Acquired obsessive-compulsive disorder associated with basal ganglia lesions

The authors report 5 cases of acquired obsessive-compulsive disorder occurring later in life. Patients' presentations, which could be readily mistaken for a delusional disorder, were associated with depressive symptoms and basal ganglia lesions, implicating dysfunction of the cortical-basal ganglia-thalamic-cortical neuroanatomical circuit.

Episodically remitting akinetic mutism following subarachnoid hemorrhage

Akinetic mutism is characterized by alertness with near complete absence of volitional activity. The authors report a case of episodically remitting akinetic mutism following subarachnoid hemorrhage.

Self-report evaluation of health behavior, stress vulnerability, and medical outcome of heart transplant recipients

OBJECTIVE

The purpose of this study was to explore the value of patient self-report assessment in heart transplant candidacy evaluation, utilizing the Millon Behavioral Health Inventory (MBHI). Patient's MBHI measures were related to important pretransplant patient characteristics and posttransplant measures of health behavior, medical morbidity, and mortality.

METHOD

Ninety heart patients with end-stage cardiac disease completed the MBHI during pretransplant candidacy evaluations, and also were interviewed concerning their coping effectiveness, support resources, and compliance history. Postransplant follow-up of 61 living and 29 deceased patients included measures of survival time, postsurgical medical care, rejection and infection episodes, and nurse ratings of medication compliance and problematic interpersonal health behaviors.

RESULTS

The MBHI coping scales were found to significantly discriminate good and poor pretransplant compliance, and interview judgments of good and poor coping and support resources, with modest accuracy. The MBHI also was superior to these interview judgments in predicting posttransplant survival time and medical care used. Certain scales were also positively associated with physical parameters of pretransplant and posttransplant status.

CONCLUSIONS

Patient self-report with the MBHI can contribute to identification of patients at risk for a problematic outcome with transplant, by providing information pertinent to clinical decision making and outcome management analysis with this special population of cardiac patients.

Psychiatric interview and psychometric predictors of cardiac transplant survival

OBJECTIVE

This study prospectively investigated the relation between pretransplant assessment of psychiatric diagnosis, coping skills, and social support and outcome measures of survival and health care utilization.

METHOD

Ninety-four heart transplant patients underwent structured interviews and completed a battery of self-report psychometric tests assessing coping style, health status, and psychosocial supports. Follow-up that ranged from 9 to 56 months after transplant produced a group of 63 survivors and 31 nonsurvivors, who were found to be comparable in terms of pretransplant cardiac status and severity of illness.

RESULTS

Survival analysis showed that dimensional psychometric measures of coping and social support based on patient self-assessment were the best significant predictors of survival. Considered separately, interview-determined ratings of social support and pretransplant compliance with treatment regimens were also potential predictors. Formal DSM-III-R diagnoses were related specifically to posttransplant hospital utilization (axis I diagnoses) and posttransplant health behavior (axis II diagnoses).

CONCLUSIONS

The data demonstrate the value of multifaceted assessment, since psychiatric diagnosis, coping style, and psychosocial support may contribute differently to prediction of such aspects of outcome as mortality and health care utilization.

Relationship of psychiatric morbidity and psychosocial factors in organ transplant candidates

The purpose of this study was to explicate the statistical relationship between psychiatric diagnosis and psychosocial adjustment and health status in organ transplant candidates. Interview and psychometric data were obtained from 311 heart, kidney, lung, and liver transplant candidates. Over 60% of the cases met criteria for DSM-III-R Axis I diagnoses, nearly 32% for Axis II disorders. Axis II disorders were significantly associated with medical compliance problems, whereas Axis I disorders were predominantly associated with poorer psychosocial adjustment and health status. Nearly one-quarter of the patients had comorbid Axis I and Axis II disorders, and evidenced poorest premorbid coping and degree of marital harmony, defining a subgroup at special risk for problematic outcome. The incidence of psychiatric disorders and their association with lack of psychosocial resources and poor physical health supports the use of systematic, multidisciplinary assessment of transplant candidates.

SPECT findings on psychosis in Alzheimer's disease

OBJECTIVE

This study examined whether psychosis in Alzheimer's disease is associated with cerebral perfusion patterns appreciable by single photon emission computed tomography (SPECT) scans.

METHOD

All cooperative outpatients enrolled in an Alzheimer's disease research center with the diagnosis of probable Alzheimer's disease and a Clinical Dementia Rating of mild or moderate were interviewed with their primary caregivers. Current and past psychiatric functioning was assessed by using the Hamilton Depression Rating Scale, the Structured Clinical Interview for DSM-III-R, and the Behavioral Pathology in Alzheimer's Disease Rating Scale. Patients without premorbid psychosis received SPECT scans, and the scans of the patients with delusions or hallucinations (N = 30) were compared to the scans of patients without these symptoms (N = 16).

