Catatonia in Autistic Spectrum Disorders: A Medical Treatment Algorithm

Autism is a developmental syndrome with an unknown biology and inadequate therapeutics. Assessing the elements of the syndrome for the presence of depression, psychosis, mania, or catatonia, offers opportunities for systematic intervention. Since almost all descriptions of autism highlight the presence of motor symptoms that characterize catatonia, an assessment for this eminently treatable syndrome is recommended for all patients considered to be autistic. A minimum examination includes a catatonia rating scale and for those patients with defined catatonia, a lorazepam test. For those whose catatonia responds to lorazepam, high dose lorazepam therapy is recommended. If this fails, electroconvulsive therapy is recommended. The assessment and treatment of catatonia offers positive medical therapy for the victims of autism and their families.

Catatonia: a syndrome appears, disappears, and is rediscovered

Catatonia is the psychiatric syndrome of disturbed motor functions amid disturbances in mood and thought first described in 1874. It was quickly found in 10% to 38% of psychiatric populations. After it was tied to schizophrenia as a type in the psychiatric classification, its recognition became increasingly limited and by the 1980s questions were asked as to where the catatonics had gone. The decline is largely owing to the change in venue for psychiatric practice from asylum to office, the rejection of physical examination, and the dependence on item rating scales for diagnosis. In the 1970s, broad surveys again showed that catatonia was as common as before among patients with mania and depression, and as a toxic response to neuroleptic drugs. The latter recognition, that the neuroleptic malignant syndrome is the same syndrome as malignant catatonia, and is effectively treated as such, sparked a renewed interest. Clinicians developed rating scales to identify the catatonia syndrome and applied the immediate relief afforded by a barbiturate or a benzodiazepine as a diagnostic test, the lorazepam test. Effective treatments were described as high doses of benzodiazepines and electroconvulsive therapy (ECT). Surveys using catatonia rating scales showed catatonia to have many faces. Catatonia is presently limited to a type of schizophrenia in the psychiatric classification. Its recognition as a disorder of its own, such as delirium and dementia, should now be recognized. This experience reinforced the utility of the medical model for diagnosis. An application for melancholia is described.

Measurement of elastic nonlinearity of soft solid with transient elastography

Transient elastography is a powerful tool to measure the speed of low-frequency shear waves in soft tissues and thus to determine the second-order elastic modulus mu (or the Young's modulus E). In this paper, it is shown how transient elastography can also achieve the measurement of the nonlinear third-order elastic moduli of an Agar-gelatin-based phantom. This method requires speed measurements of polarized elastic waves measured in a statically stressed isotropic medium. A static uniaxial stress induces a hexagonal anisotropy (transverse isotropy) in solids. In the special case of uniaxially stressed isotropic media, the anisotropy is not caused by linear elastic coefficients but by the third-order nonlinear elastic constants, and the medium recovers its isotropic properties as soon as the uniaxial stress disappears. It has already been shown how transient elastography can measure the elastic (second-order) moduli in a media with transverse isotropy such as muscles. Consequently this method, based on the measurement of the speed variations of a low-frequency (50-Hz) polarized shear strain waves as a function of the applied stress, allows one to measure the Landau moduli A, B, C that completely describe the third-order nonlinearity. The several orders of magnitude found among these three constants can be justified from the theoretical expression of the internal energy.

ECT in metropolitan New York hospitals: a survey of practice, 1975-1976

Of New York psychiatric facilities surveyed, 83% used ECT. Five percent of patients in university and private nonprofit hospitals, less than 1% in public hospitals, and 21% in private for-profit hospitals received ECT. Practices and procedures were remarkably uniform, except that less than 17% of units used unilateral ECT. Training programs were minimal and unplanned. Differences in incidence of use result from staff training, public antipathy, and economic factors.

Blood levels and electroencephalographic effects of diazepam and bromazepam

Blood levels and electroencephalographic (EEG) data were collected for 2 hr after single oral doses of bromazepam (9 mg), diazepam (10 mg), and placebo in 13 male adult volunteers. Both drugs caused an increase in beta activity (above 13 Hz) and a decrease in alpha activity (9 to 11 Hz) in the EEG. Blood levels of 100 ng/ml of diazepam or 50 ng/ml of bromazepam were associated with significant changes in EEG beta activity. Temporal changes in the EEG after administration of diazepam or bromazepam paralleled development of plasma levels of these drugs. Although a weakly significant correlation was found between measurable diazepam blood levels and amount of increased EEG beta activity, the relationship between measurable bromazepam blood levels and the degree of EEG changes was not significant. Quantitative EEG is a sensitive continuous response measure, useful in defining cerebral activity, response latency, and relative potency of psychoactive benzodiazepines.

