Case study: worsening Tourette's disorder or withdrawal dystonia?

This case report focuses on withdrawal dystonia, a movement disorder associated with neuroleptics. Its occurrence in a patient with Tourette's disorder complicated the clinical picture. A misinterpretation of the symptoms led to ineffective management of the movement disorder. The presence of increased blinking with facial pain, dystonic movements, and other facial movements at each neuroleptic dose reduction pointed toward withdrawal dystonia rather than toward a worsening of Tourette's disorder. Implications for diagnosis and treatment are discussed.     

Serotonin syndrome: case report and review of the literature

We present the case of a 35-year-old woman who developed serotonin syndrome after receiving a single dose of the cyclic antidepressant imipramine (Tofranil). She was already being treated for depression with paroxetine (Paxil), a selective serotonin reuptake inhibitor. Two hours after receiving imipramine, the patient developed tachycardia, delirium, bizarre movements, and myoclonus, all classic findings of serotonin syndrome. Her antidepressants were discontinued and she was treated with intravenous fluids, sedation, and a short course of cyproheptadine, a serotonin receptor antagonist. All symptoms resolved completely within 24 hours. In this case report, we review the drug interactions that can precipitate serotonin syndrome, and give recommendations for the diagnosis and treatment of this potentially fatal disorder.     

Benzodiazepines and exposure-based cognitive behavior therapies for panic disorder: conclusions from combined treatment trials

OBJECTIVE: Concurrent use of benzodiazepines and psychotherapy for panic disorder is a prevalent but highly controversial practice. Although there are many rationales for that approach, critics contend that benzodiazepines foster drug abuse and dependence and undermine psychosocial treatments in various ways. The authors examine that controversy in the light of recent empirical findings and offer some tentative conclusions and recommendations. METHOD: Data from studies combining benzodiazepines and the leading psychosocial treatment for panic disorder, exposure-based cognitive behavior therapy, are reviewed, and their application to clinical practice is discussed. RESULTS: The strongest support for combined treatment is for the addition of cognitive behavior therapy to pharmacotherapy for patients with agoraphobia and for those whose benzodiazepine treatment is being discontinued. The greatest problem with combined treatment is relapse after drug discontinuance. CONCLUSIONS: Combined treatment may be advantageous for some patients, but it must be carefully designed to avoid potential problems. Suggestions for that are given.     

Use of eye movement to reduce stress after trauma

In 1987 an accidental discovery revealed an association between certain eye movements and reduced levels of distress resulting from traumatic memories. The result was a new psychological intervention, eye movement desensitisation and reprocessing (EMDR). The treatment consists of generating rapid and rhythmic eye movements while simultaneously holding traumatic images, thoughts and emotions in the active memory. This paper describes the experiences of one psychotherapist in using EMDR to treat people with post-traumatic stress disorder. Six case studies illustrate aspects of this complex treatment.     

Bilateral eye movements enhance the retrieval of episodic memories.

Two experiments examining effects of eye movements on episodic memory retrieval are reported. Thirty seconds of horizontal saccadic eye movements (but not smooth pursuit or vertical eye movements) preceding testing resulted in selective enhancement of episodic memory retrieval for laboratory (Experiment 1) and everyday (Experiment 2) events. Eye movements had no effects on implicit memory. Eye movements were also associated with more conservative response biases relative to a no eye movement condition. Episodic memory improvement induced by bilateral eye movements is hypothesized to reflect enhanced interhemispheric interaction, which is associated with superior episodic memory (S. D. Christman & R. E. Propper. 2001). Implications for neuropsychological mechanisms underlying eye movement desensitization and reprocessing (F. Shapiro, 1989, 2001), a therapeutic technique for posttraumatic stress disorder, are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Eye movement desensitization and reprocessing (EMDR): A meta-analysis.

