Extent of recovery in the first 12 months of complex regional pain syndrome type-1: A prospective study

BACKGROUND

The literature concerning the outcomes of complex regional pain syndrome (CRPS) is contradictory, with some studies suggesting high rates of symptom resolution, whilst others demonstrate that CRPS symptoms can persist and lead to significant disability. The aim of the present study was to carefully document the extent of recovery from each of the signs and symptoms of CRPS.

METHODS

A sample of 59 patients with recently onset (<12 weeks) CRPS-1 were followed prospectively for 1 year, during which time they received treatment-as-usual. At baseline, 6 and 12 months, the following were measured: CRPS severity scores (symptoms and signs of CRPS), pain, disability, work status and psychological functioning.

RESULTS

Analyses showed that rates of almost all signs and symptoms of CRPS reduced significantly over 1 year. Reductions in symptom severity were clinically relevant and were greatest in the first 6 months and plateaued thereafter. However, at 1 year, nearly 2/3 of patients continued to meet the IASP-Orlando criteria for CRPS and 1/4 met the Budapest research criteria for CRPS. Only 5.4% of patients were symptom-free at 12 months.

CONCLUSIONS

Overall the results were less optimistic than several previously conducted prospective studies and suggest that few cases of CRPS resolve completely within 12 months of onset. Improvements were generally greater in the first 6 months, and suggest that it may be worth exploring early interventions to prevent long-term disability in CRPS.

Pharmacokinetics of 'party pill' drug N-benzylpiperazine (BZP) in healthy human participants

There have been many reports of benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP) being used as recreational drugs which have been widely marketed in the form of 'party pills' since the late 1990's. However, there is no information currently available describing the pharmacokinetics of these drugs in humans. Human plasma concentrations of BZP were measured in blood and urine samples taken from healthy adults (n=7) over 24h following a 200mg oral dose of BZP. Plasma concentrations of BZP were found to peak at 262 ng/mL (C(max)) and 75min (T(max)). Plasma concentrations of the major metabolites of BZP, 4-OH BZP and 3-OH BZP, were found to peak at 7 ng/mL (at 60 min) and 13 ng/mL (at 75 min) respectively. The elimination half-life (t(1/2)) for BZP was found to be 5.5h. Clearance (Cl/F) was found to be 99L/h. The results of this study indicate that BZP may be detectable in plasma for up to 30 h following an oral dose. Additionally, several urinary metabolites can be detected.

Early intervention for schizophrenic disorders. Implementing optimal treatment strategies in routine clinical services. OTP Collaborative Group

BACKGROUND

Early detection and intervention in schizophrenic disorders is an important challenge for psychiatry.

METHOD

Review of literature on effective biomedical and psychosocial intervention strategies.

RESULTS

Comprehensive programmes of drug and psychosocial interventions with adults who show early signs and symptoms of schizophrenic disorders may contribute to a lower incidence and prevalence of major episodes of schizophrenia. These programmes combine early detection of psychotic features by primary care services, with close liaison with mental health professionals. Long-term monitoring of signs of recurrence, with further intervention, appears essential to maintain these benefits.

CONCLUSIONS

Field trials demonstrate that effective early treatment strategies can be routinely applied in clinical practice.

The role of general practitioners in mental health care: a survey of needs and problems

OBJECTIVE

To assess the attitudes of general practitioners to central Auckland mental health service provision, and their perceived role and educational needs for clinical management of patients with mental disorders.

METHOD

A postal questionnaire survey of all general practitioners within the Auckland Healthcare (Central Auckland CHE) area.

RESULTS

140 (49%) valid responses were returned from 287 sampled. 94% supported a shared care role with mental health services; 57% considered their role as main case manager to be important. 79% of the general practitioners considered they had insufficient time to manage patients with mental disorders. 69% of respondents reported difficulties receiving information about changes to treatment; 65% were unsure whether patients had a case manager, and 64% reported general difficulties with liaison with the mental health services. Education about a range of mental health issues was sought by three quarters of the group.

CONCLUSION

This survey suggested that liaison between general practice and specialist mental health services in central Auckland is poor, but that general practitioners are eager to seek ways to improve the care of people suffering mental disorders.

