Prompt differentiation of Addison's disease from anorexia nervosa during weight loss and vomiting

An 18-year-old white woman had nausea, vomiting, weight loss, and a diagnosis of anorexia nervosa. Copper-colored skin was noted on physical examination, and serum chemistry values were normal. Subsequent fever, disorientation, and confusion led to the discovery of Addison's disease, which responded well to corticosteroid replacement therapy. Addisonian and anorexic patients exhibit clinical similarities, including nausea, vomiting, weight loss, abdominal pain, cold intolerance, hypothermia, and orthostasis. Other commonalities include prolongation of electrocardiographic PR and QT intervals and generalized slowing on electroencephalogram. Important differences include a brown color to the skin in Addison's disease instead of a yellowish color in anorexia. Addisonian patients also display hypocortisolism, hypoglycemia, and hyperkalemia, in contrast to the hypercortisolism, hyperglycemia, and hypokalemia seen in anorexia.

Divalproex: a possible treatment alternative for demented, elderly aggressive patients

Elderly, demented people often exhibit behavioral dyscontrol. Divalproex appears to be safe and effective in the management of this presentation. Twelve cases treated with divalproex all responded with improved emotional control. Patients became less verbally and physically disruptive and much more socially appropriate. Divalproex was well tolerated in this population with none of the subjects experiencing significant medicinal side effects. This uncontrolled report suggests that divalproex should be considered as a pharmacotherapy for aggressivity in cognitively impaired, elderly people.

How to treat coexistent mental illness and substance abuse

Integration of mental illness and substance abuse treatments is important for patients with "dual diagnosis", the coexistence of an emotional ailment and a chemical dependency. Such comorbidity is usually associated with a poor prognosis. Both disorders require appropriate therapy so that remission of psychiatric symptoms and maintenance of sobriety become reachable goals for these individuals. A joint therapeutic approach improves outcome, functional expectation, and community adjustment.

ECG intervals in acute bipolar and schizophrenic relapse

Psychosis in general and acute relapse of bipolar illness, in particular, are associated with elevated catecholamine excretion, cardiovascular changes, and changes in intracellular calcium concentration. In an effort to determine if these changes result in observable ECG abnormalities, we retrospectively examined ECG parameters of acutely disturbed bipolar and schizophrenic patients. There were no discrete patterns of abnormalities, and no significant differences were observed between the two patient groups. Most ECG changes in acutely hospitalized bipolar and schizophrenic patients appear to be benign.

A two-year follow-up on the effects of a smoking ban in an inpatient psychiatric service

The effects of prohibiting cigarette smoking on the behavior of patients on a 25-bed psychiatric inpatient unit were assessed immediately after implementation of a smoking ban and two years later. No major behavioral disruptions were observed after the ban. The number of calls for security assistance, physical assaults, instances of leather restraints and of seclusions, and discharges against medical advice did not increase significantly immediately after the restriction on smoking or two years later. Significantly more verbal assaults and prescribing of p.r.n. medications for anxiety occurred immediately after the ban but not two years later.

Unsuspected subdural hematoma as a differential diagnosis in elderly patients

Subdural hematomas are among the most common forms of intracranial hemorrhage encountered in clinical practice and are a surgically remediable cause of dementia. When the symptom presentation is subtle or diffuse, a subdural hematoma can be overlooked. This is especially true among elderly people who may exhibit unrelated, preexisting dementia or delirium. Particularly confusing is that such declines in intellectual capacity can also result from subdural hematoma. It is therefore essential that a thorough physical and neurologic assessment be done on all patients with cognitive deficiencies. This always includes brain imaging. Early recognition of a subdural hematoma is important, given its treatability and potential reversibility. We describe an elderly woman with new-onset cognitive deficit and gait dyspraxia. There was no evidence of trauma. Physical examination was otherwise unremarkable. Initially, she refused evaluation, but once a subdural hematoma was identified by a tomographic scan, a satisfactory outcome followed surgical intervention.

Obsessive-compulsive disorder. How to free patients from intrusive thoughts and rituals

The antidepressants clomipramine hydrochloride (Anafranil), fluoxetine hydrochloride (Prozac), and sertraline hydrochloride (Zoloft) are the main choices for pharmacologic treatment of obsessive-compulsive disorder. Often, drug doses for obsessive-compulsive disorder are higher than for depression, and improvement occurs more slowly and is often only partial. Behavior therapy involving exposure to feared objects or situations and prevention of ritualistic behavior complements pharmacologic treatment. Referral to a behavioral therapist may be necessary to achieve recovery.

Wilson's disease. Psychiatric manifestations may be the clinical presentation

It is important to consider Wilson's disease in patients with psychiatric signs and symptoms who also have abnormal liver function test results or neurologic findings, or both. Thorough evaluation of emotionally disturbed persons, including complete history taking, careful physical examination, and appropriate laboratory profile, generally rules out or arouses suspicion of Wilson's disease during routine screening. Laboratory abnormalities necessitate repeated studies and additional family and personal history taking with emphasis on possible Wilson's disease. Further workup may then be indicated. Prompt recognition and vigorous, consistent treatment can minimize symptoms and tissue damage. Identifying a case of Wilson's disease and seeing clinical aspects improve with appropriate therapy is gratifying.

