Implementation and evaluation of a liberalized visiting policy

A total of 21 recovered bipolar patients on prophylactic treatment were prospectively followed up for a period of 1 year. Data for major recurrences were retrospectively collected for an additional 3-year period. During the entire 4-year period, over half of the patients (52%) had no major affective recurrences. Eight patients experienced a major depressive episode, while only two experienced a manic one. Psychosocial and clinical variables were assessed at entry to the study. The effect of these variables on the subsequent 4-year illness course was analysed using survivorship curves. The results show that the following psychosocial variables significantly predicted the occurrence of a major affective episode: low level of social support, maladjustment in social and leisure activities, and poor quality of relationships with extended family. In contrast, clinical variables which characterize illness history were not significantly associated with major recurrences.     

Effect of arginine vasopressin (AVP) inhibitor in the inhibition of the peritumoral edema

BACKGROUND: Major depressive disorder is often marked by repeated episodes of depression. We describe recovery from major depression across multiple mood episodes in patients with unipolar major depression at intake and examine the association of sociodemographic and clinical variables with duration of illness. METHODS: A cohort of 258 subjects treated for unipolar major depressive disorder was followed up prospectively for 10 years as part of the Collaborative Depression Study, a multicenter naturalistic study of the mood disorders. Diagnoses were made according to the Research Diagnostic Criteria, and the course of illness was assessed with the Longitudinal Interval Follow-up Evaluation. Survival analyses were used to calculate the duration of illness for the first 5 recurrent mood episodes after recovery from the index episode. RESULTS: Diagnosis remained unipolar major depressive disorder for 235 subjects (91%). The median duration of illness was 22 weeks for the first recurrent mood episode, 20 weeks for the second, 21 weeks for the third, and 19 weeks for the fourth and fifth recurrent mood episodes; the 95% confidence intervals were highly consistent. From one episode to the next, the proportion of subjects who recovered by any one time point was similar. For subjects with 2 or more recoveries, the consistency of duration of illness from one recovery to the next was low to moderate. None of the sociodemographic or clinical variables consistently predicted duration of illness. CONCLUSION: In this sample of patients treated at tertiary care centers for major depressive disorder, the duration of recurrent mood episodes was relatively uniform and averaged approximately 20 weeks.     

Demographics, family history, premorbid functioning, developmental characteristics, and course of patients with deteriorated affective disorder

OBJECTIVE: This exploratory study examined the characteristics of a group of unusual and previously undescribed patients with major affective disorder who not only had been continuously symptomatic for prolonged periods of time but were also so functionally impaired that they required years of continuous care in psychiatric facilities or by family members. METHOD: Twenty-seven inpatients with major mood disorders and 29 inpatients with schizophrenia were recruited from a large state hospital; 27 outpatients with major mood disorders were recruited from an affiliated outpatient facility. The research battery included the Structured Clinical Interview for DSM-III-R--Patient Version, the Premorbid Adjustment Scale, and a semistructured interview designed to assess demographic, family history, developmental, and course information. RESULTS: Inpatients with deteriorated affective disorder differed from outpatients with nondeteriorated affective disorder along several important dimensions, including family history of mental illness, birth-related problems, physical disorders in infancy, premorbid functioning, presence of mixed episodes and rapid cycling, and medication non-compliance between hospitalizations. Inpatients with deteriorated affective disorder differed from inpatients with schizophrenia on the Premorbid Adjustment Scale. Patients with bipolar affective disorder differed from those with unipolar disorder on many of the variables associated with deterioration of functioning. CONCLUSIONS: Birth-related problems, physical disorders in infancy, and poor premorbid adjustment in childhood and adolescence appear to play an important role in deterioration of functioning among patients with unipolar depression. Disruption in treatment because of medication noncompliance and the appearance of mixed episodes and rapid cycling are associated with functional decline in bipolar affective disorder. Several characteristics previously considered specific to deterioration of functioning in schizophrenia, such as a high rate of birth complications and poor premorbid adjustment, appear to be associated with functional deterioration among patients with major depression as well.     

