Biomedical subjects
Publications and source records attributed to H G Pope.
Among 386 consecutive patients hospitalized for substance abuse, 15% of 143 women had a lifetime diagnosis of anorexia or bulimia nervosa, compared to only 1% of 243 men. Women with eating disorders had significantly higher rates of stimulant abuse and lower rates of opioid abuse than women without eating disorders.
We conducted a placebo-controlled, double-blind study of valproate, a drug originally developed as an antiepileptic, in 36 patients with acute manic episodes who had previously failed to respond to or to tolerate lithium carbonate. Treatment duration was 7 to 21 days, with no other psychotropic medications permitted except lorazepam up to 4 mg/d during the first 10 days of treatment. Serum valproate concentrations were measured three times weekly; an unblinded investigator then adjusted dosage to produce serum concentrations between 50 and 100 mg/L. Valproate proved superior to placebo in alleviating manic symptoms. The 17 patients randomized to active drug demonstrated a median 54% decrease in scores on the Young Mania Rating Scale as compared with a median 5.0% decrease among the 19 patients receiving placebo. On the 100-point Global Assessment Scale of overall psychiatric functioning, patients receiving valproate improved by a median of 20 points as compared with a zero-point change with placebo. Significant differences also emerged on the Brief Psychiatric Rating Scale and in the number of supplemental doses of lorazepam required by the patients in each group. Substantial antimanic effects appeared within 1 to 4 days of achieving therapeutic serum valproate concentrations. Adverse effects were infrequent, with no adverse effect appearing significantly more frequently with valproate than with placebo. We conclude that valproate represents a useful new drug for the treatment of manic patients.
A review of research on kleptomania--the syndrome of compulsive stealing--suggests that kleptomania may be a common disorder, especially among women, and that it may frequently be associated with other forms of psychopathology, such as mood, anxiety, and eating disorders. There appears to be a range of abnormal or non-antisocial stealing behaviours, all with impulsive and/or compulsive features. Kleptomania, as defined by modern criteria, may represent the most compulsive variant. Kleptomania may be related to mood disorder, and might be a form of 'affective spectrum disorder'.
OBJECTIVE: The authors' objective was to provide phenomenologic, family history, and treatment response data on a group of rigorously diagnosed patients with kleptomania. METHOD: Twenty consecutive inpatients and outpatients met DSM-III-R criteria for current kleptomania or a past history of kleptomania. These patients were given structured diagnostic interviews, and their family histories of psychiatric disorders were assessed blindly. The patients' responses to psychosocial and biological treatments were also assessed. RESULTS: All of the kleptomanic patients had lifetime diagnoses of major mood disorders, 16 had lifetime diagnoses of anxiety disorders, and 12 had lifetime diagnoses of eating disorders. A high morbid risk of major mood disorders (0.31) was found in their first-degree relatives. Ten of 18 patients receiving thymoleptic medications reported reduction or remission of their stealing behavior. CONCLUSIONS: Kleptomania may be related to major mood disorder and perhaps may represent another form of "affective spectrum disorder."
OBJECTIVE: The authors investigated trends in the frequency of neuroleptic malignant syndrome at their center over a period of 8 years and assessed possible reasons for these trends. METHOD: They used previously defined operational criteria in conducting a prospective survey of cases of the syndrome among 2,695 neuroleptic-treated patients from Oct. 1, 1986, to Aug. 31, 1990. The frequency of neuroleptic malignant syndrome during this period was then compared with the frequency in a comparable period prior to October 1986. The investigators also assessed changes between the two periods in risk factors associated with the syndrome, including patients' mean age, sex ratio, diagnoses, and severity of illness; neuroleptic dosage, potency, and route of administration; concomitant use of lithium; and degree of agitation. RESULTS: Four cases of neuroleptic malignant syndrome were diagnosed during the more recent 47-month survey period, yielding a frequency of 0.15% +/- 0.05%. This represents a significant decline in the frequency of the syndrome from the estimate of 1.10% +/- 0.40% for the earlier survey period. Significantly fewer patients in the recent period had received intramuscular doses of neuroleptics. CONCLUSIONS: The frequency of neuroleptic malignant syndrome has declined significantly at this center. The decline appears to be attributable to increasing clinical awareness of the features of the syndrome, allowing early intervention and treatment, and to a reduction in risk factors, such as use of intramuscular neuroleptics.
