A cluster of cases of factitious Cushing's syndrome

OBJECTIVE

To review the patient profiles, laboratory data, and diagnostic approaches in factitious administration of glucocorticoids.

METHODS

Four cases of surreptitious use of glucocorticoids are presented. Clinical and laboratory data as well as imaging studies are summarized. Pertinent case reports in the literature are reviewed.

RESULTS

We report four cases of surreptitious use of glucocorticoids encountered within a 2-year period. All four patients were women without significant psychiatric histories. In three patients, the question of factitious Cushing's syndrome was suspected because of physical evidence or symptoms of Cushing's syndrome (or both) in the setting of suppressed cortisol levels. The fourth patient had undetectable cortisol levels in both serum and 24-hour urine samples but did not have signs or symptoms of adrenal insufficiency. In three cases, the diagnosis was confirmed by direct measurement of synthetic glucocorticoids in the patient's urine or serum. The fourth case was diagnosed by correlating increased cortisol levels with decreased precursor adrenal steroids.

CONCLUSIONS

Exogenous corticosteroid use in the absence of a medical indication poses a serious risk to a patient. This possibility should be considered in patients with signs and symptoms consistent with Cushing's syndrome but with low serum and urinary cortisol levels. Similarly, this diagnosis should be suggested in patients without symptoms of adrenal insufficiency and with low cortisol levels. Laboratory measurement of synthetic steroids can be helpful in confirming the diagnosis.

Onset of speech after left hemispherectomy in a nine-year-old boy

Case Alex, with Sturge-Weber Syndrome affecting the left hemisphere, failed to develop speech throughout early boyhood, and his comprehension of single words and simple commands remained stagnant at an age equivalent of 3-4 years. But then, following left hemidecortication at age 8.5 years and withdrawal of anticonvulsants when he was more than 9 years old, Alex suddenly began to acquire speech and language. He also showed an unusual degree of residual motor capacity on his right side. Alex's remarkable progress in learning speech and language, and the development of his other cognitive abilities, were measured periodically from the age of 9 to 15 years. His most recent scores on tests of receptive and expressive language place him at an age equivalent of 8-10 years. Comparison with the level of function attained in these domains by nine other left hemispherectomized patients with early onset of disease and comparable IQ (range, 40-68) but with early development of speech and language, suggests that, surprisingly, Alex has suffered no permanent disadvantage from his protracted period of mutism and severely limited comprehension. Although the findings in Alex, as in other left-hemispherectomized patients, indicate define limits to the cognitive and linguistic capacity of the isolated right hemisphere, Alex's achievements appear to challenge the widely held view that early childhood is a particularly critical period for acquisition of speech and language or any of their selective aspects, including phonology, grammar, prosody and semantics. It is concluded that clearly articulated, well structured, and appropriate language can be acquired for the first time as late as age 9 years with the right hemisphere alone.

Trauma-related dissociative states and long-term psychopathology in posttraumatic stress disorder

Dissociative responses to trauma have been hypothesized to be associated with long-term increases in psychopathology. The purpose of this study was to examine dissociative responses to premilitary, combat-related and postmilitary traumatic events and long-term psychopathology in Vietnam combat veterans with (n = 34) and without (n = 28) posttraumatic stress disorder (PTSD). PTSD patients reported higher levels of dissociative states at the time of combat-related traumatic events than non-PTSD patients. Higher levels of dissociative states persisted in PTSD patients in the form of higher levels of dissociative states in-response to postmilitary traumatic events. In addition, dissociative responses to combat trauma were associated with higher long-term general dissociative symptomatology as measured by scores on the Dissociative Experience Scale, as well as increases in the number of flashbacks since the time of the war. These findings are consistent with previous formulations that dissociation in the face of trauma is a marker of long-term psychopathology.

War zone traumas and posttraumatic stress disorder symptomatology

The diagnosis and clinical understanding of posttraumatic stress disorder (PTSD) rests upon the explicit identification of traumatic experiences that give rise to a well-defined constellation of symptoms. Most efforts to investigate the characteristics of these experiences have attempted to specify war zone stressors as objectively as possible. In this study, we add specification of the psychological meaning of war zone stressors to their objective specification. Eleven traumas are organized in terms of four roles that veterans played in the initiation of death and injury; namely, target, observer, agent, and failure. These roles can be ordered in terms of the degree of personal responsibility involved in the initiation of death and injury. The relationships of these roles to current symptomatology were examined in combination with a set of objective measures of war zone stressors. The sample consisted of the first 1709 Vietnam theater veterans who were assessed in a national evaluation of the PTSD Clinical Teams initiative of the Department of Veterans Affairs. Results show that having been a target of others' attempts to kill or injure is related more uniquely than any other role to symptoms that are diagnostic criteria for PTSD. On the other hand, having been an agent of killing and having been a failure at preventing death and injury are related more strongly than other roles to general psychiatric distress and suicide attempts.(ABSTRACT TRUNCATED AT 250 WORDS)