Validity of rapid cycling as a course specifier for bipolar disorder

OBJECTIVE: This study's aim was to test the validity of rapid cycling, defined by criteria consistent with those proposed in the DSM-IV draft, as a course specifier for bipolar disorder. METHOD: The study was conducted at a university center for affective disorders on patients fulfilling Research Diagnostic Criteria for bipolar disorder. Thirty-seven rapid-cycling patients, i.e., patients with at least four affective episodes during the previous year, were compared with 74 nonrapid-cycling patients on several demographic and clinical variables. All patients were then followed up prospectively for 2-5 years by monthly personal interviews. RESULTS: The rapid-cycling group was significantly older and had a significantly longer illness duration than the nonrapid-cycling group but did not have a significantly higher percentage of women or frequency of current hypothyroidism. During each year of follow-up, the mean number of affective episodes and the percentage of patients with at least four affective episodes were significantly higher among rapid-cycling patients. Rapid-cycling patients with a pole-switching pattern during the year preceding intake were significantly more likely than other rapid-cycling patients to have at least four affective episodes during each of the first 4 years of follow-up. CONCLUSIONS: These findings support the practical usefulness of rapid cycling as a course modifier for bipolar disorder, since it identifies a patient subgroup with a high recurrence rate. The predictive value of the modifier may be enhanced by the requirement of a pole-switching pattern. Since no external (i.e., unrelated to course) validator was found, the idea that rapid cycling represents one extreme of a continuum of episode frequency in bipolar disorder remains viable.     

Follow-up and family study of postpartum psychoses. Part I: Overview

A group of 119 patients suffering from a severe psychiatric postpartum disorder who were admitted for the first time in their life to a psychiatric hospital has been investigated. The onset of illness occurred within 3 months following delivery. The patients represented 92% of the total sample fulfilling the inclusion criteria. A follow-up investigation was performed after a mean of 21 years (range 2-35 years). Of the patients 66% had nonpuerperal psychotic episodes in later life. The diagnosis, taking into account the long-term course, was affective psychosis in 57%, schizoaffective psychosis in 18%, schizophreniform psychosis in 12%, brief reactive psychosis in 4% and schizophrenia in 9%. A bipolar psychosis was found in 31%. The relation of unipolar to bipolar psychoses corresponded to that in a control group of affectively ill women without puerperal onset. The frequency of a manic syndrome in bipolar psychoses at the index episode was the same as in nonpuerperal episodes, which does not suggest a mania-provoking pathoplastic effect of the puerperium. The comparison with female nonpuerperal controls matched for age and diagnosis revealed evidence of a better long-term course in the index patients. The risk of a puerperal relapse for further pregnancies was 35%. The global morbidity risk for functional psychoses in first-degree relatives was 11%, with affective psychoses representing the majority of secondary cases (6.8%). The index patients showed a nonsignificant lower morbidity risk in relatives than a control group of psychotically ill women without puerperal onset. The major aetiological factor found for postpartum psychoses is the relation of these disorders to functional psychoses. There is strong evidence that the postpartum period tends to provoke affective psychoses and other nonschizophrenic psychoses, but not, or only to a lesser degree, narrowly defined schizophrenias. The liability to puerperal decompensations suggests some common pathophysiological mechanism, the nature of which remains unknown.     