Short-term efficacy of physical therapy compared to splint therapy in treatment of arthrogenous TMD

A prospective randomized study was carried out to evaluate the efficacy of physical therapy in addition to splint therapy on treatment outcome in patients with temporomandibular disorders (TMD) with respect to objective and subjective parameters. Twenty-six patients suffering from an arthrogenic TMD and exhibiting a painfully restricted jaw opening were randomized in two groups. Thirteen patients were treated solely with Michigan splint (group I), 13 patients received supplementary physical therapy (group II). Before treatment a clinical examination and electronic recording of jaw movements were performed and subjective pain level was evaluated by visual analogue scales. After 3 months of therapy maintenance of improvement was evaluated. Within treatment groups comparison of data before and after treatment was analysed using Wilcoxon test. Groups were compared by Mann-Withney-U test. A P-value < 0.05 was considered significant. Compared with the baseline, in both groups mandibular movement capacity increased significantly after treatment, whereas subjective pain decreased significantly (P < 0.05). Active jaw opening increased from 28.6 +/- 5.8 to 35.9 +/- 4.8 mm in group I and from 30.1 +/- 5.4 to 40.8 +/- 4.1 mm in group II. After therapy the difference of active jaw opening between groups was significant (P < 0.05). Physical therapy also gave a supplementary improvement of protrusive mandibular movement capacity during electronic registration and subjective pain level. For none of these parameters this difference between groups was significant. Physical therapy seems to have a positive effect on treatment outcome of patients with TMD.

Alterations in lysosomal enzymes of the proximal tubule in gentamicin nephrotoxicity

Gentamicin accumulates in proximal tubule lysosomes, increases their number, and changes their structure. An important lysosomal function is degradation of intracellular proteins. To evaluate the effect of gentamicin on this lysosomal function, we measured the activity of the key lysosomal proteinases, cathepsin B and L, in microdissected S1, S2, and S3 segments of rat proximal tubules by means of a fluorometric microassay. The cathepsin activities were decreased in S1 and S2 following one and four gentamicin injections of 100 mg/kg body weight. The lysosomal enzyme, acid phosphatase, was also measured and was not decreased by gentamicin. The urine excretion of cathepsins B and L was decreased after gentamicin. This excludes an increase in urinary loss of cathepsins as the cause of decreased tubule activity. Structural changes of the lysosomes per se were excluded as the factor responsible for the reduced cathepsin activity by demonstrating increased cathepsin B and L activity in proximal tubule segments from rats injected with dextran, since dextran induces an increase in number and size of proximal tubule lysosomes. In vitro incubation of urine and tubule segments with gentamicin demonstrated a concentration-dependent reversible inhibition of cathepsin B and L. We conclude that gentamicin per se decreased cathepsin B and L activities in proximal tubule segments as early as 24 hours following one injection due to either enzyme inhibition or reduced generation of active intralysosomal cathepsin B and L. Gentamicin may, therefore, reduce renal protein catabolism by decreasing the activity of the key proteolytic enzymes, cathepsin B and L. Since cathepsin B and L are proteolytic activators of other lysosomal enzymes, their reduced activity may also decrease the activities of other lysosomal enzymes.

Endoscopic laser recanalisation of presaccal canalicular obstruction

AIM

To document the results of erbium (Er)-YAG laser treatment in presaccal canalicular obstruction in combination with the use of a flexible endoscope.

METHODS

For the first time an Er-YAG laser (Schwind, Sklerostom) was attached to a flexible endoscope (Schwind, Endognost) and used to recanalise a stenosis of the upper, lower, or common canaliculus. In 17 patients (mean age 41.5 (SD 11.9) years), 19 treatments (two bilateral) were performed. In all cases the scar was observed using the endoscope and was excised by laser ablation. A silicone intubation was performed in all cases. In addition to the endoscopy an irrigation was performed to prove the intactness of the lacrimal pathway system after laser treatment.

RESULTS

Membranous obstructions with a maximum length of 2.0 mm (14 procedures) in the canaliculus were opened easily using the laser, and the silicone intubation was subsequently performed without difficulty. Scars thicker than 2.0 mm could not be opened safely without canaliculus penetration (five procedures). Irrigation was positive in all cases up to the end of a 6 month period, providing the tubes remained in place. The maximum follow up is now 17 months (minimum 8 months) and in 16 cases (84.2%) the canaliculi are still intact.

CONCLUSION

Endoscopic laser treatment combined with silicone intubation enables us to recanalise presaccal stenoses of canaliculi under local anaesthesia up to a scar thickness of 2.0 mm. Best results can be achieved in cases where much tissue can be saved. Under such conditions this procedure can substitute for more invasive surgical techniques, especially a conjunctivo-dacryocystorhinostomy (CDCR).