OBJECTIVE: Recent evidence suggests that a number of psychiatric and medical conditions may be members or candidate members of a larger family of conditions, which we have termed "affective spectrum disorder (ASD)." In order to facilitate further research into this concept, we drafted seven interview modules, using the format of the Structured Clinical Interview for DSM-III-R (SCID), designed to diagnose the following psychiatric and medical disorders: irritable bowel syndrome, narcolepsy, Tourette's disorder, migraine, fibromyalgia, chronic fatigue syndrome, and kleptomania. METHOD: Published operational diagnostic criteria for these seven disorders were sought in the literature. Questions in SCID format were then drafted in accordance with these operational criteria. Draft modules were then sent to experts familiar with each of the disorders and suggestions and revisions from these experts incorporated into the final modules. RESULTS: The complete supplemental interview is presented with this report. Preliminary experience with this interview in more than 100 patients tentatively suggests that it is reliable for diagnosing the disorders in question; however, a formal test-retest reliability assessment is still required. CONCLUSIONS: It is hoped that this supplemental interview, used in conjunction with the SCID, will be helpful in further studies of the epidemiology, pathogenesis, and treatment of these possible forms of affective spectrum disorder.
The authors obtained long-term follow-up data on 20 (91%) of the 22 patients who had experienced index episodes of neuroleptic malignant syndrome (NMS) at McLean Hospital between 1983 and 1990. Eleven of the 20 patients resumed neuroleptic treatment after the index episode and have now collectively received more than 16 years of neuroleptic exposure with no recurrences of the syndrome. Furthermore, 14 of the 20 patients had already collectively accumulated more than 71 additional years of neuroleptic exposure before their index episodes; only 1 had experienced a possible episode of NMS in the past. These findings suggest that NMS may not predictably develop even in predisposed individuals upon neuroleptic exposure and that additional cofactors must be present for the full syndrome to evolve.
Seventeen patients with acute mania were treated with the antiepileptic agent valproate under placebo-controlled, double-blind conditions for 7 to 21 days. No other psychotropics were allowed, except for lorazepam, up to 4 mg per day, as needed for agitation or insomnia for the first 10 study days only. Of the 17 patients, 12 (71%) showed some response, ranging from a 30 percent to a 100 percent decrease in scores on the Young Mania Rating Scale (MRS). The remaining 5 patients displayed no response to valproate treatment, with increases on the MRS of 3 percent to 13 percent. Compared with nonresponders, responders had an older age of onset and a shorter duration of illness and displayed a higher average serum valproate concentration on Study Days 3 through 6, but not on Study Day 15 or at termination. Degree of valproate response was greater for those patients with more severe sleep disruption at baseline. However, the majority of factors assessed, including a history of rapid cycling and high levels of dysphoria, were not associated with response to valproate.
BACKGROUND: Although growing research indicates that the atypical antipsychotic agent clozapine is effective in patients with schizophrenia, little is known about the efficacy of clozapine in patients with schizoaffective disorder or psychotic mood disorders. The purpose of this study was to assess whether or not clozapine is effective in some patients with schizoaffective disorder or psychotic mood disorders. METHOD: By surveying treating clinicians and chart data, we assessed treatment response in 85 consecutive patients, including 39 with schizophrenia, 25 with schizoaffective disorder, and 14 with bipolar disorder with psychotic features, who received clozapine for at least 6 weeks at our center. RESULTS: All patients were either inadequately responsive to or unable to tolerate standard somatic therapies. Compared to patients with schizophrenia, patients with schizoaffective disorder and bipolar disorder with psychotic features displayed significantly higher response rates to clozapine. CONCLUSION: Clozapine may be a useful drug in the treatment of patients with schizoaffective disorder or psychotic mood disorders who are treatment resistant or intolerant of side effects.
