The expression of cytokines and chemokines in the blood of patients with severe weight loss from anorexia nervosa: an exploratory study

Anorexia nervosa (AN) is a serious, potentially life-threatening disorder characterized by severe weight loss, dysregulated eating, and often excessive exercise. While psychiatric illnesses such as depression are associated with increased levels of pro-inflammatory mediators, evidence for such disturbances in patients with AN has been less clear. In an exploratory study of possible disturbances in immune responses in AN, we assayed a panel of cytokines and chemokines in the blood of patients undergoing inpatient treatment, testing the hypothesis that metabolic disturbances in this disease would lead to a pattern of immune disturbances distinct from that of other psychiatric diseases. For this purpose, we evaluated patients by the Beck Depression Inventory-II (BDI-II) and the Eating Disorders Examination-Questionnaire and assessed cytokines and chemokines by enzyme-linked immunosorbent assays. Patients reported a moderate level of depression (mean BDI-II = 22.6) but exhibited few immunologic abnormalities of the kind associated with major depressive disorder [e.g., increased interleukin (IL)-6]; RANTES showed the most frequent elevations and was increased in 4 of the patients studied. Together, these findings suggest that features of AN such as loss of adipose tissue and excessive exercise may attenuate cytokine production and thus modulate the experience of illness that impacts on core features of disease.

Patterns and prevalence of disordered eating and weight control behaviors in women ages 25-45

OBJECTIVE

The current study describes detailed eating behaviors, dieting behaviors, and attitudes about shape and weight in 4023 women ages 25 to 45.

METHOD

The survey was delivered on-line and participants were identified using a national quota-sampling procedure.

RESULTS

Disordered eating behaviors, extreme weight loss measures, and negative cognitions about shape and weight were widely endorsed by women in this age group and were not limited to White participants. Thirty-one percent of women without a history of anorexia nervosa or binge eating reported having purged to control weight, and 74.5% of women reported that their concerns about shape and weight interfered with their happiness.

DISCUSSION

Unhealthy approaches to weight control and negative attitudes about shape and weight are pervasive even among women without eating disorders. The development of effective approaches to address the impact of these unhealthy behaviors and attitudes on the general well-being and functioning of women is required.

Developmental regulation of neural cell adhesion molecule in human prefrontal cortex

Neural cell adhesion molecule (NCAM) is a membrane-bound cell recognition molecule that exerts important functions in normal neurodevelopment including cell migration, neurite outgrowth, axon fasciculation, and synaptic plasticity. Alternative splicing of NCAM mRNA generates three main protein isoforms: NCAM-180, -140, and -120. Ectodomain shedding of NCAM isoforms can produce an extracellular 105-115 kilodalton soluble neural cell adhesion molecule fragment (NCAM-EC) and a smaller intracellular cytoplasmic fragment (NCAM-IC). NCAM also undergoes a unique post-translational modification in brain by the addition of polysialic acid (PSA)-NCAM. Interestingly, both PSA-NCAM and NCAM-EC have been implicated in the pathophysiology of schizophrenia. The developmental expression patterns of the main NCAM isoforms and PSA-NCAM have been described in rodent brain, but no studies have examined NCAM expression across human cortical development. Western blotting was used to quantify NCAM in human postmortem prefrontal cortex in 42 individuals ranging in age from mid-gestation to early adulthood. Each NCAM isoform (NCAM-180, -140, and -120), post-translational modification (PSA-NCAM) and cleavage fragment (NCAM-EC and NCAM-IC) demonstrated developmental regulation in frontal cortex. NCAM-180, -140, and -120, as well as PSA-NCAM, and NCAM-IC all showed strong developmental regulation during fetal and early postnatal ages, consistent with their identified roles in axon growth and plasticity. NCAM-EC demonstrated a more gradual increase from the early postnatal period to reach a plateau by early adolescence, potentially implicating involvement in later developmental processes. In summary, this study implicates the major NCAM isoforms, PSA-NCAM and proteolytically cleaved NCAM in pre- and postnatal development of the human prefrontal cortex. These data provide new insights on human cortical development and also provide a basis for how altered NCAM signaling during specific developmental intervals could affect synaptic connectivity and circuit formation, and thereby contribute to neurodevelopmental disorders.

Early postnatal development of corpus callosum and corticospinal white matter assessed with quantitative tractography

BACKGROUND AND PURPOSE

The early postnatal period is perhaps the most dynamic phase of white matter development. We hypothesized that the early postnatal development of the corpus callosum and corticospinal tracts could be studied in unsedated healthy neonates by using novel approaches to diffusion tensor imaging (DTI) and quantitative tractography.

MATERIALS AND METHODS

Isotropic 2 x 2 x 2 mm(3) DTI and structural images were acquired from 47 healthy neonates. DTI and structural images were coregistered and fractional anisotropy (FA), mean diffusivity (MD), and normalized T1-weighted (T1W) and T2-weighted (T2W) signal intensities were determined in central midline and peripheral cortical regions of the white matter tracts of the genu and splenium of the corpus callosum and the central midbrain and peripheral cortical regions of the corticospinal tracts by using quantitative tractography.