Procedural complications of electroconvulsive therapy: assessment and recommendations

We surveyed procedural techniques in 804 routine clinical sessions of electroconvulsive therapy (ECT) over 4 2/3 years. No significant problems occurred. Side effects as agitation, physical complications such as urinary stasis, and protocol deviations such as failure to use the bite block were occasionally documented. Mechanical difficulties such as trouble gaining intravenous access and medicinal problems such as inappropriate dosing were rare. Our assessment resulted in a more precise method of diminishing the risks of ECT. For example, the chin is held manually, closing the mouth during delivery of the stimulus, to obviate oral trauma. Similarly, electrode contact is always verified visually and with the ECT machine "self-test" just before each treatment. Both cuff and electroencephalographic means are used to determine seizure timing. ECT is safe; a carefully applied protocol should make it safer.

Pharmacologic treatment strategies for the depressed, poorly responsive patient

Treatment-resistant depression implies a failure of response to an ample dose of antidepressant medicine, prescribed over a sufficient length of time. Assessing drug levels in the blood is often helpful in confirming the adequacy of antidepressant dosages. Augmentation of the pharmaceutical activity can be achieved by coadministration of lithium, triiodothyronine, and/or stimulants. Neuroleptics are also prescribed with the antidepressant when psychotic features accompany depression. Such enhancements to drug efficacy are usually an advantage over beginning a new medication because of shorter response time. When a decision is made to change the antidepressant, a structurally different option is more likely to induce a remission than a medication of similar configuration. Electroconvulsive therapy is the most powerful treatment choice for depressed patients, especially when suicidal or psychotic features are present.

Preventing suicide in older people

Prompt recognition of suicidal intent can prevent suicide in the elderly. Some psychiatric disorders, such as depression, psychoses and organic brain syndromes, can predispose these persons to suicide, as can medical disorders that result in pain, disability or dysfunction. Other factors that increase the risk for suicide include chemical dependency and changing life events. Anti-depressant medications with a low anticholinergic and sedative profile are preferred because of age-related physiologic changes. Electroconvulsive therapy is reserved for serious cases.

Violent patients. Are you prepared to deal with them?

The medical community is becoming increasingly concerned about violent patients in healthcare settings. Healthcare professionals should be trained to deal with aggressive patients, and they should have access to a room free of dangerous objects for evaluation and examination. Having security personnel stand by may be appropriate in some cases. Verbal intervention is the key to dealing with violent patients. The safest and most effective pharmacologic intervention is use of benzodiazepines, either alone or in conjunction with antipsychotic agents when indicated. Seclusion or restraint may be needed for some violent patients; in such situations, close patient monitoring and explicit documentation are essential. Physicians can be held liable for injuries patients sustain while being restrained, so staff members should receive instruction in safe physical intervention techniques.

Bupropion: overview and prescribing guidelines in depression

Bupropion is a new antidepressant medicine that is chemically distinct from previous agents. Clinical studies have shown it to be as effective as the standard antidepressant drugs currently used in the treatment of major depression. It is useful in patients resistant to other agents as well as in patients with atypical depression. Bupropion is 10 to 100 times less likely to induce cardiac conduction problems than the tricyclic drugs, and orthostatic hypotension is rare. Minimal anticholinergic effects account for its being generally well tolerated. The most common side effect is dry mouth. An epileptogenic potential is prominently reported. Because it may lower the convulsive threshold, bupropion is not recommended for individuals who may be predisposed to seizures. In people without an increased ictal risk factor, and when dosage is maintained at 450 mg/day or less in a divided schedule, the seizure rate is comparable to that of other antidepressant drugs.

Dementia: what to do

Dementia is a syndrome of acquired intellectual deterioration that interferes with personal or social functioning. Diagnosis requires historical information from the family and the mental status evaluation of orientation, recent memory, comprehension, calculation, and abstraction. Most dementias create permanent, even progressive cognitive deterioration, yet there are some presentations for which remission exists. Common reversible conditions include depression, drug toxicity, normal-pressure hydrocephalus, hypothyroidism, subdural hematoma, and neoplasm. Screening laboratory studies consist of urinalysis, chemistry profile, blood count, thyroid survey, vitamin B12 and folate measurements, serology, chest roentgenogram, computerized tomographic scan of the head, electroencephalogram, and electrocardiogram. Treatment focuses on potential reversibility, psychosocial issues, restoring deficits, and specific symptoms.

Dementia in the elderly

When are confusion and forgetfulness transient signs of normal aging, when are they signs of depression or a medical illness, and when are they signs of dementia? The authors describe clinical features and diagnostic studies that help establish the presence of dementia and discuss ways of coping with both remediable and less treatable types.