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The porcine stress syndrome is a genetic disorder of swine which, like neuroleptic malignant syndrome, is characterized by hyperthermia, muscle rigidity, and autonomic dysfunction. We investigated the porcine stress syndrome as a possible animal model for neuroleptic malignant syndrome in two ways. First, we administered haloperidol and lithium carbonate, alone and in combination, to susceptible and resistant swine. Second, we attempted to prevent the syndrome by pretreating animals with bromocriptine. Porcine stress syndrome was induced in 2 of 3 susceptible and 1 of 3 resistant swine by combined treatment with lithium and haloperidol, but was not triggered by treatment with lithium or haloperidol alone. Pretreatment with bromocriptine conferred no protection against the syndrome.
Previous studies of long-term serial changes in ventricular size in schizophrenia (SCZ) have yielded mixed, albeit predominantly negative results. The current study examined ventricular changes in CT scans over intervals of 1-to 4 1/2 years in chronic schizophrenic and bipolar patients. The results indicated significant progression of ventricular size from initial to final scan in the schizophrenia group but not in the bipolar or control groups; the percent increase in VBR over baseline was 25% (p less than 0.01) in the schizophrenia group as compared with 11% (n.s.) in the bipolar group. The increases in ventricular enlargement in the schizophrenic group did not correlate with duration of illness but did appear to show an irregular stepwise pattern in several patients. It is concluded that progressive ventricular enlargement after onset of illness does occur in a subgroup of schizophrenic patients characterized by a chronic or deteriorating clinical course. The etiological implications of this finding are discussed.
Lycanthropy, an unusual psychiatric syndrome involving the delusion of being an animal, usually occurs as a transient symptom of severe psychosis. A review of the historical and modern medical literature, as well as of contemporary anthropological reports, suggests multiple etiologies for lycanthropy, including seizure disorders and use of psychotomimetic drugs. A clinical illustration is presented in which the delusion of being an animal in human form has persisted for over 15 years and has been refractory to treatment. The authors speculate that disturbances of self-identity may combine with neurological abnormalities to produce some cases of this syndrome.
Response to pharmacologic treatments may identify groups of disorders with a common pathophysiology. The authors applied a treatment-response model, based on four classes of antidepressants (tricyclic types, monoamine oxidase inhibitors, serotonin uptake inhibitors, and atypical agents), to the medical literature. The model identified eight disorders that may share a pathophysiologic abnormality: major depression, bulimia, panic disorder, obsessive-compulsive disorder, attention deficit disorder with hyperactivity, cataplexy, migraine, and irritable bowel syndrome. Phenomenologic and family studies support this grouping. If the model is validated, this family of disorders, which the authors term "affective spectrum disorder," would represent one of the most prevalent diseases in the population.
The authors conducted anonymous questionnaire studies of drug use and life style among college seniors at the same institution in 1969, 1978, and 1989. The 1989 group of students reported strikingly lower frequencies of virtually all forms of drug use than their counterparts in 1969 and 1978. As in 1969 and 1978, the drug users among the 1989 group were indistinguishable from nonusers in grades, athletic activities, other college activities, and feelings of alienation. Only visits to a psychiatrist and sexual activity distinguished users from nonusers.
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The authors describe three men, all with benign premorbid psychiatric histories, no evidence of antisocial personality disorder, and no history of violence, who impulsively committed violent crimes--including murder--while taking anabolic steroids. Structured psychiatric interviews of each man suggested that steroids played a necessary, if not primary, role in the etiology of the violent behavior. Although the men conceivably might have exaggerated their reports of the effects of steroids in the hopes of improving their legal positions, information from external sources consistently corroborated their accounts in each case. These observations raise the possibility that steroid-induced violence may pose a little-recognized public health problem.
During the course of a family-interview study of probands with psychotic disorders, the authors encountered two pedigrees in which schizophrenic individuals had first-degree relatives with bipolar disorder. The authors describe the members of both families in detail and discuss several hypotheses that might account for the co-occurrence of schizophrenia and bipolar disorder in the same family.