Biomedical subjects
Publications and source records attributed to David J Castle.
BDD remains an understudied psychiatric disorder. Further research is required to establish its etiopathology and neurocognitive underpinnings. Its relationship to other psychiatric disorders requires clarification. Also needed is a much better understanding of the best treatments to adopt should conventional approaches (eg, SRIs, CBT) fail.
OBJECTIVE: To explore critically whether there is a robust basis for the concept of an obsessive-compulsive (OC) spectrum of disorders, and if so, which disorders should be included. METHOD: Selective literature review concentrating on three proposed members of the OC spectrum, namely body dysmorphic disorder, hypochondriasis and trichotillomania. RESULTS: Obsessive-compulsive disorder (OCD) itself is a heterogeneous condition or group of conditions, and this needs to be appreciated in any articulation of a 'spectrum' of OC disorders. The basis for 'membership' of the spectrum is inconsistent and varied, with varying level of support for inclusion in the putative spectrum. CONCLUSION: A more fruitful approach may be to consider behaviours and dimensions in OCD and OC spectrum disorders, and that this should be encompassed in further developments of the OC spectrum model.
PURPOSE OF REVIEW: The present review provides an update on current research into body dysmorphic disorder. RECENT FINDINGS: Recent findings can be considered under four groupings: the classification of body dysmorphic disorder, its current inclusion under the somatoform disorders, and its relationship to obsessive compulsive disorder and other obsessive compulsive spectrum disorders; the psychotic 'variant' of body dysmorphic disorder, and whether it is simply a more severe form of the nonpsychotic type; the cognitive aspects of body dysmorphic disorder; and the treatment of body dysmorphic disorder, both in terms of pharmacological and psychological parameters. SUMMARY: Body dysmorphic disorder does not sit comfortably in the somatoform disorder category, and there is a good case for it being considered part of the obsessive compulsive spectrum, although it is not merely a subtype of obsessive compulsive disorder. Insight into the illness suggests that it represents a spectrum of disorders, and a categorical delineation of 'psychotic' and 'nonpsychotic' variants cannot be supported. We are beginning to understand more about the neurocognitive aspects of body dysmorphic disorder, but more research is required to assess which deficits/aberrations (if any) are exclusive to body dysmorphic disorder as an entity, and which are a reflection of broader phenomenological manifestations. Finally, the mainstay of treatment for body dysmorphic disorder remains behaviour/cognitive behaviour therapy and serotonin reuptake inhibitors; much more work is required to identify effective interventions for those patients who fail to respond to these treatment modalities.
STUDY OBJECTIVE: We compare intravenous midazolam and droperidol for the onset of sedation of acutely agitated patients in the emergency department (ED). METHODS: This was a double-blind, randomized, clinical trial set in the ED of a university teaching hospital. Subjects were adults, acutely agitated because of mental illness, intoxication, or both, who received midazolam or droperidol, 5 mg intravenously, every 5 minutes until sedated. We analyzed time to sedation using survival analysis, median times to sedation, and proportions sedated at 5 and 10 minutes. RESULTS: Seventy-four patients received midazolam; 79 patients, droperidol. Survival analysis showed no difference in time to sedation (hazard ratio 0.86; 95% confidence interval [CI] 0.61 to 1.23), P=.42. Median time to sedation was 6.5 minutes for midazolam (median dose 5 mg) and 8 minutes for droperidol (median dose 10 mg), P=.075 (effect size 1.5 minutes; 95% CI 0 to 4 minutes). At 5 minutes, 33 of 74 (44.6%) patients from the midazolam group were adequately sedated compared with 13 of 79 (16.5%) patients from the droperidol group, a difference of 28.1% (95% CI 12.9% to 43.4%; P<.001). By 10 minutes, 41 of 74 (55.4%) from the midazolam group were sedated compared to 42 of 79 (53.2%) from droperidol, a difference of 2.2% (95% CI -14.9% to 19.3%; P=.91). Eleven adverse events occurred in the midazolam group and 10 in the droperidol group. Three patients required active airway management (3 patients with assisted ventilation and 1 patient intubated); all received midazolam. CONCLUSION: There is no difference in onset of adequate sedation of agitated patients using midazolam or droperidol. Patients sedated with midazolam may have an increased need for active airway management.