RESULTS

We observed that central regions exhibited lower MD, higher FA values, higher T1W intensity, and lower T2W intensity than peripheral cortical regions. As expected, MD decreased, FA increased, and T2W signal intensity decreased with increasing age in the genu and corticospinal tract, whereas there was no significant change in T1W signal intensity. The central midline region of the splenium fiber tract has a unique pattern, with no change in MD, FA, or T2W signal intensity with age, suggesting different growth trajectory compared with the other tracts. FA seems to be more dependent on tract organization, whereas MD seems to be more sensitive to myelination.

CONCLUSIONS

Our novel approach may detect small regional differences and age-related changes in the corpus callosum and corticospinal white matter tracts in unsedated healthy neonates and may be used for future studies of pediatric brain disorders that affect developing white matter.

Measuring brain volume by MR imaging: impact of measurement precision and natural variation on sample size requirements

BACKGROUND AND PURPOSE

To determine the sample size needed to provide adequate statistical power in studies of brain volume by MR imaging, we examined the precision and variability of measurements in healthy controls.

MATERIALS AND METHODS

A cohort of 52 people (mean age, 25.1 years) was examined at weeks 0 and 12 at 1.5 T. We used an axial multisection T1-weighted sequence and a contiguous proton-attenuation/T2-weighted sequence. Data were registered to a probabilistic brain atlas, and an automated atlas-based program was used to segment brain tissue by type and by lobe. We assumed that there were no changes in volume because there were no intervening neurologic events. Sample sizes required to yield 80% statistical power in detecting a significant difference in volume were calculated for various experimental designs, assuming a patient-control volume difference of 5% or 2%.

RESULTS

The precision of most measurements was excellent, but required sample sizes were larger than anticipated. If the goal was to detect a 5% difference in whole brain volume in a 2-sample cross-sectional study, the required sample was 73 patients and 73 controls because brain volume varies between individuals in a way that is not informative about disease effects. For a similar 2-sample longitudinal study, the required sample size was just 5 patients and 5 controls.

CONCLUSIONS

Our results argue strongly for longitudinal studies in preference to cross-sectional studies, especially as research budgets decline. Our findings also suggest that there may be more uncertainty than expected in published MR imaging brain volume studies.

Synaptophysin and postsynaptic density protein 95 in the human prefrontal cortex from mid-gestation into early adulthood

Previous studies of postnatal synaptic development in human frontal cortex have shown that synaptic density rises after birth, reaches a plateau in childhood and then decreases to adult levels by late adolescence. A similar pattern has been seen in nonhuman primate cortex. These earlier studies in human cortex are limited, however, by significant age gaps in study subjects at critical inflection points of the developmental curve. Additionally, it is unclear if synaptic development occurs in different patterns in different cortical layers in prefrontal cortex (PFC). The purpose of this study was to examine synaptic density in human PFC across development by measuring two synaptic marker proteins: synaptophysin (presynaptic), and postsynaptic density protein 95 (PSD-95; postsynaptic). Western blotting was used to assess the relative levels of synaptophysin and PSD-95 in dorsolateral PFC of 42 subjects, distributed in age from 18 weeks gestation to 25 years. In addition, synaptophysin immunoreactivity was examined in each layer of areas 9 and 46 of PFC in 24 subjects, ranging in age from 0.1-25 years. Synaptophysin levels slowly increased from birth until age 5 and then increased more rapidly to peak in late childhood around age 10. Synaptophysin subsequently decreased until the adult level was reached by mid-adolescence, around age 16. PSD-95 levels increased postnatally to reach a stable plateau by early childhood with a slight reduction in late adolescence and early adulthood. The pattern of synaptophysin immunoreactivity seen with immunohistochemistry was similar to the Western experiments but the changes across age were more subtle, with little change by layer within and across age. The developmental patterns exhibited by these synaptic marker proteins expand upon previous studies of developmental synaptic changes in human frontal cortex; synaptic density increases steadily from birth to late childhood, then decreases in early adolescence to reach adult levels by late adolescence.

Olanzapine and haloperidol in first episode psychosis: two-year data

Few studies have assessed the comparative efficacy and safety of atypical and typical antipsychotic medications in patients within their first episode of psychosis. This study examined the effectiveness of the atypical antipsychotic olanzapine and the typical antipsychotic haloperidol in patients experiencing their first episode of a schizophrenia-related psychotic disorder over a 2-year treatment period. Two hundred and sixty-three patients were randomized to olanzapine or haloperidol in a doubleblind, multisite, international 2-year study. Clinical symptoms and side effects were assessed at baseline and longitudinally following randomization for the duration of the study. Olanzapine and haloperidol treatment were both associated with substantial and comparable reductions in symptom severity (the primary outcome measure) over the course of the study. However, the treatment groups differed on two secondary efficacy measures. Patients were less likely to discontinue treatment with olanzapine than with haloperidol: mean time (in days) in the study was significantly greater for those treated with olanzapine compared to haloperidol (322.09 vs. 230.38, p<0.0085). Moreover, remission rates were greater in patients treated with olanzapine as compared to those treated with haloperidol (57.25% vs. 43.94%, p<0.036). While extrapyramidal side effects were greater in those treated with haloperidol, weight gain, cholesterol level and liver function values were greater in patients treated with olanzapine. The data from this study suggest some clinical benefits for olanzapine as compared to haloperidol in first episode patients, which must be weighed against those adverse effects that are more likely with olanzapine.