Eye movement desensitization and reprocessing (EMDR), a controversial treatment suggested for posttraumatic stress disorder (PTSD) and other conditions, was evaluated in a meta-analysis of 34 studies that examined EMDR with a variety of populations and measures. Process and outcome measures were examined separately, and EMDR showed an effect on both when compared with no treatment and with therapies not using exposure to anxiety-provoking stimuli and in pre–post EMDR comparisons. However, no significant effect was found when EMDR was compared with other exposure techniques. No incremental effect of eye movements was noted when EMDR was compared with the same procedure without them. R. J. DeRubeis and P. Crits-Christoph (1998) noted that EMDR is a potentially effective treatment for noncombat PTSD, but studies that examined such patient groups did not give clear support to this. In sum, EMDR appears to be no more effective than other exposure techniques, and evidence suggests that the eye movements integral to the treatment, and to its name, are unnecessary. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Addiction is a brain disease, and it matters

Scientific advances over the past 20 years have shown that drug addiction is a chronic, relapsing disease that results from the prolonged effects of drugs on the brain. As with many other brain diseases, addiction has embedded behavioral and social-context aspects that are important parts of the disorder itself. Therefore, the most effective treatment approaches will include biological, behavioral, and social-context components. Recognizing addiction as a chronic, relapsing brain disorder characterized by compulsive drug seeking and use can impact society's overall health and social policy strategies and help diminish the health and social costs associated with drug abuse and addiction.     

CD4+ T lymphocytes contribute to protective immunity induced in sheep and goats by Haemonchus contortus gut antigens

"Freezing" is a sudden, unforeseen state of immobility occurring independently of L-Dopa dosage timing and often presents in connection with walking, speech and hand movements. The immobility results from deficits in initiating or simultaneously and sequentially executing movements, in correcting inappropriate movements or planning movements. However, since the progression of motor activity is strongly dependent upon external stimuli, the patient can overcome the freezing phenomena with the aid of certain stimuli or subjective strategies. No consistent relationships have been found with respect to age, length of illness, L-dopa dosis or L-dopa treatment. Neurotransmitter models to explain the freezing phenomena are: a noradrenalin deficiency in locus coeruleus or alternately a dopamine deficiency in substantia nigra, pars compacta, which can possibly be coupled with a GABA deficiency in substantia nigra, pars reticulata. In addition to optimal drug therapy, patients require physiotherapeutical and ergotherapeutical assistance to develop subjectively effective strategies in counteracting freezing during everyday activities.     

Development of essential thrombocythemia in a patient treated with interferon alfa and pentostatin for hairy cell leukemia

A patient is reported who developed essential thrombocythemia after successful treatment for hairy cell leukemia. He was initially treated with interferon alfa and subsequently relapsed within one year of treatment. His diagnosis was reconfirmed and then treated with Pentostatin. Six years after treatment he had a progressive increase in the platelet count and was diagnosed as essential thrombocythemia. Second cancers including various types of hematological malignancy have been reported in patients with hairy cell leukemia treated with chemotherapy or interferon alfa. These malignancies may represent either a new clonal disorder or a complication of drug treatment. This is the first report of a chronic myeloproliferative disorder following successful treatment of hairy cell leukemia.     

Periodic limb movement disorder and restless legs syndrome in children with attention-deficit hyperactivity disorder

Sleep disruption can lead to symptoms of attention-deficit hyperactivity disorder (ADHD) in children. Since periodic limb movement disorder and/or restless legs syndrome can cause sleep disruption, we assessed whether these two specific sleep disorders are likely to occur in children with ADHD. We asked a series of 69 consecutive parents of children with ADHD questions about the symptoms of periodic limb movement disorder. Based on a positive response to these periodic limb movement disorder queries, 27 children underwent all-night polysomnography. Eighteen children (aged 2 to 15 years) of the 27 (26% of the 69 children with ADHD) had 5 or more periodic leg movements in sleep per hour of sleep and had complaints of sleep disruption, thus fulfilling the criteria for periodic limb movement disorder. A comparably age- and sex-matched group of children referred to a sleep laboratory for sleep complaints but without ADHD showed only a 5% prevalence (2 of 38 subjects) of periodic leg movements in sleep (P=.017). Eight of the 18 children with ADHD and periodic limb movement disorder and one of the two control patients with periodic limb movement disorder had both a personal and parental history of restless legs syndrome symptomatology. This study further documents the occurrence of periodic limb movement disorder and restless legs syndrome in children and is the first large-scale study establishing a possible comorbidity between ADHD and periodic limb movement disorder. We propose that the sleep disruption associated with periodic limb movement disorder and restless legs syndrome and the motor restlessness of restless legs syndrome while awake could contribute to the inattention and hyperactivity seen in a subgroup of ADHD-diagnosed children.     