Suicide mortality in patients on lithium maintenance therapy

Mood disorders are frequently recurrent and it has been shown that maintenance treatment can reduce long-term morbidity in this condition. It has also been shown that mood disorders carry an increased risk of suicide and that a significant proportion of individuals who commit suicide suffer from a mood disorder. This paper reports the results of a long term follow-up of a cohort of patients attending a specialist mood disorder clinic over a period of 18 years. Sixty-seven suffered from unipolar depression and 36 had bipolar or schizo-affective disorders In order to qualify for entry to the cohort the unipolar patients had to have had at least three episodes of depression and those with bipolar disorders had to have had at least three episodes - with at least one manic episode and one depressive episode. All patients were treated with lithium. The initial treatment refusal rate and drop our rates were low. The mortality from suicide in this group was compared with that reported in five recent studies - all of which involved patients who had not been given maintenance therapy. The standardised mortality ratio (SMR) for all causes for the whole group was 0.93. There were two suicides. In one case the patient had continued treatment with lithium until death and in the other the patient had discontinued treatment 12 months before death. The overall suicide rate was 1.3 per 1000 patient years. Amongst similar groups of patients who had not been given maintenance therapy suicide rates of about 5.5 per 1000 patient years have been reported. It is concluded that maintenance treatment of mood disorders reduces the suicide rate in this vulnerable group of patients.     

Eye tracking in patients with unipolar and bipolar affective disorders in remission.

Examined patients (20–66 yrs old) with a history of recurrent affective disorder on a variety of smooth-pursuit and saccadic eye-tracking tasks and on psychomotor analogs of these tasks. The 25 unipolar and 24 bipolar Ss were compared to 24 schizophrenics; all Ss were in remission. Results indicate that the performance of the 2 affective-disorder groups was not significantly different from that of the controls on any of these tasks. Smooth-pursuit tracking error was greater for Ss receiving Li and for those with a higher frequency of prior episodes of the disorder. When the pursuit eye movements of these Ss were compared to those of the schizophrenics, the latter produced more tracking error than both affective-disorder groups but significantly so only with respect to unipolar Ss. Although findings are consistent with the interpretation that tracking dysfunction is not a trait characteristic of affective disorders, further investigations contrasting remitted patients with bipolar and schizophrenic disorders are needed to determine the specificity of deviant tracking to schizophrenia. (38 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alcoholism and drug abuse in three groups--bipolar I, unipolars and their acquaintances

OBJECTIVE: Previous work has shown that manic-depressive illness and alcohol abuse are linked. This study further explores the relationship of alcohol and drug abuse in bipolar I patients and unipolar depressives and a comparison group obtained through the acquaintance method. METHOD: Diagnosis was accomplished according to Research Diagnostic Criteria (RDC): controls = 469; bipolars = 277; unipolar depressives = 678. Systematic data were gathered using the SADS on lifetime and current drug abuse and alcoholism. Both patients and comparison subjects were then followed prospectively for 10 years. First degree family members were interviewed using the RDC family history method. RESULTS: The group of bipolar patients and the group of unipolar patients had higher rates of drug and alcohol abuse than the comparison group when primary and secondary affective disorder patients were combined. However, primary unipolar patients did not have higher rates of alcohol or drug abuse than the comparison group. In contrast, primary bipolar patients had higher rates of alcoholism, stimulant abuse, and ever having abused a drug than the primary unipolar group and the control group. In an evaluation of the bipolar patients, drug abusers were significantly younger at intake and had a significantly younger age of onset of bipolar disorder. There was a significant increase in family history of mania or schizoaffective mania in the drug-abusing bipolar patients as compared to the non-abusing bipolar patients. LIMITATION: As in all adult samples of patients with affective illness, the chronology of alcohol and substance problems vis-à-vis the onset of illness was determined retrospectively. CONCLUSIONS: (1) Alcoholism and drug abuse are more frequent in bipolar than unipolar patients. (2) The drug abuse of bipolar patients tends toward the abuse of stimulant drugs. (3) In a bipolar patient, familial diathesis for mania is significantly associated with the abuse of alcohol and drugs. (4) More provocatively, these findings suggest the hypothesis of a common familial-genetic diathesis for a subtype of bipolar I, alcohol and stimulant abuse. CLINICAL IMPLICATIONS: The present analyses, coupled with two previous ones from the CDS, suggest that drug abuse may precipitate an earlier onset of bipolar I disorder in those who already have a familial predisposition for mania. Furthermore, in dually diagnosed patients with manic-depressive and alcohol/stimulant abuse history, mood stabilization of the bipolar disorder represents a rational approach to control concurrent alcohol and drug problems, and should be studied in systematic controlled trials.     