Limited influence of olanzapine on adult forebrain neural precursors in vitro

We evaluated the activity of the atypical antipsychotic drug olanzapine on differentiation and gene expression in adult neural precursor cells in vitro. Neural precursors obtained from forebrain subventricular zone (SVZ)-derived neurospheres express a subset (13/24) of receptors known to bind olanzapine at high to intermediate affinities; in contrast, all 24 are expressed in the SVZ. In the presence of 10 nM, 100 nM or 1 microM olanzapine, there is no significant change in the frequency of oligodendrocytes, neurons, GABAergic neurons and astrocytes generated from neurosphere precursors. In parallel, there is no apparent change in cell proliferation in response to olanzapine, based upon bromodeoxyuridine incorporation. There are no major changes in cytological differentiation in response to the drug; however, at one concentration (10 nM) there is a small but statistically significant increase in the size of glial fibrillary acidic protein-labeled astrocytes derived from neurosphere precursors. In addition, olanzapine apparently modulates expression of one serotonin receptor -- 5HT2A -- in differentiating neurosphere cultures; however, it does not modify expression of several other receptors or schizophrenia vulnerability genes. Thus, olanzapine has a limited influence on differentiation and gene expression in adult neural precursor cells in vitro.

Treatment of somatization disorder with nefazodone: a prospective, open-label study

Somatization disorder (SD) is commonly seen in medical clinics and is associated with significant impairment in functioning as well as excessive utilization of health care. While antidepressants have been studied in some functional somatic syndromes such as fibromyalgia and chronic fatigue, there are no pharmacologic treatment studies of SD itself. In this prospective, 8-week, open-label study, 15 patients diagnosed with either full SD or abridged somatization, by Escobar's criteria (four unexplained physical symptoms for men or six for women), were given nefazodone, titrated to 150 mg bid. The primary outcomes included measures of physical symptom severity (visual analogue scale), functioning (SF-36), and overall improvement (CGI). Fourteen of the 15 patients achieved the target dose of 300 mg/day and completed the trial. 73% of the patients were rated as improved on the CGI, 79% improved on the self-rated visual analogue scale and 73% of the patients improved on the SF-36. There was significant improvement for the whole group (prepost) on the SF-36, as well as on the HAM-D and the HAM-A. Of the nine patients with a categorical depression diagnosis, 55% of them were rated as improved on the CGI, and 67% improved on both the VAS and the SF-36. Of the six nondepressed patients, 67% were rated as improved on the CGI, 83% improved on the SF-36, and 50% improved on the VAS. Adverse events were generally mild and resulted in only one discontinuation. Although these data need to be confirmed in a larger, double-blind, placebo-controlled trial, they suggest that patients with SD will accept and tolerate therapy with nefazodone and that nefazodone may be a useful treatment for these patients.

Odor perception: multiple chemical sensitivities, chronic fatigue, and asthma

Patients with multiple chemical sensitivities (MCS) often report heightened sensitivity to odors. Odor detection thresholds to phenyl ethyl alcohol (PEA) and pyridine (PYR) were evaluated as a measure of odor sensitivity for 33 MCS subjects, 13 chronic fatigue syndrome subjects, 16 asthmatic subjects, and 27 healthy controls. Odor identification ability (based on University of Pennsylvania Smell Identification Test results) and ratings in response to four suprathreshold levels of PEA and PYR were also assessed. Odor detection thresholds for PEA and PYR and odor identification ability were equivalent for all groups; however, when exposed to suprathreshold concentrations of PEA, MCS subjects reported significantly more trigeminal symptoms and lower esthetic ratings of PEA. No group differences were found in response to suprathreshold concentrations of PYR. In summary, MCS subjects did not demonstrate lower olfactory threshold sensitivity or enhanced ability to identify odors accurately. Furthermore, they were differentiated from the other groups in their symptomatic and esthetic ratings of PEA, but not PYR.

Sildenafil effects on sexual and cardiovascular responses in women with spinal cord injury

OBJECTIVES

Sexual dysfunction is common in women with spinal cord injuries (SCIs) and other neurologic conditions. Sildenafil has previously been shown to be safe and effective in the treatment of erectile dysfunction due to SCI. This study is the first to evaluate the sexual and cardiovascular effects of sildenafil in women with SCIs in a controlled, laboratory setting.

METHODS

Nineteen premenopausal women with SCIs were randomly assigned to receive either sildenafil (50 mg) or placebo in a double-blind, crossover design study. Physiologic and subjective measures of sexual response, heart rate, and blood pressure were recorded during baseline and sexual stimulation conditions. Adverse events were also recorded.

RESULTS

Significant increases in subjective arousal (SA) were observed with both drug (P <0.01) and sexual stimulation conditions (P <0.001), and a borderline significant (P <0.07) effect of drug administration on vaginal pulse amplitude (VPA) was noted. Maximal responses occurred when sildenafil was combined with visual and manual sexual stimulation. Cardiovascular data showed modest increases in heart rate (+/-5 bpm) and mild decreases in blood pressure (+/-4 mm Hg) across all stimulation conditions, consistent with the peripheral vasodilatory mechanism of the drug. Sildenafil was well tolerated with no evidence of significant adverse events.