OBJECTIVE: To review the role of antipsychotic medications in the treatment of obsessive-compulsive disorder (OCD); to explore current hypothesized conceptualizations of their mechanism of action; to highlight evolving interest in the validation of meaningful OCD subtypes within a heterogeneous spectrum of OCD, based on treatment response and other psychobiological variables. METHOD: A computerized literature search (MEDLINE: 1966 to December 2003, EMBASE: 1982 to December 2003) was used to locate relevant literature, using the terms obsessive-compulsive, antipsychotic and subtypes, with no restrictions imposed on searches. RESULTS: Earlier studies of augmentation of serotonergic antidepressants (SRIs) with typical antipsychotics including haloperidol and pimozide in OCD demonstrated favourable responses, also highlighting patient subgroups with robust treatment response. Studies examining augmentation with atypical agents are emerging. SRI-resistant OCD patients are likely to benefit from augmentation with atypical antipsychotics in around 50% of cases. CONCLUSIONS: While there is little role for antipsychotic monotherapy in OCD, there is growing evidence in support of adjunctive antipsychotics in OCD refractory to serotonin-reuptake inhibitors (SRIs). Further controlled trials are warranted. Particular subgroups of OCD patients, notably those with comorbid tic disorder and those with schizotypal personality disorder, have been shown to respond more robustly to augmentation strategies in some trials of both typical and atypical antipsychotics. Dopaminergic mediation with or without a moderating effect on serotonergic systems is likely to be important in the pharmacodynamic mechanisms of action of antipsychotic-SRI combinations in OCD.
A review of the relevant published literature regarding disorders of thermoregulation in people with schizophrenia was undertaken. This entailed a search of the Medline and PsychINFO databases to 28th May 2003 using the search terms "schizophrenia and thermoregulation" and "schizophrenia and temperature". The relevant articles as well as secondary references were reviewed. It has generally been shown that, when compared with controls, people with schizophrenia exhibit dysregulation of body temperature including different baseline temperatures; abnormal daily range of temperatures and diurnal variation showing an earlier peak; an impaired ability to compensate to heat stress; and compensating more effectively to cold stress. This may be intrinsic to the syndrome of schizophrenia but is potentially confounded by the administration of neuroleptic medication. The underlying cause is likely to be a combination of "peripheral" and "central" mechanisms of thermoregulation. Further study is required to delineate clearly the quality and magnitude of the temperature dysregulation as well as elucidating its mechanism(s). This could further our understanding of the mechanism underlying the syndrome of schizophrenia.
The authors reviewed the literature on psychological and psychosocial outcomes for individuals undergoing cosmetic surgery, to address whether elective cosmetic procedures improve psychological well-being and psychosocial functioning and whether there are identifiable predictors of an unsatisfactory psychological outcome. They conducted a search of appropriate computerized databases for studies that evaluated psychological and psychosocial status both before and after elective cosmetic surgery. They identified 37 relevant studies of varying cosmetic procedures that utilized disparate methodologies. Overall, patients appeared generally satisfied with the outcome of their procedures, although some exhibited transient and some exhibited longer-lasting psychological disturbance. Factors associated with poor psychosocial outcome included being young, being male, having unrealistic expectations of the procedure, previous unsatisfactory cosmetic surgery, minimal deformity, motivation based on relationship issues, and a history of depression, anxiety, or personality disorder. Body dysmorphic disorder was also recognized by some studies as a predictor of poor outcome, a finding reinforced by reference to the psychiatric literature. The authors conclude that although most people appear satisfied with the outcome of cosmetic surgical procedures, some are not, and attempts should be made to screen for such individuals in cosmetic surgery settings.