A randomized controlled trial comparing the memory effects of continuation electroconvulsive therapy versus continuation pharmacotherapy: results from the Consortium for Research in ECT (CORE) study

OBJECTIVE

To compare the memory effects of continuation electroconvulsive therapy (C-ECT) versus continuation pharmacologic intervention (C-PHARM) at 12 and 24 weeks after completion of acute electroconvulsive therapy (ECT).

METHOD

Eighty-five patients with Structured Clinical Interview for DSM-IV-diagnosed unipolar major depressive disorder, enrolled in a multisite, randomized, parallel-design trial conducted at 5 academic medical centers from 1997 to 2004, who had remitted with an acute course of bilateral ECT and remained unrelapsed through 24 weeks of continuation therapy, were included in this analysis. They were randomly assigned to C-ECT (10 treatments) or nortriptyline plus lithium (monitored by serum blood levels) for 24 weeks. Objective neuropsychological measures of retrograde and anterograde memory and subjective assessment of memory were obtained at baseline, 12 weeks, and 24 weeks. The Rey Auditory-Verbal Learning Test and the Autobiographical Memory Interview were the primary outcome measures.

RESULTS

The C-PHARM group showed a greater group difference (P < .01) for baseline to 12-week change for the Autobiographical Memory Interview. No other memory measures showed group differences for change scores from baseline to 12 weeks. Groups showed no baseline to 24-week change-score differences on any of the memory measures. For both groups, 12-week objective anterograde memory scores (eg, Auditory-Verbal Learning Test percent retention P = .0001; Rey-Osterrieth Complex Figure or Taylor Figure percent retention P < .002) and 24-week subjective memory scores were significantly improved (Squire Subjective Memory Questionnaire P < .02) over baseline. This result reflects the apparent resolution of a presumed decrement in anterograde memory associated with acute ECT preceding this study.

CONCLUSIONS

The finding of no memory outcome differences between unrelapsed recipients of C-ECT and C-PHARM is consistent with clinical experience. Memory effects have only a small role in the choice between C-ECT and C-PHARM.

Resurrecting melancholia

OBJECTIVE

To define melancholia as a distinct mood disorder, identified by unremitting depressed mood, vegetative dysfunction, and psychomotor disturbances, verifiable by neuroendocrine tests, and treatable by electroconvulsive therapy and tricyclic antidepressants.

METHOD

A review of the literature of two centuries finds descriptions of severe mood disorders, either depression or mania or circular, defined as 'melancholia.' In the 1980 diagnostic revision (DSM-III), melancholia was relegated to a features specifier only.

RESULTS

DSM classification criteria develop heterogeneous patient samples that are neither guides to prognosis nor to treatment response, and confound studies of pathophysiology. Within the large population of mood disorders, a syndrome of melancholia is identifiable by specific behaviors, vegetative signs, and validated by neuroendocrine abnormalities (cortisolemia). Populations so identified are clinically homogeneous and have improved treatment responses. Patients meeting criteria for melancholia are now identified as psychotic depressed, geriatric depressed, postpartum psychosis, and pharmacotherapy resistant.

CONCLUSION

The review supports the establishment of melancholia by empirically derived criteria rather than by a checklist is an alternative to the major depression choice and offers an improved model for psychiatric classification.

Botulinum toxin type A and EMG: a key to the understanding of chronic tension-type headaches?

BACKGROUND

The pathogenesis of chronic tension-type headache remains unclear, and the role of muscle tension is especially controversial. Botulinum toxin type A, a potent inhibitor of muscle tone, has been used to treat chronic tension-type headache.

OBJECTIVE

To determine whether clinical response to treatment of chronic tension-type headache with Botox A parallels changes in resting muscle activity recorded through serial electromyography (EMG).

METHODS

We randomly assigned eight patients with chronic tension-type headache to pericranial injection of 500 MU Botox A versus placebo (isotonic saline).

RESULTS

At 6 and 12 weeks following treatment, there were no significant differences in clinical outcome between the placebo and the Botox A groups. This occurred despite EMG evidence of a reduction in resting muscle activity in the Botox A-treated patients.

CONCLUSION

These results support the hypothesis that peripheral mechanisms such as increased muscle tone play, at most, a minor role in the pathophysiology of chronic tension-type headache.