CONCLUSIONS

Findings suggest that sildenafil may partially reverse the sexual dysfunction commonly associated with SCI in women. Consistent with previous findings in men, the sexual effects of the drug were most evident under conditions of optimal stimulation. Mild, clinically insignificant cardiovascular effects were also noted. Further large-scale studies of sildenafil's effects in women with neurogenic sexual dysfunction are strongly indicated.

The Lie/Bet Questionnaire for screening pathological gamblers: a follow-up study

This study follows up one in which was derived a two-item screening questionnaire for pathological gambling. In the previous study, the two-item screening questionnaire had sensitivity of .99 and specificity of .91. In this study, testing 295 men (116 pathological gamblers and 179 controls) and 128 women (30 pathological gamblers and 98 controls), sensitivity was 1.00 and specificity .85. In the previous study, the predictive value of a positive result was .92 and of a negative result .99. In this sample, the predictive value of a positive result was .78 and of a negative result 1.00. These results indicate the two questions represent a useful screening device for a DSM-IV diagnosis of pathological gambling.

Psychiatric consultation in the nursing home. A survey of six states

The authors examined availability, characteristics, and perceived adequacy of psychiatric consultation in nursing homes, as reported by directors of nursing, who returned 899 questionnaires. Thirty-eight percent of nursing home residents were judged to need a psychiatric evaluation; current frequency of consultation was rated as adequate by half of nursing directors. Nearly two-thirds reported that psychiatrists adequately provided diagnostic and medication recommendations; however, advice on nonpharmacologic management techniques, staff support, and dealing with staff stress and family conflicts was largely viewed as inadequate. Findings suggest that perceived need for psychiatric services is far greater than the level actually provided. Overall, more attention must be directed to identifying incentives for psychiatrists to practice in nursing homes, determining clinical effectiveness of mental health services, and examining effects of alternative payment mechanisms on level of care.

Association of a serotonin transporter gene promoter polymorphism with harm avoidance behaviour in an elderly population

A polymorphic 44-nucleotide insertion/deletion in the promoter region of the serotonin transporter gene (5-HTTLPR) has been shown to affect the level of expression of the serotonin transporter protein. An association between anxiety-related behavioural traits and the short form of the 5-HTTLPR has been reported. We determined the 5-HTTLPR genotype in genomic DNA samples from 84 subjects (47 Parkinson's disease patients and 37 controls) with a mean age of 67.4 years. The TPQ of Cloninger was used to obtain values for harm avoidance (HA), reward dependence and novelty seeking for all subjects. Analysis of variance showed a significant influence of the s-allele of the 5-HTTLPR on HA in both subject groups, with no significant interaction between diagnosis and genotype. Subjects with the l/l-genotype had significantly lower mean HA scores than the l/s subjects (P < 0.04) and s/s subjects (P < 0.003). A linear change in HA with genotype was observed, indicating a gene dose effect of the 5-HTTLPR s-allele on this personality dimension. Based on these findings it is suggested that there may be increased influence of the 5-HTTLPR short allele on anxiety-related traits during aging.

Association of long variants of the dopamine D4 receptor exon 3 repeat polymorphism with Parkinson's disease

The dopamine D4 receptor (D4DR) has a highly polymorphic region in the third exon which has been associated with novelty seeking (NS) behavior. Due to the central position of dopamine and the documented low NS in Parkinson's disease (PD), the frequency of the exon 3 variants of D4DR in 95 PD patients and 47 controls was investigated. A significantly higher frequency of exon 3 alleles with six or more repeat units was found in the PD group (p = 0.039). This provides evidence that some forms of the highly polymorphic D4DR may represent a genetic susceptibility factor for PD.

Psychopathology and pain in medical in-patients predict resource use during hospitalization but not rehospitalization

The authors investigated the relationship between psychopathology and resource use in general medical in-patients during hospitalization and rehospitalization. Between 1 July 1987, and 30 April 1989, 1020 in-patients were prospectively screened for depression, anxiety, cognitive dysfunction, and pain. Overall, the screen identified 47% of patients as having high psychopathology or pain, including 25.7% depressed, 21.8% anxious, 17.6% with cognitive dysfunction, and 5.2% with high pain. There were no measured differences in demographics or disease severity between high and low psychopathology groups. High psychopathology patients had longer stays and higher costs during the index hospitalization but there were no differences during subsequent hospitalizations. Length of stay declined overall during the study period, but there were no changes over time in the association between high psychopathology or pain with increased resource use. The measured symptoms of psychopathology and pain we measured are associated with increased short-term utilization of health care resources, but the increase does not extend to subsequent hospitalizations. Outcome studies aiming to reduce psychopathology in medical in-patients should pay particular attention to short term costs.

A randomized controlled study of psychiatric consultation guided by screening in general medical inpatients

OBJECTIVE

The purpose of the study was to test the hypothesis that psychiatric consultation would reduce health care utilization during and after medical hospitalization.