Early detection and intervention for initial episodes of schizophrenia

Comprehensive programs of drug and psychosocial interventions with adults who show early signs and symptoms of schizophrenic disorders may contribute to a lower incidence and prevalence of florid episodes of schizophrenia. These programs combine (1) early detection of psychotic features by family practitioners and other primary care providers and (2) close liaison with mental health professionals well trained in psychiatric assessment and treatment strategies effective in reducing the prevalence of established cases of schizophrenia. Long-term monitoring for signs of recurrence of these subthreshold psychotic episodes, with further intervention as needed, appears essential to maintain these benefits.

Cognitive brain potentials and regional cerebral blood flow equivalents during two- and three-sound auditory "oddball tasks"

Ten healthy volunteers were examined with single photon emission tomography and 99mTc-exametazime. They were studied on 2 occasions, during a 2- and a 3-sound auditory discrimination (oddball) task. Twenty healthy volunteers were used as controls, studied once at rest. During the 2-tone task there was a bilateral posterior (occipito-) temporal and medial frontal activation, a left pericentral increase, and posterior cingulate suppression. During the 3-sound task activation was again found in posterior (occipito-) temporal, medial frontal cortex, left pericentral, with a small non-significant reduction in posterior cingulate uptake. Compared with the 2-tone task, there was a trend towards higher activity in left medial frontal, right posterior temporal and posterior cingulate cortex in the 3-sound task. P3b amplitudes were negatively correlated with posterior cingulate tracer uptake during both tasks. Positive correlations with P3b amplitudes were found in various frontal and temporal regions. These results are consistent with more invasive localisation studies of P3b. Posterior cingulate cortex appears to be inhibited during the oddball tasks, the more so, the more restricted the range of stimuli, and the greater the task-related recruitment of neurones (P3b amplitude). As expected from its more frontal distribution, P3a amplitude was positively correlated with anterior cingulate tracer uptake, and negatively correlated with temporal cortical activity.

The expert witness in forensic psychiatry

Forensic psychiatry operates at the interface of the Justice and Health systems and has been defined as: "That branch of psychiatry which requires special knowledge and training in the law as it relates to the mental state of the offender, or alleged offender" [1]. As a consequence of working in this area, psychiatrists are often called into court to give evidence as "expert witnesses". This article examines some of the professional and legal issues involved in providing expert testimony. Secondly, it aims to outline some practical guidelines for giving evidence in the court-room. The predominant focus is on criminal, rather than civil, proceedings in which the forensic psychiatrist gives expert testimony; however much of the information is also relevant to other psychiatrists and psychologists undertaking this role in the legal arena.

Mental health needs in Auckland: 1982-6. An analysis using the Jarman index

Sociodemographic variables obtained from 1986 census data were used to calculate the Jarman index (a measure of underprivilege) for census area units of Auckland. The index was found to correlate with psychiatric admission rates for the years 1982-6 suggesting it might have some utility as an indicator of demand for mental health services. However, the highest admission rates were from particular central city areas reflecting the presence of a deinstitutionalised patient population with chronic mental disorder. This group would appear to require independent assessment of their needs and specific allocation of resources. Factor analysis of the census variable scores comprising the Jarman index revealed principal components equatable with poverty, living without adult company and transient residence.

Gross electrocortical activity as a linear wave phenomenon with variable temporal damping, regulated by ascending catecholamine neurones

We report critical tests for a theory of electrocortical wave processes, in which telencephalic dendritic potentials reflect the mass action of coupled oscillatory circuits exhibiting complicated and unspecified non-linearities, the whole system being driven by active cell firing. Specific assumptions were: stochastic independence for instantaneous coupling parameters in the system, an individual central tendency to the cycle time for each circuit, and the maintenance of steady state conditions. Application of the central limit theorem to the state transition matrix shows that the gross electrocortical waves should be linear waves, exhibiting a multitude of invariant resonant modes, with the natural frequencies of all the modes being clustered about a smaller number of center values. Ascending brain-stem neurones of at least the dopaminergic and noradrenergic classes should regulate both the power of noise-like signals driving the telencephalic resonant patterns, and the temporal damping of each resonance. We devised tests which involved between hemisphere comparisons of electrocortical spectra, before and after unilateral lesion of transhypothalamic ascending fibres, thus obtaining ratio power changes attributable to post lesion asymmetry of damping and driving, in modes of equivalent left-right center-frequencies. These ratio spectra were curve-fitted to an approximate theoretical expression, and the parameters obtained enabled tests of several specific predictions. Estimates of the center values for resonant mode frequencies, comparison of the relative changes in left/right phase with that expected from the ratio changes in power, and estimates of the surface-to-signal transformation of left and right signals made by a back-calculation, all conform to expectation from the theory, and are consistent across lesion of different types of ascending neurone.