Clinical characteristics of unipolar and bipolar depression

INTRODUCTION: In the last decades affective disorders were divided into unipolar and bipolar and this division has been generally accepted. The bipolar type is manifested by mania or by both mania and depression. On the other hand, unipolar affective disorders are manifested only by depression. In numerous investigations authors have noticed that there are very distinctive differences between these two types of depressive disorders such as: course of illness, personality disorders, sex, family history etc. Nevertheless, in practice it is often very difficult to make the right diagnosis. The bipolar type often starts with a few pure depressive episodes and sometimes mania occurs a few years later so only at that point the psychiatrist can make the right diagnosis and treat the patient correctly. MATERIAL AND METHODS: This investigation comprised 50 patients hospitalized at the Psychiatric Clinic in Novi Sad during 1992-1995. The experimental group consisted of 20 patients with a bipolar affective disorder (according to ICD-X), while the control group consisted of 30 patients with clinical diagnosis of unipolar depression (intensive, without psychiatric features). Both groups of patients were weekly evaluated by Hamilton Depression Rating Scale (HDRS), whereas the initial score for all patients had to be higher than 16. RESULTS: Patients suffering from unipolar depression were older than patients with bipolar depression and there were more females in this group. There were no differences in demographic characteristics (level of education, migration, etc.), but the experimental group had a greater genetic loading for affective disorders. Unipolar depressive patients had more agitation and they were more anxious than patients with bipolar depression. DISCUSSION AND CONCLUSION: The fact that unipolar depressive patients were older than bipolar is similar to most of the results gained in this kind of investigation. On the other hand, we did not find statistical differences in the intensity of disorders, and in the literature these results are contraindicating. Numerous investigators report that bipolar depressives had a stronger genetic loading for affective disorders and our study confirms the same. All these results can help us to make the right diagnosis of unipolar and bipolar affective disorders.     

Clinical correlates of anhedonia and perceptual aberration in first-episode patients with schizophrenia and affective disorder.

Examined the association between scales measuring physical anhedonia, social anhedonia, and perceptual aberration and premorbid functioning, clinical state, and current level of adjustment in 91 psychotic Ss. The patients were examined at the onset of their 1st psychotic episode and again 18 mo later. For patients with schizophrenia, anhedonia was significantly related to premorbid functioning. No association was found between the scales and clinical state or level of adjustment at intake or follow-up. In affective disorder patients, no correlation was found between premorbid functioning (a stable characteristic) and scale scores, but moderately large correlations emerged between the scales and clinical state and level of adjustment at both assessment times. These results suggest that schizophrenic and affective disorder patients endorse items on these scales for different reasons. The authors hypothesize that for patients with schizophrenia the scales assess enduring personality characteristics, whereas for the affective disordered patients they assess clinical condition at the time of testing. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Total joint replacement in multiplex congenita contractures: a case report

Tryptophan hydroxylase (TPH) is the rate-limiting enzyme in the synthesis of 5-hydroxytryptamine (5-HT). An association study in bipolar affective disorder I or unipolar major affective disorder was performed by using a Bfa I restriction site polymorphism within intron 7 of the tryptophan hydroxylase gene. A total of 118 bipolar, 125 unipolar, and 437 control subjects were used in the study (1:3.7 bipolar:control, 1:3.5 unipolar:control). There were no significant differences in TPH allele or genotype frequencies between the affective disorder and control groups. In addition, bipolar and/or unipolar subjects with or without a history of suicide attempts were compared for the TPH polymorphism. No significant differences were found between suicidal and non-suicidal groups in major affective disorder, in contrast to a previous study suggesting an association of this polymorphism with a history of suicide attempts among alcoholic violent offenders.     