RESULTS

The patients with delusions (N = 29) had hypoperfusion of the left frontal lobe in relation to the right frontal lobe. The patients with hallucinations (N = 10) had hypoperfusion in the parietal lobe.

CONCLUSIONS

Psychotic patients with Alzheimer's disease had a pattern of cerebral blood flow deficits significantly different from that of nonpsychotic patients. This suggests that patterns of cerebral dysfunction may be expressed symptomatically as psychosis.

Clinical variables associated with psychosis in Alzheimer's disease

OBJECTIVE

The authors explored whether personal or family history of major mental illness, negative symptoms, or behavioral measures are associated with positive psychotic symptoms in Alzheimer's disease.

METHOD

Fifty-seven patients with Alzheimer's disease were studied prospectively during interviews with the patients and their primary caregivers.

RESULTS

Psychotic patients with Alzheimer's disease did not differ in cognitive functioning from nonpsychotic patients with Alzheimer's disease. No association was found between personal or family history of mental illness and psychosis. Asociality was the only negative symptom associated with psychosis. Psychotic patients had more behavioral disturbances.

CONCLUSIONS

Positive psychotic symptoms in Alzheimer's disease are not associated with certain aspects of cerebral functioning but are associated with behavioral disturbances.

Clozapine for acute and maintenance treatment of psychosis in Parkinson's disease

In a prospective, open-label study, 12 patients manifesting psychosis associated with Parkinson's disease were treated with clozapine. Cognitive functioning and type of psychotic symptoms were measured prior to treatment, and changes in psychiatric and behavioral symptoms were studied by using the Behave-AD Scale. Significant resolution in psychotic symptoms was found and improvement in global behavioral status observed in all cases, with 10 patients maintaining improvement at follow-up. Careful initiation and titration of the drug resulted in few side effects, and dementia was not found to be a contraindication to such treatment.

A case of organic mania associated with open heart surgery

Organic mania has been reported to have multiple etiologies. A case is described of a patient who developed mania following a coronary artery bypass graft and mitral valve replacement. Cerebral abnormalities were not detected by computed tomographic or magnetic resonance imaging scans, but an area of dysfunction was found using single photon emission computed tomographic (SPECT) imaging. The lesion resolved when the patient became clinically asymptomatic. The area of decreased cerebral perfusion associated with the patient's mania was in an atypical location, raising questions about which brain regions can result in well-defined psychiatric syndromes.

Clozapine use in diffuse Lewy body disease

Diffuse Lewy body disease, a severely disabling neuropsychiatric disease, presents with progressive dementia, psychotic symptoms, depression, and parkinsonian symptoms. The authors report a case illustrating that clozapine, a novel neuroleptic drug, has special efficacy in treating psychotic symptoms in these patients.

Comparison of two cognitive screening measures for efficacy in differentiating dementia from depression in a geriatric inpatient population

The Folstein Mini-Mental State Examination (MMSE) and dementia screening measures developed by Benton (temporal orientation, oral word association, and visual reconstruction tasks) were compared for diagnostic efficacy with geriatric inpatients manifesting depression without dementia or mild or moderate dementias complicated by depression. Both instruments showed generally acceptable differentiation between dementia and depression-only cases overall. The MMSE was less sensitive in identifying mild and moderate multi-infarct dementias but showed better specificity than the Benton measures. The degree and type of dementia and the associated risk of classification error were found to be important factors in the choice of screening instruments.

The prevalence of tardive dyskinesia in geropsychiatric outpatients

The prevalence of tardive dyskinesia was studied in a geropsychiatric outpatient clinic. All currently active patients were examined using the Abnormal Involuntary Movement Scale (AIMS) and a standardized procedure. Data were collected on a number of previously reported risk factors. A higher prevalence was noted in both tardive dyskinesia and spontaneous involuntary movement disorders in this patient population. Only sex and duration of exposure to antipsychotic drugs were noted to be significant risk factors.

ECT and tardive dyskinesia: two cases and a review

A brief review of the literature on electroconvulsive therapy in the management of tardive dyskinesia is presented and two patients are described who were treated for major functional disorders with ECT and showed dramatic remissions in tardive dyskinesia. This response was noted during the course of ECT and has been sustained at 1-year follow-up.

Boom areas: implications for mental health care systems

Areas of rapidly shifting population are a perennial phenomenon. Such occurrences offer particular challenges to mental health services. The boom areas which have developed recently in the southwestern rim of the United States have highlighted certain inadequacies in our mental health system. The Houston Consortium, a multi-institutional endeavor, offers one model for addressing these problems. This model emphasizes innovative educational programs geared to local service needs.

Attitudes in the development of public sector clinicians

Attitudes have been a neglected variable in the development of public sector clinicians. Clinicians of differing disciplines may commonly possess attitudes which would affect their role in the public sector. The Houston Consortium assessed some of these attitudes in their students and faculty. The results may have heuristic implications for improving mental health care.