METHOD

A randomized, double-controlled clinical trial of psychiatric consultation was conducted on the general medical inpatient services of a university hospital. After meeting inclusion criteria, 1,541 patients were screened for depression, anxiety, confusion, and pain over a period of 21 months. The 741 patients with high levels of psychopathology or pain were subdivided into baseline control subjects (N = 232), contemporaneous control subjects (N = 253), and an experimental consultation group (N = 256). The major outcome measures were length of hospital stay and hospital costs. Secondary outcome measures were posthospital health status, rehospitalization rates, and use of outpatient medical care.

RESULTS

This study did not demonstrate an effect of experimental psychiatric consultation on hospital resource use or posthospital medical care utilization after adjustment was made for disease severity. Hospital resource use decreased in the entire sample over the 21-month duration of the study.

CONCLUSIONS

The brief, efficient screen for anxiety, depression, confusion, and pain identified a group of patients who also used more hospital resources, but a single experimental psychiatric consultation did not reduce costs. The double-controlled nature of the design proved essential to avoid being misled by background changes in hospital resource use.

Hospital utilization and readmission rates for geriatric and young adult patients with major depression: results from a historical cohort study

Late-life depression may have different clinical features, hospital utilization patterns, and natural history, depending on whether the illness begins in midlife or late life. This historical cohort study examined three patient groups, late-onset geriatric depressed patients, early-onset geriatric depressed patients, and young adult depressed patients, to determine hospital utilization patterns, readmission rates, and whether specific clinical symptoms on admission predisposed patients to readmission. The two geriatric patient groups had similar demographic, medical comorbidity, and hospital utilization profiles, except that the early-onset geriatric depressed group had longer hospital lengths of stay. Hospital utilization patterns for the young adult patients were different from the geriatric patients, but in the expected direction, ie, less medical comorbidity and shorter lengths of stay. Patients with late-onset geriatric depression had the highest 24-month readmission rate (47.4%), followed by early-onset geriatric depression patients (23.1%) and young adult patients (16.7%). Delusional symptoms and agitation were similar across the three patient groups and, as expected, somatic complaints were more frequent in the geriatric patient groups. The relative risk for readmission was greatest for geriatric patients who were somatic. Readmission risk was increased for agitated late-onset geriatric depressed patients and young adult patients, but not for early-onset geriatric depressed patients. Delusional symptoms did not predict readmission for any patient group.

Symptom report in orofacial pain patients: relation to chronic pain, experimental pain, illness behavior, and personality

A study was conducted to determine symptom report patterns in a heterogenous population of orofacial pain patients and to evaluate how symptom patterns relate to various dimensions of the human pain experience. Results indicated that symptoms frequently associated with chronic orofacial pain disorders can be described by four indices related to the temporomandibular joint (TMJ) and its movement; discomfort of and parafunctional activities related to the masticatory muscles; interference of pain with activities of daily living; and presence of orofacial pain unrelated to myogeneous or arthrogenous TMJ disorders. Of these four symptom indices, only the pain interference (symptom) index was related to clinical pain and illness behavior. None was related to personality. Two of the indices were influenced by diagnosis. Biomechanical symptoms and parafunctional activities appear to be insignificantly related to perceived pain intensity, pain responsiveness, illness behavior, or personality, but are related to diagnosis. The results indicated that relatively simple symptom checklists have potential utility in screening orofacial pain patients and in evaluation of treatment outcome.

Antecedents and interventions for aggressive behavior of patients at a geropsychiatric state hospital

Aggressive geropsychiatric patients pose major problems for long-term care facilities. Two exploratory surveys at a geropsychiatric state hospital, separated by brief programs of inservice training on managing aggressive patients, examined several aspects of aggressive behavior and staff interventions. Major findings included a stable overall prevalence of aggressive behavior in both survey periods; a persistently higher prevalence of aggression and a higher rate of physical aggression among dementia patients than among other patients; and staff-patient exchanges as a major triggering event for aggression. In the survey period after the inservice training, staff interventions remained similar for nondementia patients; however, for dementia patients, interpersonal interventions were used less frequently, and p.r.n. medications, alone or in combination with seclusion or restraint, were used more often.

Effects of buspirone and alprazolam on the cognitive performance of normal elderly subjects

OBJECTIVE

To increase understanding of the potential in elderly persons for disability related to behavioral side effects of anxiolytic medications, cognitive and psychomotor effects of clinical doses of buspirone and a popular intermediate-acting benzodiazepine, alprazolam, were examined in carefully screened, healthy elderly subjects.

METHOD

Sixty subjects recruited through community organizations and newspaper advertisements and screened on the basis of history, physical examination, and laboratory studies were randomly assigned to one of three drug treatment groups. After 2 days of washout placebo, subjects were given 0.25 mg t.i.d. of alprazolam, 5 mg t.i.d. of buspirone, or placebo three times a day for a total of 14 days in a double-blind design. Behavioral assessments were completed beginning 1 hour after ingestion of medication on the second washout placebo day, day 1 of the treatment period, and day 14 of the treatment period. Tests included the continuous performance test, recall memory for word lists, digit-symbol substitution, retention of pictorial stimuli over 1 hour, the Profile of Mood States, and subjective ratings of mental status.

RESULTS

Buspirone did not affect reaction time, vigilance, psychomotor speed, or memory function. Alprazolam had minimal effects on vigilance, psychomotor speed, and memory on the first treatment day and had no effects after repeated doses.