Schizophrenia as a disorder of cerebral state transition

This paper offers a speculative consideration of the schizophrenic process in the light of recent findings concerning the wave nature of electrocortical activity. These findings indicate that changes of brain state can be described in the terminology of finite-state machines, and both the instantaneous states and the state transitions can be specified. It is suggested that the mental phenomena of schizophrenia may be reducible to events (some specific type of instability) which could be observed by appropriate analytic techniques applied to EEG. Present empirical EEG findings in schizophrenics are reviewed in this light, and the role of dopamine blockade in treatment is also considered.

Mental phenomena as changes of state in a finite-state machine

This paper examines the classical functions of the psyche--cognition, affection and conation--from a phenomenological viewpoint and finds them to be defined each in terms of the other. It is held that this circularity of definition reflects the fundamental unity of conscious experience and, as a consequence, that the search for the biological substrate underlying individual functions too readily degenerates into a morphological and biochemical phrenology. An alternative approach, based on considerations from the field of artificial intelligence, is discussed. This approach provides a description of mental phenomena as changes of state in a finite-state machine, the next state being determined by both previous states and current inputs. This concept is shown to be compatible with the descriptions of conscious experience outlined in the phenomenology of Karl Jaspers. It is suggested that neurobiological investigations should be directed towards defining the processes by which state changes occur and further seeking to define mental pathology as aberrations of these dynamic processes.

Relationship between sensorimotor neglect and the specificity, degree and locus of mesotelencephalic dopaminergic cell loss following 6-hydroxydopamine

The involvement of cell groups within the dopaminergic mesotelencephalic system in the development of the sensorimotor neglect syndrome was re-evaluated in two ways. Firstly, dopaminergic specificity of the neglect was further established by studying the relationship between nomifensine protection of dopamine cells against 6-hydroxydopamine damage and the degree of neglect which resulted. The sensorimotor neglect syndrome which developed following injection of 6-hydroxydopamine was diminished by concomitant treatment with nomifensine in parallel with the degree of protection afforded the dopaminergic cells. Non-specific damage produced by 6-hydroxydopamine was unaltered by nomifensine. Secondly, the role in sensorimotor neglect of both total cell damage, and damage to regional sub-classes of dopaminergic cells was considered. It was found that the extent of the resulting neglect was correlated with the overall damage to the substantia nigra and ventral tegmental area, rather than to any individual region within this dopaminergic system. There was a threshold, involving destruction of approximately one third of the system, below which no neglect syndrome developed. Certain regions, including the ventral tegmental area (VTA), showed a higher partial correlation with the extent of neglect than other regions. While specific lesioning of the A8 or A10 dopaminergic neurons is probably insufficient to produce a neglect syndrome, damage to these areas potentiates the severity of the neglect produced by nigrostriatal lesions. It appears that the involvement of the individual subclasses of the mesotelencephalic dopaminergic neurons in the neglect syndrome is more widespread than previously thought.

Effect of nomifensine on the toxicity of 6-hydroxydopamine for mesotelencephalic dopamine neurons

The ability of nomifensine to protect the dopaminergic cells of the substantia nigra and ventral tegmental areas against 6-hydroxydopamine-induced destruction was evaluated. Nomifensine at high doses (20 mg/kg, i.p.) protected the cells from the effects of low amounts of 6-hydroxydopamine (2 micrograms) injected intracerebrally. This protective effect was markedly decreased with an increased amount of 6-hydroxydopamine (8 micrograms), or by lower doses of nomifensine (6.7 mg/kg). These doses of nomifensine are higher than those required to protect dopaminergic nerve terminals.

