Clinical characteristics of schizophrenia associated with velo-cardio-facial syndrome

Velo-cardio-facial syndrome (VCFS) is caused by a microdeletion in the long arm of chromosome 22 and is associated with an increased frequency of schizophrenia and bipolar mood disorder. The purpose of this study was to investigate the genetic, physical, developmental and psychiatric features of schizophrenic patients with VCFS microdeletion. It describes the clinical findings in four schizophrenic inpatients with the characteristic chromosomal deletion. The four patients displayed delayed motor development, language deficits, learning disabilities, mental retardation, early age of onset, chronic and disabling course of illness and poor response to classical neuroleptic drugs and electroconvulsive therapy. Two patients benefited from treatment with clozapine. We suggest that schizophrenic patients with a history of delayed motor development, early onset of the disorder, history of learning disability, mental retardation, congenital cardiac anomalies and/or hypernasal speech should be screened for the velo-cardio-facial syndrome deletion. The implications of this study for psychiatric phenotype, nosology, disease mechanism, and possible new treatments in the future are discussed.

Elevated serum creatine kinase activity in adolescent psychiatric inpatients on admission

Studies in adults have indicated a significant relationship between high serum creatine kinase levels on admission and acute psychosis. However, data on children are sparse. The files of 183 hospitalized children and adolescents (93 boys, 90 girls) with severe psychiatric disorders were reviewed for serum creatine kinase activity on admission, psychomotor agitation, Clinical Global Impression Score, need for intramuscular injection, number of neuroleptic medications and presence of neuroleptic malignant syndrome. Serum creatine kinase levels > 201 IU/ml were considered abnormal. Boys had significantly higher creatine kinase activity than girls. Division of the cohort by diagnosis yielded significantly higher levels in those with schizophrenia, affective disorders and mental retardation. Higher levels were also associated with higher Clinical Global Impression score on admission, use of injections and physical restraint, and nonresponse to neuroleptic medication. There were no cases of neuroleptic malignant syndrome. This first large-scale investigation of serum creatine kinase activity in young psychiatric inpatients shows a significant association between high creatine kinase activity and acute psychosis, similar to that in adults. Furthermore, high creatine kinase levels on admission are predictive of the severity of the psychosis, but are not associated with neuroleptic malignant syndrome. Because psychotic adolescents with high admission creatine kinase levels tend to be nonresponders, clinicians should consider the early use of atypical antipsychotics in this subgroup.

Bone age in adolescents with schizophrenia and obsessive-compulsive disorder

The bone age (BA), height and weight of 20 adolescents with schizophrenia and 21 matched adolescents with obsessive-compulsive disorder (COD) were measured. The BA of the schizophrenic patients was significantly higher than their chronological age (CA)(p < 0.05), while the OCD subjects' BA was non-significantly lower than their CA. In addition, the difference between CA and BA (delta ages) in the schizophrenic adolescents was significantly different from the delta ages of the OCD adolescents (p , 0.05). Gender did not significantly affect BA or delta ages. A positive correlation (r = 0.5, p < 0.01) was obtained between CA and delta ages in the schizophrenic patients but not in the OCD patients. Both groups were within the normal range of weight and height percentiles.

Application of models of working at the interface between primary care and mental health services in Israel

Psychiatric morbidity is common in primary care, a large proportion being treated without specialist referral. A significant proportion may be undetected or inadequately treated. This article describes current models of mental health services (MHS) working at the interface between primary care and MHS with review of data regarding these models and discussion of the application of these models to the Israeli health system. The shifted out-patient model, primarily provided by psychiatrists independent of the Primary and Secondary Care Teams, would seem to increase access to psychiatric services, increase treated prevalence of the disorders and attract a similar population to hospital out-patient services. The psychiatric community liaison model aims to improve primary care practitioner detection and management skills, might reduce referrals to psychiatrists with similar patient outcome and enables treatment of patients unwilling to see a mental health professional (MHP). The attached MHP Model would allow access to a greater range of psychosocial interventions provided by a primary care team member. The community mental health team, currently a model not in practise in Israel, provides a single point of referral for multidisciplinary care but has shown varying patterns of integration and responsiveness to primary care. Other interfaces of collaboration such as Balint groups and education are also discussed.