CONCLUSIONS

Buspirone did not produce behavioral side effects that could lead to disability, and alprazolam had minimal side effects. Because the patients were carefully screened, it is unclear whether these medications in the doses used would have more side effects in less healthy elderly patients.

Relation of psychopathology in general medical inpatients to use and cost of services

The authors investigated the relation between psychopathology in medically ill inpatients and use and cost of medical care services. Of 455 medical inpatients, the Medical Inpatient Screening Test identified 27.9% as very depressed, 27.5% as very anxious, 20.2% as having cognitive dysfunction, and 8.6% as having high pain levels. Overall, the test identified 51% of the patients as having high levels of psychopathology or pain. These subjects had a 40% longer median length of hospital stay and 35% greater mean hospital costs than those with low levels of psychopathology or pain. Patients with greater psychopathology also had higher hospital charges, more procedures during hospitalization, and more discharge diagnoses but did not differ from the other patients in sex, race, age, diagnosis-related group (DRG) major diagnostic category, or DRG weight.

A prospective assessment of the Garren-Edwards Gastric Bubble and bariatric surgery in the treatment of morbid obesity

Morbid obesity is a serious medical hazard, and effective alternatives to surgery have been unsuccessful. In 1985, the Garren-Edwards Gastric Bubble (GEGB) was offered as an adjunct to dietary and behavioral therapy for weight loss treatment. The safety and efficacy of the GEGB were compared with bariatric surgery, the current standard for the treatment of morbid obesity. Fifty-seven patients received GEGB and 77 underwent bariatric surgery. GEGB patients were divided into two groups: those who attended group therapy and those who did not. This study showed that bariatric surgery was far more effective in reducing excess body weight during a 12-month period compared with the GEGB plus group therapy and the GEGB alone. The morbidity from bariatric surgery was greater than in the GEGB-treated groups, while the cost for uncomplicated cases for a year's treatment was comparable. It is concluded that the GEGB does not offer an effective alternative to bariatric surgery in the treatment of morbid obesity.

Neuropsychological effects of occupational exposure to cadmium

Neuropsychological functioning was measured in 31 male workers exposed to cadmium in a refrigerator coil manufacturing plant. Workers with high urinary cadmium levels performed less well than did those with low urinary cadmium levels on measures of attention, psychomotor speed, and memory. There were modest correlations between one of two biologic measures of cadmium exposure and neuropsychological performance. The neuropsychological impairments cannot readily be attributed to exposure to other neurotoxins, alcohol intake, CNS effects of renal dysfunction, or psychological distress. Cadmium body burden has previously been related to intelligence and school achievement of children; this study would appear to be the first to suggest that occupational exposure to cadmium is associated with cognitive impairment in adults. Cadmium interferes with several important nervous system functions, but the mechanisms of neurotoxicity remain uncertain.

Amphetamine challenge test, response to treatment, and lateral ventricle size in schizophrenia

The hypothesis of two independent pathologies in schizophrenia proposed by Crow (1980) were tested. Two dimensions of the dopamine variable, namely, the behavioral response during the Amphetamine Challenge Test (ACT) and the response to neuroleptic treatment, were studied in a cohort of 19 subjects with a research diagnosis of schizophrenia (n = 18) or schizoaffective disorder (n = 1) in an acute inpatient setting. The size of the lateral ventricle was assessed by mesauring the ventricle-brain ratio (VBR) on the computerized tomographic brain scan. Patients who had greater symptom reduction with the neuroleptic treatment worsened more in their positive psychotic symptoms during the ACT. Those with larger VBRs showed less treatment responsiveness and no worsening during the ACT. The findings are supportive of Crow's hypothesis. The ACT has the potential to be an index of both Type I and Type II pathologies.

Denial and medical outcome in unstable angina

Denial may be adaptive during hospitalization for acute coronary disease. We studied the impact of denial in 48 patients referred to a tertiary care center for treatment of unstable angina. Using the Hackett-Cassem Denial Scale, we divided the group into 25 high deniers and 23 low deniers. The two groups were comparable in baseline demographic and social data, coronary risk factors, cardiac history, medical treatment, vital signs, and cardiac catheterization results (number of diseased vessels and ejection fraction). Compared to low deniers, high deniers had half as many episodes of angina during hospitalization (1.3 vs. 2.5; p less than 0.03, t = 2.2, df = 46) and were more likely to reach medical stabilization, i.e., pain free for 36 hr (92% vs. 65%, p less than 0.03, Fisher exact probability test). Intravenous nitroglycerin drips were also required less often in high deniers (32% vs. 78%, p = 0.002, Fisher exact). Two myocardial infarctions and one death occurred, all in low deniers. We conclude that denial independently predicts better medical outcome during acute hospitalization for unstable angina.