OBJECTIVE: To determine the clinical correlates of dysmorphic concern in persons seeking cosmetic enhancement from cosmetic physicians. METHOD: A questionnaire survey of 137 patients attending the practices of two cosmetic physicians. RESULTS: Four subjects (2.9%; 95% CI = 0.8%-7.3%) had a diagnosis of body dysmorphic disorder (BDD), but many more expressed overconcern with physical appearance ('dysmorphic concern'). Dysmorphic concern accounted for a substantial amount of the variance for mood, social anxiety, and impairment in work and social functioning, while concerns related to how self or others perceive the putative flaw in appearance, impacted significantly on work and leisure activities, but did not apparently influence mood and social anxiety to any significant degree. CONCLUSIONS: Dysmorphic concern is a broad dimensional construct that is related to both inter- and intrapsychic distress and disablement associated with people seeking cosmetic enhancement
Body dysmorphic disorder (BDD) is relatively common in cosmetic practise, yet it remains under-recognized. BDD patients are unnaturally concerned with minimal or non-existent flaws, most commonly in the skin (e.g. facial acne or scarring) and hair (e.g. hair loss). Many patients develop social avoidance and suffer occupational or academic impairment. More severely ill patients may become housebound or even attempt suicide. Despite the minimal or non-existent nature of the perceived appearance flaws, patients with BDD may request dermatological treatments such as isotretinoin or dermabrasion. Although treatment outcome has received little investigation, it appears that most patients are dissatisfied with dermatological treatment and, even if the outcome is objectively acceptable, they do not worry any the less about their appearance afterwards. In contrast, a majority of patients respond to serotonin reuptake inhibitors or cognitive behavioural therapy. Treatment of these patients is best given by an experienced health professional. This may be a mental health professional or a dermatologist with an interest in psychological medicine.
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Pharmacological treatment remains the mainstay of the management of schizophrenia. Older, "typical" antipsychotics carry a significant burden of side effects, notably extrapyramidal and neurocognitive side effects. Newer, "atypical" agents carry a lower risk of extrapyramidal side effects. They appear to have added benefit for treating negative and cognitive symptoms of schizophrenia, and hence can enhance the quality of life of some patients. The choice of particular agents for individual patients requires a balancing of efficacy and side effects. Medication is only one element of what should be an individualised comprehensive treatment plan for people with schizophrenia.
OBJECTIVE: We describe a system of outcome evaluation for early psychosis programmes and present preliminary data. The Early Psychosis Outcome Evaluation System (EPOES) was designed for use in a naturalistic, prospective study of a cohort of early-episode psychosis patients. We describe patients in terms of symptoms, substance use, social functioning and family burden, and examine the effectiveness of treatment programmes. METHOD: Four sites in Perth, Western Australia, participated. Outcome was evaluated from three sources: case manager (CM), patient (P) and family member (FM). Seven clinical outcome measures were used: the Brief Psychiatric Rating Scale (CM), Brief Symptom Inventory (P), Substance Use (CM); Social Functioning Scale (P); Global Assessment Scale (CM); Burden Assessment Scale (FM), and the General Health Questionnaire-12 (FM). Measures were collected at intake (baseline) into a specialist early psychosis service and thereafter every 6 months until discharge from the service. RESULTS: After the first year of data capture, 84 baseline assessments have been completed, and 23 patients have been followed up at 6 months. Clinicians and patients reported significantly less psychopathology at 6 months. Sixty per cent of patients reported marijuana use within 3 months of baseline assessment, and 30% amphetamine, ecstasy or cocaine use. Increased levels of psychopathology were recorded for substance-using patients. Family members (59%) reported psychological distress at baseline; this was reduced at 6 months. Patient social functioning and family burden did not improve measurably. CONCLUSIONS: The EPOES is an effective system that provides feedback on the clinical status of early-episode psychosis patients. Both observed and self-rated psycho-pathology and family psychological distress, is improved after 6 months of intervention. Family burden and patient social functioning did not demonstrate improvement. Patient social functioning is an important area for treatment. Substance use is associated with poorer psychopathology. EPOES provides a feasible system of measuring outcome in early psychosis intervention.
Olanzapine is an atypical antipsychotic effective in the treatment of schizophrenia. The present study has examined the potential use of target concentration monitoring of olanzapine in plasma as a marker of clinical response and an aid in patient management. Fifty-three patients (mean age 32 years; 40 M, 13 F) with a DSM-IVR diagnosis of schizophrenia completed a 6-week trial of oral olanzapine. Participants received once-daily olanzapine, and their psychotic symptoms were measured with the PANSS (Positive and Negative Symptom Scale) on admission and again after 6 weeks. Responders were classified as having a >/=20% decrease in PANSS scores. Plasma olanzapine was quantified by high-performance liquid chromatography. Receiver operator characteristic (ROC) curve analysis was used to identify a break point in plasma olanzapine that might serve as a surrogate for PANSS classification, and the two methods were compared using the McNemar chi2 test. After 6 weeks the median olanzapine dose was 15 mg/d (range 5-30 mg/d), and the mean plasma olanzapine was 32 micrograms/L at a mean of 13.5 hours after dose. With the PANSS (total), there were 42 responders and 11 nonresponders. ROC curve analysis for total PANSS identified a break point at 23 micrograms/L plasma olanzapine, with the proportions of responders and nonresponders identified by PANSS and the plasma break point being similar. Similar break points were found for the positive, negative, and global PANSS subscores. Nevertheless, these relationships were very modest, and at best the target plasma olanzapine concentration identified only 20% more responders than nonresponders. We suggest that plasma olanzapine monitoring can be used for dose-response optimization, but only to complement the normal clinical evaluation process.