Time-reversal of ultrasonic fields. III. Theory of the closed time-reversal cavity

For pt.II see ibid., vol.39, no.5, p.567-78 (1992). A theoretical model for time-reversal cavities to optimize focusing in homogeneous and inhomogeneous media is described. The concept of the cavity can be understood as the most realistic approximation to an exact three-dimensional (3-D) time-reversal of ultrasonic fields; it is also a generalization of the time-reversal mirrors realized experimentally in the laboratory. The proposed method is based on an approach in the transient regime that is more general than the monochromatic formalism used in optics to analyze the phase conjugation mirrors efficiency. This method uses impulse diffraction theory to obtain the impulse response of the cavity in any inhomogeneous medium. An original interpretation of the limitations due to diffraction observed in wave field propagation in terms of the different waves generated inside the cavity is also proposed. The time-reversal focusing process using a closed cavity in a weakly inhomogeneous medium is compared with more classical techniques to compensate wavefront distortions, thus illustrating the focusing improvement due to the time-reversal method.

DSM melancholic features are unreliable predictors of ECT response: a CORE publication

OBJECTIVE

To determine the relationship between baseline melancholic features with outcomes in patients with major depressive disorder referred for electroconvulsive therapy (ECT).

METHOD

In a multihospital (Consortium for Research in ECT) collaborative ECT study, SCID-1 interviews were obtained at study entry. Ratings of the 24-item Hamilton Rating Scale for Depression were obtained thrice weekly during the course of ECT, once during a subsequent treatment-free week, and periodically during 6-month continuation treatment with either bitemporal ECT or nortriptyline plus lithium (continuation pharmacotherapy).

RESULTS

The evaluable sample was severely ill with a mean 24-item Hamilton Rating Scale for Depression score of 35.2 (+/-6.9). Of 489 patients, 63.6% (311) met DSM-IV criteria for melancholic features. During acute ECT, 62.1% of those with melancholic features remitted, as compared with 78.7% for those without melancholic features (P = 0.002). During medication continuation treatment (continuation pharmacotherapy), relapse rates were higher for those with melancholic features than for those without these features. Conversely, with continuation ECT, the rate of relapse was lower for those with, compared with those without, melancholic features.

CONCLUSIONS

Ascertaining melancholic features by SCID-1 criteria does not identify depressed patients more likely to respond to ECT as had been anticipated from the literature. Melancholic features were associated with poorer treatment outcomes in acute ECT. Those with melancholic features were less likely to relapse with continuation ECT, but those with melancholic features were more likely to relapse with continuation pharmacotherapy. The limitations of the DSM-IV criteria for melancholia are discussed.

Optimal focusing by spatio-temporal inverse filter. I. Basic principles

A focusing technique based on the inversion of the propagation operator relating an array of transducers to a set of control points inside a medium was proposed in previous work [Tanter et al., J. Acoust. Soc. Am. 108, 223-234 (2000)] and is extended here to the time domain. As the inversion of the propagation operator is achieved both in space and time, this technique allows calculation of the set of temporal signals to be emitted by each element of the array in order to optimally focus on a chosen control point. This broadband inversion process takes advantage of the singular-value decomposition of the propagation operator in the Fourier domain. The physical meaning of this decomposition is explained in a homogeneous medium. In particular, a definition of the number of degrees of freedom necessary to define the acoustic field generated by an array of limited aperture in a focal plane of limited extent is given. This number corresponds to the number of independent signals that can be created in the focal area both in space and time. In this paper, this broadband inverse-focusing technique is compared in homogeneous media with the classical focusing achieved by simple geometrical considerations but also with time-reversal focusing. It is shown that, even in a simple medium, slight differences appear between these three focusing strategies. In the companion paper [Aubry et al., J. Acoust. Soc. Am. 110, 48-58 (2001)] the three focusing techniques are compared in heterogeneous, absorbing, or complex media where classical focusing is strongly degraded. The strong improvement achieved by the spatio-temporal inverse-filter technique emphasizes the great potential of multiple-channel systems having the ability to apply completely different signal waveforms on each transducer of the array. The application of this focusing technique could be of great interest in various ultrasonic fields such as medical imaging, nondestructive testing, and underwater acoustics.

Catatonia: syndrome or schizophrenia subtype? Recognition and treatment

Two views of catatonia influence clinical practice. In the classical European view, adopted by DSM classifications, the signs of catatonia indicate a form of schizophrenia. In the syndromal view, the signs of catatonia are motor signs that are readily identified in many psychiatric disorders. Catatonia is a parallel behavior phenomenon to delusions (in thought) and delirium (in cognition). The syndromic view includes the neuroleptic malignant syndrome. It encourages a different treatment algorithm, the use of benzodiazepines and electroconvulsive therapy, to replace the customary use of antipsychotic drugs alone. The benefits of such treatment warrant the recommended change in concept and classification.