First admission young adult patients to a state hospital: relative risk for rapid readmission

High readmission rates by young adult patients to state hospitals represents a major service utilization problem for the public mental health system. By identifying those patients who have an increase risk for rapid readmission, effective community-based services could be developed to help reduce utilization of costly hospital services. A nonconcurrent prospective study of 210 first admission young adult patients admitted to a state hospital was conducted to ascertain the incidence of readmission within 180 days of discharge from the index admission (rapid readmission), and to establish relative risk for rapid readmission based on demographic, hospital utilization, and diagnostic variables. The cohort was partitioned into two subgroups: patients with no prior hospitalization, (NPH; N = 119), and patients with prior hospitalization, (PH; N = 91). Group comparisons revealed NPH patients had a lower readmission rate, had shorter hospital lengths of stay, and had a higher proportion on patients with personality or adjustment disorders. The relative risk for rapid readmission in the NPH patient group was greatest for nonwhite female patients (3.30) and for patients who had hospital length of stays between 4-15 days (1.76). In the PH patient group, the relative risk for rapid readmission was greatest for those patients with hospital length of stay less than 15 days (2.15). In both groups, patients with major mental illness were more likely to get readmitted. An association between hospital occupancy rate, the time of discharge from the index admission and readmission to the hospital, hospital length of stay, sex, race, or diagnostic category was not found.

Differences in CT findings within schizophrenics may be due to varying severity of the illness

The authors investigated the importance of severity and duration of illness in schizophrenia with regard to findings on computerised tomographic (CT) scans. Two groups are compared, one from a state hospital's chronic ward and the other group from a university hospital. They provide evidence to propose increased ventricular size is an indicator of severity of illness.

Who benefits from tricyclic antidepressants: a survey

To determine what patients are likely to benefit from treatment with a tricyclic antidepressant, the authors surveyed American researchers, teachers of psychiatry, general psychiatric practitioners, and foreign researchers. Areas of agreement were appreciable and can serve as an index of accepted community practice and as guidelines for teaching. Responses indicated that patients most likely to benefit from a tricyclic antidepressant are those with primary depression; early morning awakening; motor retardation; loss of appetite; weight loss; prior positive response to a tricyclic antidepressant; loss of interest in work or hobbies; sad, blue, or depressed feelings; improved mood in evening; and loss of interest in sex. Amitriptyline was preferred for agitated depressions, and imipramine was preferred for retarded depressions.

Borderline personality disorder: replication of MMPI profiles

The purpose of this study was to determine whether a particular MMPI profile is associated with borderline personality disorder (BPD). Forty-seven symptomatic volunteers who satisfied DSM-III criteria for borderline and/or schizotypal personality disorder were given the full MMPI. Concordance of MMPI profile for BDP confirmed the findings of four previous studies. Elevations were noted on F, D, PD, PA, PT, and SC. A subject's profile with this pattern is interpreted from item content as generally neurotic, dysthymic, socially withdrawn, suspicious, apathetic toward the future, affectively erratic, unable to anticipate the consequences of his or her own behavior, and unable to judge the social desirability of his or her own behavior. Correlations of the foregoing scales with a total BPD score ranged from .44 to .77, with a multiple R of .80 and a cross validity of .77. The accuracy of predicting actual BPD and non-BPD cases was 89%. Accordingly, the MMPI could be used as a coarse screen for BPD casefinding in that patients with the MMPI profiles above should be selected for more thorough diagnostic workup. In the future, the MMPI might be linked to other variables, such as drug response, to understand further the pathophysiology of BPD.

Schizophrenic symptoms and deterioration. Relation to computed tomographic findings

Thirty-two patients with a research diagnosis of chronic schizophrenia were studied using structured clinical scales for premorbid adjustment, clinical symptomatology, and social deterioration. By computed axial tomography (CAT), ventricle-brain ratio (VBR) and cortical atrophy were assessed. The relation between the clinical variables and CAT findings was assessed using linear correlation. CAT-based subgroups were compared using univariate analysis of variance. Previous findings of ventricular enlargement and cortical atrophy in some schizophrenics were replicated. Premorbid asociality and social deterioration were found to have a modest, positive relation with CAT findings but formal thought disorder had a negative relation to ventricle size. There was no relation between the negative symptoms and CAT measures. Within the CAT-positive group the presence of cortical atrophy appeared to be associated with a more severe illness compared with those with ventricular enlargement but the sample sizes were too small to obtain any significant differences.

Productive naming and memory in depression and Alzheimer's type dementia

Patients with mild to moderate dementia of the Alzheimer's type (DAT), patients with major depression, and normal controls completed tests of productive naming and verbal recall memory. Both depressed and DAT patients demonstrated reduced verbal fluency on productive naming tasks, indicating limited utility of such tasks in differential diagnosis. There was a stronger relationship between verbal fluency and memory in DAT patients than in depressed patients. The linguistic component as well as the requirement for cognitive speed may be important in explaining the deficit of DAT patients on productive naming tasks. In contrast, the speed component may be particularly important for depressed patients whose poor performance may reflect a motivational deficit.

Selective reminding procedure in depression and dementia

Patients with mild dementia of the Alzheimer's type (DAT), patients with major depression, and normal elderly control subjects were administered a verbal learning task using the selective reminding procedure. Depressed patients were impaired on total recall and the proportion of items retained from one trial to the next without reminding and did not benefit from imagery in retaining items over consecutive trials. The DAT patients were impaired on all measures derived from the test, including storage and recognition memory. With the exception of the ability to benefit from imagery, all of the measures distinguished depressed and mild DAT patients. These findings are consistent with deficient encoding in DAT and performance deficits as a function of effortful cognitive processing in depression.