Therapeutic drug monitoring (TDM) is frequently utilized in the treatment of psychiatric conditions, but its clinical application concerning the use of clozapine is unclear. We present three case reports of patients taking clozapine, review the relevant literature, and propose guidelines to aid the clinical use of TDM of clozapine. Due to its complex metabolism, there are significant inter- and intra-individual variations in clozapine serum levels, for a given dose. However, the range of serum levels that corresponds with toxicity remains unclear. Although central nervous system side-effects may correlate with serum level, many adverse effects of clozapine appear to be unrelated, including haematological and cardiac events. There are numerous clinically significant interactions between clozapine and other substances, including prescribed medications, nicotine and caffeine. TDM of clozapine may be of clinical value in certain situations, such as poor clinical response; signs of toxicity; onset of seizures; changes in concurrent medication, caffeine or nicotine; liver disease; and suspected non-compliance. The current literature does not support the routine testing of serum clozapine levels in everyday clinical practice.
BACKGROUND: Body dysmorphic disorder (BDD) is a distressing and impairing illness characterised by an intense time consuming preoccupation with an imagined or slight defect in appearance of a body part or parts. OBJECTIVE: This article outlines the characteristic features and treatment approaches for BDD and suggests screening techniques that can be usefully applied in the general practice setting. DISCUSSION: Body dysmorphic disorder has been shown to be common and chronic yet goes under recognised as the patient is often secretive about their distress. In an endeavour to alleviate the distress, time consuming rituals are performed that are either without effect or paradoxically may exacerbate the distress. Recent treatment studies show that the selective serotonin reuptake inhibitors and cognitive behavioural therapy, used simultaneously or alone, can be beneficial in alleviating the distress and impairment associated with the condition.
Both men and women are becoming increasingly concerned about their physical appearance and are seeking cosmetic enhancement. Most studies report that people are generally happy with the outcome of cosmetic procedures, but little rigorous evaluation has been done. More extensive ("type change") procedures (eg, rhinoplasty) appear to require greater psychological adjustment by the patient than "restorative" procedures (eg, face-lift). Patients who have unrealistic expectations of outcome are more likely to be dissatisfied with cosmetic procedures. Some people are never satisfied with cosmetic interventions, despite good procedural outcomes. Some of these have a psychiatric disorder called "body dysmorphic disorder".
Gender differences in premorbid adjustment, clinical presentation, and longitudinal course have been considered increasingly in explanatory models of psychotic disorders, such as the schizophrenias. Indeed, findings of a male propensity to poor premorbid adjustment, negative and non-affective symptoms, and poor outcome relative to their female counterparts, has led to suggestions that males are more prone to an early-onset dementia praecox type of schizophrenic disorder. The current study investigated a sample of 38 male and 20 female patients presenting with their first episode of psychosis (broadly defined, but excluding obvious drug-induced disorders) from a defined catchment area population, which had been systematically ascertained without prejudice to diagnostic subtype or illness duration. The study investigated gender, diagnosis and interaction of gender and diagnosis on differences within the three developmental age categories of childhood, early adolescence and late adolescence, to identify where, within these age categories, differences lie. The second part of the study was to investigate the relationship between premorbid adjustment, gender, and psychopathology as measured by the PANSS and SCL-90. General linear modelling revealed that males were reported to have had poorer premorbid adjustment in late adolescence when compared to females, notably in items examining school performance, adaptation to school, social interests and sociosexual development. Males were observed to have higher levels of negative symptoms but not for positive or general symptoms on the PANSS. This finding is independent from the effect of diagnosis or of the interaction effect between gender and diagnosis on premorbid adjustment. There were no gender effects for the self reported global indices on the SCL-90. The results suggest that in comparison with their female counterparts, males who develop a psychotic illness have significantly poorer premorbid adjustment at the late adolescent stage and that this may contribute to higher levels of negative symptoms.