High risk for children with DAMP/ADHD to become addicts later in life

The prevalence of attention deficit hyperactivity disorder (ADHD) and of the overlapping condition, deficit in attention, motor control and perception (DAMP), among children of early school age is approximately 5 per cent (1.5% being severe cases). Boys are more commonly affected than girls. The symptoms continue to be disabling at 20 years of age in 50 per cent of cases, and social maladjustment is common. Half of the young boys develop oppositional defiant disorder (ODD), very often progressing to conduct disorder (CD) and antisocial personality disorder (ASPD). Low socio-economic status, parental mental disorder, and persistence of DAMP/ADHD symptoms are all predictors of the development of CD/ASPD. Prospective studies of children with DAMP/ADHD have shown them to be characterised by a high level of alcohol and/or drug abuse comorbidity, particularly the subgroup progressing to CD/ASPD. Conversely, studies of drug abuse and of alcohol abuse series have shown them to be characterised by a high level of DAMP/ADHD comorbidity. Approximately one in five alcoholics has or has had DAMP/ADHD, a comorbidity probably even more pronounced among type II alcoholics. Approximately every third substance-abuser has or has had DAMP/ADHD. The need of more persevering support and treatment efforts for the well-defined category of boys at high risk is emphasised. Better awareness, active diagnosis and treatment of adults with persisting DAMP/ADHD is also warranted.     

Integrative Borderline Adolescent Family Therapy: Meeting the Challenges of Treating Adolescents With Borderline Personality Disorder.

With the growing acceptance of the borderline personality disorder diagnosis for adolescents has come a need for specialized treatments for this challenging population. Further, because of the prominence of the family system during early and later adolescence, family treatments are particularly needed. The purpose of this article is to present the integrative borderline adolescent family therapy (I-BAFT) model that emerged from a National Institute on Drug Abuse-funded (Stage 1) treatment development and enhancement effort. I-BAFT integrates (a) key interventions from the family treatment of adolescent drug abuse (D. A. Santisteban et al., 2003; J. Szapocznik & W. Kurtines, 1989), (b) skills training shown effective with adults with borderline personality disorder (M. Linehan, 1993a) and adapted for adolescents, and (c) individual treatment interventions that promote motivation for treatment and enhance the integration of the 3 treatment components. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacologic management of depression in the elderly

Depression, the most common geriatric psychiatric disorder, is a disabling mood disorder that impairs one's well-being and may even threaten a sufferer's life. Severely depressed elderly persons are more likely to kill themselves than individuals in any other age group. However, geriatric depression is, for the most part, a treatable and manageable illness. Antidepressant medication can be very effective in treating major depressive disorder (MDD). Because age-related physical changes in the elderly produce pharmacokinetics that are often different than that experienced by younger adults, different doses are often necessary. This article summarizes recommendations for selecting and initiating appropriate antidepressant therapy in elderly persons suffering from MDD. The benefits and drawbacks of tricyclic antidepressant agents, and other atypical antidepressant agents are discussed. Phases of treatment, drug selection, dosing, and educational tips for pharmacotherapy are presented.     