Alprazolam withdrawal delirium: a case report

Benzodiazepine withdrawal delirium is thought to be uncommon. Only two clear reports of alprazolam withdrawal appear in the literature, but the use of this drug is expected to increase because of its recent approval for the treatment of panic disorder. We report on a patient with severe alprazolam withdrawal delirium that developed immediately after an accidental reduction of the dose. This case demonstrates importance of clinician awareness of the previous use of alprazolam in individual patients, especially in hospital settings where free patient use of drugs is prohibited.

Recurrence pattern of serum creatine phosphokinase levels in repeated acute psychosis

BACKGROUND

Elevated serum creatine phosphokinase (CPK)MM level is frequently found in acute psychosis. Theories relate this CPKemia to psychomotor agitation and medication. We hypothesized that psychosis-related CPKemia observed in individual patients is relatively consistent.

METHODS

Ninety psychotic patients were studied; 83% were schizophrenics (Brief Psychiatric Rating Scale scores > or = 40) whose serum CPKMM levels were recorded during two or more different acute psychoses. The serum CPKMM levels used were the maximal levels monitored during the beginning of each hospitalization. The last CPK measurement in a circumscribed period was defined as the index serum CPK level (IndCPK). The mean of all other individual maximal CPK measurements during other psychotic episodes was defined as the average CPK (AvgCPK).

RESULTS

Multiple linear regression analysis showed a significant correlation of natural logarithm (Ln) of (IndCPK with Ln(AvgCPK), as well as with gender (coefficient = .65 and .63, p < .0001 and p < .01, respectively). There were significantly higher IndCPK levels among male patients than among female patients (p < or = .001). A relatively consistent individual pattern of serum CPKMM levels during repeated acute psychotic episodes was observed.

CONCLUSIONS

Serum CPKMM levels and gender were found to be good predictors of maximal serum CPKMM levels during every repeated acute psychotic episode. High IndCPK levels are probably risk factors for neuroleptic malignant syndrome.

Bruxism secondary to antipsychotic drug exposure: a positive response to propranolol

We present two cases of acute nocturnal bruxism occurring as an early side effect of antipsychotic drug treatment. The development of bruxism was coupled with the appearance of neuroleptic-induced akathisia. Both complications were relieved after the beta-adrenergic blocker propranolol was added, suggesting the involvement of the adrenergic and serotonergic central nervous systems, besides the dopaminergic system, in the pathogenesis of bruxism. The positive response of iatrogenic bruxism to propranolol implies that propranolol also deserves a trial for the treatment of noniatrogenic nocturnal bruxism.

Severe withdrawal akathisia following neuroleptic discontinuation successfully controlled by clozapine

Akathisia is one of the most distressing side effects of neuroleptic treatment. It is usually managed by manipulating the neuroleptic dose and administering anti-akathisic compounds (beta-blockers, anticholinergics, serotonin antagonists). However, the pathophysiological background of withdrawal akathisia which follows the discontinuation of neuroleptic treatment remains unclear, and there is as yet no adequate treatment. We report a case of severe withdrawal akathisia associated with suicidal and autoaggressive behaviour during a gradual transition from perphenazine/trihexyphenidyl to clozapine. The akathisia was effectively managed by titration of clozapine (maximum dose 200 mg/day) Thereafter, reduction of the clozapine dose resulted in a recurrence of the akathisia, and the resumption of clozapine dose was accompanied by full amelioration of symptoms. We suggest that the antiserotonergic properties of clozapine were responsible for its anti-akathisic effect. Differences in the treatment of acute and withdrawal types of akathisia are emphasized.

A combined clinical approach to treating and understanding prolonged combat stress reaction

Over the last decade combat stress reaction (CSR) has received increasing attention in Israel and abroad. The treatment of prolonged CSR is known to be complicated and unrewarding, and the majority of cases became chronic. The authors describe the difficulties of diagnosing delayed and prolonged CSR and present a model of combined treatment approach through a case study.