Dissociation and posttraumatic stress disorder in Vietnam combat veterans

OBJECTIVE

This study compared current dissociative symptoms and dissociation at the time of specific traumatic events in Vietnam combat veterans with posttraumatic stress disorder (PTSD) and Vietnam combat veterans without PTSD.

METHOD

Vietnam combat veterans who sought treatment for PTSD (N = 53) were compared to Vietnam combat veterans without PTSD (N = 32) who sought treatment for medical problems. Dissociative symptoms were evaluated with the Dissociative Experiences Scale. Dissociation at the time of a combat-related traumatic event was evaluated retrospectively with the modified Dissociative Experiences Questionnaire. The Combat Exposure Scale was used to measure level of combat exposure.

RESULTS

There was a significantly higher level of dissociative symptoms, as measured by the Dissociative Experiences Scale, in patients with PTSD (mean = 27.0, SD = 18.0) than in patients without PTSD (mean = 13.7, SD = 16.0). This difference persisted when the difference in level of combat exposure was controlled with analysis of covariance. PTSD patients also reported more dissociative symptoms at the time of combat trauma, as measured retrospectively by the Dissociative Experiences Questionnaire (mean = 11.5, SD = 1.6) than non-PTSD patients (mean = 1.8, SD = 2.1).

CONCLUSIONS

Dissociative symptoms are an important element of the long-term psychopathological response to trauma.

Hemifacial spasm in infancy

Three infants presented with the onset of hemifacial spasm after birth and at the age of 10 months. One patient was found to have occlusion of the straight sinus and large collateral veins at the base of the brain, presumably due to venous sinus thrombosis, supporting the concept of vascular compression of the facial nerve at its exit from the brain stem as a mechanism for the production of hemifacial spasm. The other patients each had an intrinsic mass compressing the fourth ventricle, located in the lower pons and extending into the cerebellar vermis and right cerebellar peduncle in one; in the other patient, the mass involved the cerebellar vermis and right middle cerebellar peduncle alone. These patients widen the etiologic spectrum of the syndrome and show that serious intracranial diseases may underlie hemifacial spasm in infancy.

Symptom patterns associated with posttraumatic stress disorder among Vietnam veterans exposed to war trauma

The authors tested whether the relationship between traumatic stress and posttraumatic stress disorder is captured more accurately by aggregating symptoms, as in DSM-III, or differentiating them into the subtypes of denial and reexperiencing. Their findings indicate that distinguishing between the responses of denial and reexperiencing is an alternative and potentially more useful approach for understanding posttraumatic stress disorder and its origins in war trauma than the comprehensive model proposed in DSM-III. The analysis suggests that biases in the current model of posttraumatic stress disorder may lead to underestimation of its prevalence. The authors conclude that reconsideration of what constitutes the disorder is warranted.

Dimensions of posttraumatic stress disorder among Vietnam veterans

DSM-III criteria and clinical models of stress are used to identify discrete dimensions of posttraumatic stress disorder. The authors test the hypothesis that war trauma differentially affects four dimensions of posttraumatic stress--intrusive imagery, hyperarousal, numbing, and cognitive disruption--by studying data from 251 Vietnam veterans probability sampled in seven sites. The hypothesis was confirmed. Different dimensions of stress symptomatology are found to vary across individuals exposed to different types of war trauma. Stress responses to war trauma also differ by race of the veteran. The relationship between stressors and symptomatology change over time, indicating specific experiences are related to particular long-term patterns of posttraumatic stress disorder.

Implicit messages concerning menstruation in commercial educational materials prepared for young adolescent girls

Interviews with young girls aged 9 to 18 revealed that commercial educational materials are an important source of information about menstruation. Although these materials are valuable educational supplements, they do not provide a complete, accurate, and realistic description of menarcheal changes and emphasize good hygiene rather than dealing with the young girl's emotional needs and anxieties. The authors stress the need for more research into the physiological, cognitive, and psychological changes during puberty and the obligation of parents, schools, and other social institutions to provide more comprehensive information to the maturing girl about the essential issues of pubertal development.