An increase in basal glucocorticoid concentration with age induces suppressor macrophages with high-density Fc gamma RII/III

BACKGROUND: The diagnosis of Tourette syndrome may be overlooked in patients with severe psychopathologic disorder but mild motor manifestations of Tourette syndrome. OBJECTIVE: To describe 4 patients with long-lasting general psychopathologic disorder and previously unrecognized mild motor and phonic tics exacerbated during adulthood by the onset of tremor; all of the patients had been referred for the evaluation of psychogenic tremor. SUBJECTS: Four adult patients, with previous psychiatric diagnoses of depression (2 cases), generalized anxiety disorder (3 cases), malingering (1 case), and conversion disorder (3 cases). METHODS: Single case studies. RESULTS: Clinical interviews disclosed that the 4 patients had positive family histories of Tourette syndrome, and all had mild motor and phonic tics that had started before the age of 18 years. On neurologic examination, 2 patients had bilateral postural tremor of the hands that varied in frequency, rhythmicity, and amplitude, and the other 2 had resting tremor mimicking parkinsonism. All 4 patients described involuntary somatic sensations of the affected limbs, which they attempted to alleviate by executing movements. No consistent positive placebo response was observed, but in all patients tremoric movements improved with haloperidol. CONCLUSIONS: These cases illustrate an unusual movement disorder (tremor as a "tic equivalent") in adults with Tourette syndrome and emphasize that cases of the syndrome with mild tics often go unrecognized, precluding adequate treatment.     

Limb-shaking carotid transient ischemic attacks successfully treated with modification of the antihypertensive regimen

Involuntary episodic movements associated with transient cerebral ischemia are a rare but well-described presentation of carotid artery occlusive disease. We describe a young man with a left carotid artery occlusion who presented with daily episodes of involuntary movements of the right side that occurred for months. His symptoms virtually disappeared after his antihypertensive drug was reduced. This case supports the possibility of noninvasive management of this condition, which is traditionally treated with revascularization procedures.     

New minimal substrate structural requirements in the enzymatic peroxidation of alkenes with soybean lipoxygenase

A longitudinal study was conducted to investigate the association between human immunodeficiency virus (HIV) infection, history of major depressive disorder (MDD), and persistent or recurrent MDD among intravenous drug users. Psychiatric disorders were assessed in a sample of HIV-positive (HIV+) and HIV-negative (HIV-) intravenous drug users every 6 months for 3 years. Results indicated that HIV status and baseline MDD independently predicted persistent or recurrent episodes of MDD after gender, drug use, ethnicity, income, and the presence other psychiatric disorders were controlled statistically. Among HIV+ intravenous drug users with baseline MDD, 90% experienced at least one subsequent episode of MDD and 47% experienced at least three subsequent episodes of MDD. However, less than 40% of intravenous drug users with current MDD received treatment for emotional problems. These findings indicate that intravenous drug users with HIV infection and a history of MDD are at considerable risk for future episodes of MDD or recurrent MDD, and that increased provision of treatment for intravenous drug users with MDD may be necessary.     

Acute anxiety and its therapy

Acute anxiety is a quite common event for a general practitioner to solve. Anxiety could be of a various ethiology and the treatment should be based on the ethiology. It is important to differentiate panic attacks from general anxiety so as panic disorder treatment differs specifically. The drug of choice for parenteral application for acute anxiety seems to be diazepam in the Czech republic conditions and the most convenient drug for oral administration is alprazolam.     

Eye-movement desensitisation. Symptom change in post-traumatic stress disorder

A novel approach is described for the treatment of post-traumatic stress disorder (PTSD). Eye-movement desensitisation (EMD) requires the patient to generate images of the trauma in the mind and define physiological and emotional arousal states. While concentrating on these states, lateral multisaccardic eye movements are induced. Ten consecutive cases are reported who presented with symptoms originating from a range of traumas. The effectiveness of EMD in reducing symptoms outlined by DSM-III-R is described. An independent rater indicated that eight of the ten cases showed considerable improvement in PTSD symptoms following EMD, which was maintained at follow-up. Particular reference is given to the 'specificity' of EMD in treating symptoms and the changing pattern of effect at follow-up.