Psychological factors predict symptoms of severe recurrent genital herpes infection

In a group of patients with severe recurrent genital herpes infection, we measured symptoms (pain and itching), psychological factors (depression, anxiety, somatisation, interpersonal sensitivity, and life change) and objective indices of disease (number of recurrences in the previous year, total number of recurrences, duration of recurrences, number of lesions per recurrence). Psychological factors were more predictive of pain and itching than were somatic indices, even after correcting for sex.

Selective reminding procedure in depression and dementia

Patients with mild dementia of the Alzheimer's type (DAT), patients with major depression, and normal elderly control subjects were administered a verbal learning task using the selective reminding procedure. Depressed patients were impaired on total recall and the proportion of items retained from one trial to the next without reminding and did not benefit from imagery in retaining items over consecutive trials. The DAT patients were impaired on all measures derived from the test, including storage and recognition memory. With the exception of the ability to benefit from imagery, all of the measures distinguished depressed and mild DAT patients. These findings are consistent with deficient encoding in DAT and performance deficits as a function of effortful cognitive processing in depression.

A survey of psychiatrists' practices related to the use of tricyclic antidepressants

Four groups of psychiatrists were surveyed about their clinical practices in relation to the use of tricyclic antidepressants to determine if there is any unanimity about procedures. The four groups were U.S. experts in the pharmacotherapy of depression, faculty who taught the pharmacotherapy of depression in accredited departments of psychiatry, general psychiatrists in Virginia who treated depressions with drugs, and non-U.S. experts. The authors report on practices related to dosage buildup, side effects, concurrent medical conditions, blood level information, and maintenance on tricyclics. They found moderate to high consensus on most issues; exceptions were treatment of a patient with chronic hypertension and maintenance dosage and duration.

Alprazolam versus imipramine in depressed out-patients with neurovegetative signs

The purpose of this study was to compare the safety and efficacy of a relatively new antidepressant drug, alprazolam (a triazolobenzodiazepine) with imipramine in the treatment of 60 depressed symptomatic volunteers. Eligible patients were randomly assigned after a 1-week washout to one of the medications and followed for 6 treatment weeks. Contrary to the earlier report of Feighner et al. (1983), who found alprazolam superior to imipramine and placebo, but consistent with Rush et al. (1985) we find imipramine superior in efficacy to alprazolam on a variety of symptoms. Both the present study and Rush's study employed patients with signs indicative of response to tricyclics. Feighner's patients may have been the type who tend to be less responsive to tricyclics but may be more responsive to alprazolam. Some of our data also show that alprazolam may have a more advantageous effect in the early weeks of treatment but is overtaken in subsequent treatment weeks by imipramine.

Borderline and schizotypal personality disorders treated with low-dose thiothixene vs placebo

Fifty outpatients with borderline and/or schizotypal personality disorder were randomly allocated to thiothixene (Navane) or placebo treatment that was continued for 12 weeks. The mean daily dosage of thiothixene hydrochloride in the final week of the study was 8.7 mg, a lower dosage than is used in outpatient schizophrenics. Significant drug-placebo differences were found, regardless of diagnosis, on "illusions," "ideas of reference," "psychoticism," "obsessive-compulsive symptoms," and "phobic anxiety," but not on "depression." Thiothixene seems to have more than an antipsychotic effect. Since response to treatment studies are a means for reformulating diagnostic concepts, we suggest a subdiagnosis defined by those symptoms that are drug-responsive, some of which are not included in current diagnostic criteria. Patients with borderline and schizotypal disorder without the foregoing symptoms probably would not profit from thiothixene and might needlessly be placed at risk for adverse drug effects.

Posttraumatic stress disorder from pentaborane intoxication. Neuropsychiatric evaluation and short-term follow-up

Fourteen individuals briefly exposed to a toxic industrial compound, pentaborane, were evaluated for neuropsychiatric abnormalities four to 12 weeks after exposure. Results of physical, neurological, and routine laboratory evaluations were normal. Initial and persistent psychiatric symptoms, neuropsychological deficits, electroencephalographic changes, elevated central nervous system neurotransmitter levels, and ventricular brain ratios (computed tomographic scan) provide evidence of central nervous system damage. Seven patients met diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, ed 3, for posttraumatic stress disorder, and seven patients had neuropsychological test evidence of mild brain dysfunction. No statistically significant relationship was found between neuropsychiatric test results and psychiatric diagnoses. These results contradict previous literature that reports most symptom resolution within the first week after exposure to pentaborane. Results suggest that patients suffered a combination of organic brain insult and psychological trauma.

Brain ventricular size and CSF monoamine metabolites in an adolescent inpatient population

The cerebrospinal fluid monoamine metabolites, homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5HIAA), were compared with ventricle-brain ratios (VBRs) in a group of adolescent inpatients who were divided into psychotic and nonpsychotic groups. HVA, 5HIAA, and VBR did not differ significantly between the two groups. There were no significant relationships between these variables in the nonpsychotic group. Psychotic adolescents, however, displayed significant negative correlations between VBR and HVA, and between VBR and 5HIAA. The relationship between VBR and monoamine metabolites appears to occur in psychoses other than schizophrenia, is present early in the course of illness, and probably does not represent a dilutional effect.