Cytokine production in obsessive-compulsive disorder

Cytokine production was previously demonstrated to be reduced in untreated major affective patients. In addition, recovery from depression following clomipramine (CMI) treatment was accompanied by the restoration of interleukin-1 beta (IL-1 beta) and interleukin-3-like activity (IL-3-LA) to normal range. In the present study we assessed the in vitro production of IL-1 beta IL-2, and IL-3-LA by peripheral blood mononuclear cells (PBMC) in 11 nondepressed patients with obsessive compulsive disorder (OCD) before and after 8 weeks of CMI treatment. Results were compared with those of 11 healthy subjects. CMI treatment induced a significant improvement in OCD symptoms. No alteration was observed in cytokine production in OCD patients before treatment as compared to control subjects. Moreover, 8 weeks of drug treatment had no effect on cytokine production. In conclusion, OCD per se, as well as CMI treatment, have no effect on interleukin production as measured in this study.

Fluvoxamine treatment in clozapine-induced obsessive-compulsive symptoms in schizophrenic patients

Interest in the association of obsessive-compulsive (OC) symptoms and schizophrenia has been reawakened since the introduction of clozapine for treatment of schizophrenia. We describe the appearance of this disorder and examine the efficacy of adding fluvoxamine to ongoing clozapine treatment of the OC and schizophrenic symptoms. Four patients with DSM-III-R schizophrenic disorder, in whom OC symptoms appeared during the course of clozapine treatment, are reported. In two patients, fluvoxamine, a serotonin-selective reuptake inhibitor (SSRI), was added to clozapine under open-trial conditions. The patients were serially assessed by using the Brief Psychiatric Rating Scale, Yale-Brown Obsessive-Compulsive Scale, and Scale for the Assessment of Negative Symptoms. The de novo occurrence and eventual spontaneous reduction of OC symptoms were noted in two schizophrenic patients treated with clozapine. In the other two patients, one with previous and the other with a family history of OC disorder, the addition of fluvoxamine to clozapine was effective in eliminating the OC symptoms. A concomitant improvement in the schizophrenic symptomatology was seen as well. It appears that disabling OC symptoms may occur as in response to clozapine treatment in chronic drug-resistant schizophrenic patients. Some of the latter may benefit from the addition of an SSRI to the ongoing clozapine regimen.

Cyproheptadine treatment in neuroleptic-induced akathisia

BACKGROUND

Cyproheptadine, an antiserotonergic agent, was used to treat neuroleptic-induced akathisia.

METHOD

In an open clinical trial 17 neuroleptic-treated patients with akathisia were administered cyproheptadine (16 mg/day) over 4 days. Assessment of akathisia, psychosis and depression were monitored by BAS, BPRS and HAM-D.

RESULTS

All subjects showed improvement in the severity of akathisia, which in the majority (15/17) was of a marked degree. There was no aggravation of psychosis or depression. Symptoms of akathisia returned when cyproheptadine was discontinued.

CONCLUSIONS

Cyproheptadine may be useful in neuroleptic-induced akathisia.

First month of neuroleptic treatment in schizophrenia: only partial normalization of the late positive components of visual ERP

In a previous study we recorded visual event-related potentials (ERP) in drug-naive schizophrenics during passive-attention and active-attention tasks. Patients, compared to normal controls, had much lower late positive components (LPC) in both sessions, but nearly normal LPC increase from passive to active task. The present sample consisted of drug-naive and drug-free patients who were tested before and during the first month of neuroleptic treatment. Neuroleptics initiated gradual amelioration of psychiatric symptoms expressed by reduced Brief Psychiatric Rating Scale (BPRS) scores. Schizophrenics compared to controls showed a session-related increase in LPC amplitude, but this process of LPC recovery was too minor to fully normalize the low LPC amplitudes in patients. Furthermore, the treatment either did not improve or even reduce the LPC reaction to the active-attention task. These findings indicate that normalization of low LPC in schizophrenia might require a long period of treatment, and that patients' reduced LPC reactivity to the task might be contributed, rather than treated, by neuroleptics.