Enhancement of morphine antinociception by ibogaine and noribogaine in morphine-tolerant mice

BACKGROUND: The authors evaluated and compared the efficacy of 20 mg versus 40 mg of paroxetine in a randomized, double-blind, parallel-group study during a maintenance period of 28 months. METHOD: Ninety-nine inpatients with recurrent, unipolar depression (DSM-IV criteria) who had at least 1 depressive episode during the 18 months preceding the index episode were openly treated with paroxetine 40 mg/day. Seventy-two subjects had a stable response (Hamilton Rating Scale for Depression score < 8) to paroxetine treatment and remained in the continuation treatment as outpatients for 4 months. At the time of recovery, 68 patients were randomly assigned to 1 of the 2 maintenance treatment groups: paroxetine 20 mg or paroxetine 40 mg daily. RESULTS: Sixty-seven patients completed the 28-month follow-up period. Seventeen (51.5%) of 33 patients in the 20-mg paroxetine regimen had a single recurrence compared with 8 (23.5%) of 34 subjects in the 40-mg dose regimen (chi2 = 5.56, p = .018). CONCLUSION: These data suggest that a full dose of paroxetine is recommended in unipolar patients who are at high risk for recurrent depressive episodes.     

Relation of age at onset to duration of episode in unipolar depression.

On the basis of elevated scores on the Center for Epidemiologic Studies Depression Scale, 2,020 persons were selected from a larger community sample to be interviewed and diagnosed using the Schedule for Affective Disorders and Schizophrenia and the Research Diagnostic Criteria procedures. 865 Ss (aged 18–88 yrs) had a history of one or more episodes of unipolar depression. The potential effects of the following variables (singly and in interaction) on duration of episode were assessed by means of multiway frequency table analysis and chi-square: age at onset, sex of S, interval since occurrence of the episode, and type of disorder (major vs minor depressive disorder). The hypothesis that duration of episodes of depression increases with age at onset was not supported. Women, who formed 73.5% of the sample, were more likely to have multiple episodes but did not have longer-lasting episodes. (28 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effect of acute exposure of the organophosphate insecticide Rogor on some biochemical aspects of Clarias batrachus (Linnaeus)

The prevalence of DSM-IV atypical depression and comparisons between atypical and typical depression were studied in 203 consecutive unipolar and bipolar depressed outpatients presenting for treatment of depression in private practice. The prevalence of atypical depression was 31%. Of the variables investigated (unipolar/bipolar diagnosis, age at baseline/onset of first major depressive episode, gender, psychosis, comorbidity, chronicity, duration of illness, recurrence, and severity), a bipolar II diagnosis was significantly more common, the age at baseline and duration of illness were significantly lower, and the proportion of females and psychiatric comorbidity were significantly higher in atypical versus typical depression. Secondary analysis showed that bipolar II atypical depression had a significantly earlier age at baseline/onset and affected more females, but there were no other significant differences versus typical depression. The findings suggest important clinical differences between atypical and typical depression, and a bipolar II subtype may be separated from the broad category of atypical depression.     

Association of recurrent suicidal ideation with nonremission from acute mixed mania

OBJECTIVE: The authors' goal was to examine suicidality in relation to acute symptom remission in inpatients with mixed and pure bipolar disorder. METHOD: Using chart review of 184 adult inpatients with bipolar I disorder, the authors assessed patients' past and current suicidality, other psychopathology, treatment, and remission. RESULTS: Past, current, and recurrent suicidality were significantly more common among patients with mixed mania than among those with pure mania. The probability of remission declined by 49% for every suicide attempt made before the index manic episode. Mixed mania, multiple previous hospitalizations, and previous suicide attempts were significantly associated with current suicidality. CONCLUSIONS: Suicidality is linked with mixed manic states and may be a clinical marker for recurrent dysphoric mania. Multiple suicide attempts are associated with nonremission from mixed manic episodes.     

