ultrasonography system was modified for continuous long-term and on-line recording of cerebral hemodynamics in combination with polysomnography. Mean flow velocity (MFV) decreased steadily during deepening nonrapid eye movement (NREM) sleep and increased suddenly during rapid eye movement sleep, corresponding to changes in brain function. However, spontaneous or provoked changes in sleep stage patterns as well as awakenings from NREM sleep were not regularly accompanied by corresponding changes in MFV. Differing values for MFV in subsequent sleep cycles could be shown for several sleep stages. Furthermore, MFV values in sleep stage II at the end of an NREM-sleep period were lower than in preceding slow-wave sleep. After application of short acoustic signals the electroencephalogram frequency rose, indicating an arousal, whereas MFV rapidly decreased for several seconds and then gradually returned to the prior level. These results imply an uncoupling between cerebral electrical activity and cerebral perfusion during sleep and support a dissociation in the activity of central regulatory mechanisms. In light of the proposal that cortical energy consumption can be accounted for by cerebral electrical activity, the concept that cerebral perfusion during sleep is regulated solely by the metabolic rate must be reconsidered.

Diagnosis of dementia in primary care: results of a representative survey in lower Saxony, Germany

To investigate whether an early diagnosis of dementia is established, whether a differentiation is made between vascular and primary degenerative etiology, and whether treatable causes of dementia are considered in primary care, we performed a survey using three written sample case histories describing slight memory impairment (case 1) or moderate dementia (case 2a: vascular dementia; case 2: degenerative dementia of Alzheimer type). The combinations 1 and 2a or 1 and 2b were randomly assigned and presented to ambulatory-care physicians (145 general practitioners and primary care internists and 14 neuropsychiatrists in private practice) in Göttingen and rural surroundings by a trained investigator who then performed a standardized interview. The study was representative (response rate 83.2%). For the sample case with slight memory complaints 13.8% of all physicians arrived at a primary diagnosis of depression and 44.0% considered depression for differential diagnosis. Senile dementia of Alzheimer type was considered less often. In the sample cases with moderate dementia according to established scientific criteria, there was a striking under-diagnosis of dementia, and in both cases an over-diagnosis of underlying vascular etiology. Treatable causes of dementia, such as possible drug interactions and substance abuse, were considered only by a minority of physicians. In conclusion, memory deficits seem to be regarded mainly as consequences of disturbed cerebral perfusion, and dementia as well as depression and drug adverse effects seem to be under-diagnosed in primary care.

Efficacy of the peptidergic nootropic drug cerebrolysin in patients with senile dementia of the Alzheimer type (SDAT)

Cerebrolysin is a peptidergic nootropic drug with a multimodal mechanism of action. It is expected to have a positive influence on neurodegenerative diseases such as senile dementia of the Alzheimer type (SDAT). Experimental studies have shown Cerebrolysin to have a regulatory effect on energy metabolism, a positive influence on behavior through neuromodulation due to its peptide fraction, and most important, a neurotrophic stimulation. In SDAT and related disorders the neurotrophic effect of the drug could play a major role and influence the progress of the illness. A placebo-controlled double-blind trial was designed to examine the efficacy of the drug in SDAT. Confirmatory statistics were used for analysis. 120 subjects with mild to moderate dementia according to the Global Deterioration Scale (GDS) were included in the trial. Their performance on the Mini Mental State Examination (MMSE) was between 15 and 25. The diagnosis was substantiated by the Hachinski Ischemic Score and cranial computed tomography. The inclusion and exclusion criteria were formulated so as to prevent a distortion between the two arms by secondary dementia or other disease. The two arms received either placebo or the drug once a day (30 ml Cerebrolysin in 100 ml physiological saline i.v.) from Monday to Friday for four weeks. Physiological saline (130 ml) was used as placebo. Primary variables used for the statistical analysis were the Clinical Global Impression (CGI), which measures the improvement in symptoms, the SCAG score, and the performance in the trial-making test (ZVT-G). The self-assessment in the Bf-S and the activities of daily living in the NAI were used as secondary variables.(ABSTRACT TRUNCATED AT 250 WORDS)

Zopiclone improves sleep quality and daytime well-being in insomniac patients: comparison with triazolam, flunitrazepam and placebo

In a randomized, double-blind, parallel group study in private practice, zopiclone given for 28 days was compared with flunitrazepam, triazolam and placebo in its effect on quality of sleep and daytime well-being in 1507 patients suffering from insomnia. For quantitative assessment, patients were defined as responders according to either a shortening of sleep latency by at least 15 min, or prolongation of total sleep time by at least 20%, or reduction of the number of nocturnal awakenings to three or less and a fresh feeling in the morning, as well as lack of impairment in daytime well-being as a result of tiredness or anxiety. The responder rate tended to be higher with zopiclone (37.4%) than with flunitrazepam (30%) and triazolam (32.2%) and was significantly greater (p = 0.0017) than with placebo (26.8%). Daytime well-being was particularly responsive to zopiclone and most responsive in severe insomniacs. With the exception of those to triazolam, rates of response were most pronounced in patients with insomnia of a short duration (< or = 1 year) than in those with insomnia of a longer duration (> or = 1 year). Following discontinuation of treatment, all groups showed a moderate reduction in therapeutic effect, but no rebound insomnia occurred.

Cluster arousal analysis in chronic pain-disturbed sleep

A new cluster arousal analysis system was developed to quantify microdisturbances in the sleep architecture. The system was evaluated in 10 healthy volunteers and the sleep of 23 outpatients with chronic low back pain was investigated before and after a special rehabilitative training. The comparison of sleep parameters before and after the treatment showed a significant reduction of the cluster disturbed sleep (CDS), whereas sleep efficiency and the number of stage shifts remained unchanged. The reduction of the CDS correlated with a reduction of depression scale. This cluster arousal analysis appears to be a sensitive tool for evaluating alterations in the sleep microstructure.