T-cell subsets in acute psychotic schizophrenic patients

Two-color flow cytometric analysis was performed on peripheral blood lymphocytes of 16 untreated schizophrenic patients during an acute psychotic attack and 16 healthy control subjects to evaluate differences in T-cell subpopulations. In schizophrenic patients, we observed decrease in CD4+ 2H4+ (suppressor-inducer) and CD8+ 2H4+ (suppressor-effector) T-cell subsets. The selective loss of 2H4+ cell markers both on helper and suppressor T cells was not correlated to the severity of the acute psychosis. Our results may indicate a mechanism of an immune disequilibrium in schizophrenic patients during an acute psychotic attack.

The platelet benzodiazepine receptor is unaltered in obsessive-compulsive disorder

Mitochondrial benzodiazepine receptors (MBR) are sensitive to anxiety and stress. The aim of the present study was to investigate whether platelet MBR are altered in untreated obsessive-compulsive disorder (OCD) patients and whether chronic treatment with clomipramine (CMI) regulates these receptors. MBR were assessed in 13 drug-free OCD patients as compared with 15 healthy controls. Seven of the 13 patients were treated with CMI (200-300 mg/day). The density and affinity of the receptors to their ligand [3H]PK 11195 in OCD patients and controls were not affected by the CMI treatment despite the clinical improvement. It seems that, in contrast to generalized anxiety disorder, OCD is not associated with alterations in platelet benzodiazepine receptors.

Poor neuroleptic response in acutely exacerbated schizophrenic patients

Poor neuroleptic response is a major unresolved clinical problem. Precise data concerning the frequency of poor neuroleptic response are not available. The implementation of treatment modalities that are specifically recommended for non-responders (such as clozapine) increases the desirability of such data. This study evaluated the proportion of acutely exacerbated schizophrenics who remained unimproved by consecutive administration of haloperidol, chlorpromazine and perphenazine, in randomly determined order. The overall improvement rate was 95%. The frequency of good responses to the first, second and third drug were 67%, 55%, and 67% respectively. Differences in receptor affinity profile might explain the added beneficial effect of a second or third drug.

[Withdrawal reactions after clomipramine]

Abrupt or gradual discontinuation of tricyclic antidepressants may precipitate withdrawal symptoms. The most common of these are general somatic or gastrointestinal distress, anxiety and agitation, sleep disturbance, akathisia, parkinsonism, paradoxical behavioral activation and mania. There are very few reports of withdrawal reactions following discontinuation of clomipramine since it has not been in use in the US until recently. 2 patients with withdrawal symptoms following discontinuation of clomipramine are presented. A 45-year-old man had general somatic symptoms, including headache, myalgia, weakness, fatigue (flu-like syndrome) and nervousness and insomnia after clomipramine, 75 mg/d, had been discontinued abruptly. All symptoms disappeared without treatment after 3 days. A 47-year-old woman presented mainly with severe insomnia, anxiety, agitation, jitteriness and tension after discontinuing a low dose of 25 mg/d of clomipramine. Symptoms disappeared after she started self-treatment with 50 mg/d of the drug. It is important to differentiate withdrawal symptoms from relapse of the primary psychiatric disorder.

Risk for definite neuroleptic malignant syndrome. A prospective study in 223 consecutive in-patients

The occurrence of neuroleptic malignant syndrome (NMS) was studied prospectively in two series of consecutive psychiatric in-patients (n = 223). The first group (n = 120) suffered from schizophrenia and was treated only with haloperidol. The second group (n = 103) was treated with diverse neuroleptics. All patients were on a single antipsychotic agent with no anticholinergic drug as prophylaxis. The incidence of full NMS per admission and first neuroleptic exposure was 5/223 (2.2%). Patients with bipolar affective disorder and those treated with injections were significantly over-represented in the NMS group.

Electroconvulsive therapy for persistent neuroleptic-induced akathisia and parkinsonism: a case report

Neuroleptic-induced akathisia (NIA) and parkinsonism (NIP) continued for 3 months, despite two courses of anticholinergic treatments, a shift to low-potent neuroleptic (NL) and a NL-free period. The two adverse effects responded dramatically to electroconvulsive therapy (ECT) to reemerge 3 months after termination of ECT. The case supports the idea that ECT is effective for both NIA and NIP even when they are resistant.