Amplitude and phase relations of electrocortical waves regulated by transhypothalamic dopaminergic neurones: a test for a linear theory

We have previously proposed that electrocortical activity (EEG) arises as a manifestation of linear waves generated by resonance among telencephalic neurones, and that this activity is controlled in part by ascending neurones from the brain-stem, which regulate the damping of each resonance. The present experiments focus on a specific class of ascending neurones, the mesotelencephalic dopaminergic cells, because these cells are thought to mediate important psychological effects, and are conveniently subject to selective lesion. A critical test of the theory is undertaken, by performing selective unilateral lesion, assessing the changes in the power spectrum of the EEG attributable to lesion, and determining whether the changes in phase of the EEG correspond to that predicted from the changes in power. Results support the theory, although the model order applicable in these experiments in inadequate. The consequences of these findings for automata theory, linear network theory and their application to mammalian brains are briefly discussed.

A test for constant natural frequencies in electrocortical activity under lateral hypothalamic control

An initial test for a theory of lateral hypothalamic regulation of electrocortical activity is undertaken. The theory supposes lateral hypothalamic input directly or indirectly damps telencephalic resonances involving linear wave phenomena, enabling this pathway to act as parametric control of information processing in cortical neural networks. Relative changes in left and right electrocortical power spectra are used to test for the presence of resonant modes with constant natural frequencies in conditions of asymmetrical damping, following unilateral lesion of the lateral hypothalamus. Natural frequency values for the modes clustered about center frequencies in the EEG band are obtained. This method has the advantage of minimising the effects of time-variation and the recorded signal's distortion from the electrocortical local spatial average, but limits consideration to five dominant modes of resonance. The uncertainty of true model order, and errors in curve-fitting impose limitations on the test.

A linear theory for global electrocortical activity and its control by the lateral hypothalamus

A linear model for electrocortical waves and their control by the lateral hypothalamus is proposed. It is argued that such a linear model is not in contradiction to non-linearity of neural elements on the microscopic scale. Telencephalic structures are treated as a mass of linked oscillators generating activity with a number of resonant modes. The lateral hypothalamus is regarded as controlling damping of activity in the telencephalic mass, and therefore exerting a specific parametric control over all signal processing in the cortical networks. An initial test is proposed to assess the constancy of telencephalic natural frequencies, with variation in lateral hypothalamic damping.

Inference of a stable dispersion relation for electrocortical activity controlled by the lateral hypothalamus

A second test is undertaken for a theory of linear wave motion in electrocortical waves, under lateral hypothalamic control via regulation of damping. This test invokes a general property of linear systems, namely that wave motion with characteristic natural frequencies implies fixed phase velocities associated with each wavelength, independent of the changes in hypothalamic input. A means of testing the invariance of this dispersion relation at the point of recording is derived from a simplified biophysical model for waves in a dipole layer. The method avoids some problems implicit in direct spatio-temporal wave analysis. Results confirm that the model under test is internally consistent, and is also consistent with other findings concerning the origin and spatial nature of the EEG.

Schizophrenia in children under 16 years

Schizophrenic children admitted as inpatients to a child psychiatric unit over a 10-year period were reviewed in terms of demographic characteristics, clinical features, and social adaptation using the DSM-III as a frame of reference. Ten children who were first seen at least 1 year previously were followed up and reassessed as regards clinical status and level of adaptive functioning. As in other studies, outcome was related to age at onset, premorbid level of adaptation, rapidly of onset, clinical subtype, and presence of affective symptoms. However, deterioration following the active phase of the illness occurred in only four cases. The outcome in childhood schizophrenia may be more favorable than generally assumed, but there is a need for longer and larger studies of carefully diagnosed groups.

Self poisoning: who supplies the drugs? 100 examples

One hundred self-poisoners, consecutively referred to the psychiatric liaison service at Auckland Hospital were questioned regarding the source of the substances taken, the taking of regular medication and their last contact with a doctor. In total, 82 percent took legitimately prescribed medications, in 67 cases prescribed for themselves, while 12 percent bought over-the-counter preparations. Alcohol was associated in one-third of all cases. In one half of all cases the substance ingested had been prescribed at the last visit to a doctor. These patients were statistically more likely to be depressed, to be taking regular medication and to have taken a previous overdose. Two-thirds of all cases had seen a doctor no more than a month prior to self-poisoning.