[Dementia and psychotic symptoms in amyotrophic lateral sclerosis]

We present 2 case histories of patients, treated in psychiatric clinics because of psychotic disorders, in whom further investigation revealed the presence of amyotrophic lateral sclerosis (ALS) and dementia. The causal relationship between psychotic symptoms and dementia on the one hand and ALS on the other hand is discussed. Probably in ALS other functional systems besides motor-neuron pathways are involved.

Effects of indirectly acting 5-HT receptor agonists on circulating melatonin levels in rats

Because circulating melatonin levels are generally thought to be under the strict control of pineal N-acetyltransferase, little attention has been paid to the impact of an altered availability of serotonin (5-HT) on melatonin formation. In order to see whether melatonin synthesis is stimulated by an increased availability of free, cytosolic 5-HT, we studied the effects of 5-HT precursors, 5-HT releasers and reuptake inhibitors and of monoamine oxidase inhibitors, alone and in combination, on circulating melatonin levels in experimental animals. The administration of tryptophan and 5-HT-releasing drugs (fenfluramine, +/- 3,4-methylenedioxymethamphetamine) to rats caused a dose- and time-dependent elevation of circulating melatonin levels during the day and night. This increase in melatonin was further enhanced by inhibition of monoamine oxidase. The elevation of plasma melatonin caused by 5-HT-releasing drugs was prevented by prior administration of fluoxetine. Monoamine oxidase inhibitors and fluoxetine alone had no effect on circulating melatonin levels. These findings indicate that the administration of indirectly acting 5-HT receptor agonists which increase the free cytoplasmic pool of 5-HT may also elevate circulating melatonin levels. The results of this study suggest that the rate of pineal melatonin synthesis is dependent on the free cytoplasmic pool of 5-HT in pinealocytes and that the drug-induced elevation of this pool stimulates melatonin formation and increases circulating melatonin levels. At least some of the effects of indirectly acting 5-HT receptor agonists, e.g. on sleep, mood, food intake, pain perception, and neuroendocrine secretion, may therefore be mediated by the elevation of circulating melatonin and the subsequent activation of central melatonin receptors.

[Blood circulation and energy metabolism of the brain in healthy sleep]

Studies on sleep-related changes of cerebral blood flow (CBF) and cerebral metabolic rate (CMR) provide important information about sleep as an active neurophysiological process. Decreases in global values of CBF and CMR during non-rapid-eye-movement sleep illustrate rate role of this sleep period as a quiescent phase for the human brain. Increases in CBF and CMR and fast alterations in cerebral perfusion during rapid-eye-movement sleep are indicative of an active state with labile regulation. Local changes in CBF and CMR characterize the heterogeneity of the underlying physiological regulation. The dynamic feature of cerebral perfusion in relation to electroencephalographic patterns obtained by new recording techniques reflects quantitative uncoupling between cerebral electrical activity and cerebral perfusion during parts of the sleep period. A critical analysis of the current literature and history of sleep research on this topic is presented.

Adverse psychic reactions to psychotropic drugs--a report from the AMUP study

The AMUP study (AMUP = Arzneimittelüberwachung in der Psychiatrie (Drug Monitoring in Psychiatry)) was conducted from 1979 to 1989 in order to provide for a systematic and standardized assessment of all adverse reactions to psychotropic drugs under the conditions of routine clinical treatment at two psychiatric hospitals. This paper presents data from the AMUP study on the type and frequency of adverse psychic reactions to psychotropic drug groups and relevant single drugs. Psychic ADR leading to drug discontinuation were observed in 4.5% of 15,264 inpatients monitored over an eight-year period. Only neurological ADR were more frequent (4.9%). Neuroleptics and antidepressants were involved with similar frequencies in ADR that were at least "probably" drug-related (3.3 and 3.5%). Lithium salts and benzodiazepines were only rarely involved in psychic ADR. Toxic delirium (1.0%), agitation (0.9%), and sedation (0.8%) were the most frequent single events, usually rated as "probably" drug-related. Depression and psychotic states were next in frequency, but judged as only "possibly" drug-related in a considerable proportion of cases. Haloperidol, the most common high-potency neuroleptic, was imputed mainly for depression, sedation, agitation, and (malignant) neuroleptic syndrome; with medium-potency perazine, toxic delirium and sedation prevailed; among the most common antidepressants, amitriptyline was above all connected with toxic delirium, while with clomipramine agitation predominated. The paper discusses the particular difficulties encountered in the field of psychic ADR in psychiatric patients regarding causality assessment, and emphasizes the need for continuous ADR assessment studies including state hospitals.

Dopamine D2 receptor alteration in patients with periodic movements in sleep (nocturnal myoclonus)

Periodic movements in sleep (PMS) can cause severe sleep disturbances. We investigated the central dopamine D2 receptor density in patients with PMS with 123I-IBZM and single photon emission tomography (SPET). In PMS there was a lower 123I-IBZM binding in the basal ganglia compared to the control group. The results indicate a loss of central D2 receptors in PMS.

[Somnambulism and pavor nocturnus--review and case report]

A case of night terror with sleepwalking in an adult patient is described. Sleep polygraphic data are presented. The literature related to sleepwalking, night terror and its treatment is reviewed. The psychopathologic patterns of sleepwalking and night terror are illustrated and the differentiations of parasomnias and epileptic seizures discussed. The clinical applications of these findings are described and practical recommendations made for the management of NON-REM parasomnia.