The prevalence of verbal communication disability in patients with Parkinson''s disease

BACKGROUND: We evaluated and compared the efficacy and safety of sertraline and fluvoxamine in a randomized, double-blind, parallel-group study during a follow-up of 24 months. METHOD: Sixty-four patients with recurrent, unipolar depression (DSM-IV criteria) who had at least one depressive episode during the 18 months preceding the index episode were accepted into the trial. Patients were randomly assigned to one of the two long-term treatment groups and evaluated monthly by trained psychiatrists, blinded to treatment option, on the basis of the Hamilton Rating Scale for Depression. RESULTS: All patients completed the 24-month follow-up period. Sertraline and fluvoxamine showed an equal efficacy in preventing new recurrences. In fact, there was no significant difference in survival rates between the two medication groups: 7 sertraline-treated patients (21.9%) and 6 fluvoxamine-treated patients (18.7%) had a single new recurrence (z = 0.14; p = .88). Moreover, recurrence observed during maintenance therapies was less severe and/or of shorter duration than index episodes. CONCLUSION: Long-term treatment with sertraline or fluvoxamine has been shown to be effective for prevention of highly recurrent unipolar depression. The high tolerability of these compounds, together with their prophylactic effectiveness, has an important role in improving the quality of life of these patients.     

Abnormal G protein alpha(s) - and alpha(i2)-subunit mRNA expression in bipolar affective disorder

Disturbances of events associated with intracellular signaling pathways have been suspected of involvement in the development or progression of affective disorders. Often, heterotrimeric G proteins are located at the beginning of these pathways as modulators of extracellular messages. For this reason, messenger RNA expression of three G protein alpha-subunits and of phosphatidylinositol-3 kinase (PI-3 K) regulatory subunit p85 was examined in granulocytes from patients with bipolar or unipolar affective disorder and compared to healthy controls. Messenger RNA expression of the G protein subunit alpha(q) and of p85 was identical in unipolar and bipolar patients and in controls. Furthermore, mRNAs of G protein subunits alpha(s) and alpha(i2) were not different in unipolar patients as compared to healthy controls. Alpha(s) mRNA, however, was markedly increased in bipolar patients. This increase was observed in lithium-treated (more than 12 months) and in unmedicated patients. Elevated levels of alpha(i2) mRNA in unmedicated bipolar patients did not reach statistical significance, whereas mRNA in bipolar patients receiving lithium was significantly above controls. Finally, long-term medication of unipolar patients with lithium had no influence on alpha(i2) mRNA levels. The data reveal elevated mRNA levels of G alpha(s) as a robust feature of bipolar affective disorder. Moreover, despite responsiveness of alpha(i2) gene expression to cAMP-related events, no substantial upregulation of alpha(i2) mRNA was observed in bipolar patients. The lack of alpha(i2) mRNA upregulation, hence, could be an additional abnormality in these patients. Even though lithium was able to reinstate this upregulation, there was no feedback downregulation of alpha(s). This strongly supports the notion of major disturbances of the cAMP signaling system in bipolar illness.     

Factors associated with outcome in major depression: a 6-month prospective study

A number of authors have indicated in recent years that the course of depression is not as favourable as previously expected. Research conducted in order to identify predictors of recovery has shown widely different results. In this paper a sample of 90 consecutive patients with non-chronic major depressive disorders (index episode < 6 months) attending four mental health centres in Madrid were followed up prospectively for 6 months, and clinical social and cognitive variables were studied. The patients were treated pharmacologically and controlled. The rate of recovery was measured according to the Hamilton Rating Scale for Depression (HAM-D). Other tools used were: Life Events and Chronic Difficulties, Global Assessment Functioning in the 6 months prior to the onset of episode, Brown Rating Scale for Self-Esteem and Mannheim Interview of Social Support. The results showed that 41 cases recovered (HAM-D score < 8), 29 cases achieved a partial remission, and major depressive disorder persisted in 17 cases (HAM-D score > or = 18). The presence of personality disorders, having suffered a previous episode, GAF score and some aspects of social support were the variables most associated with non full remission in the logistic regression analysis. Personality disorders and the initial HAM-D score were related to non-improvement. Some clinical and cognitive variables maintain a weak relation to outcome and are rejected in logistic regression. This study emphasizes the relationship of personality, and social variables such as social support and previous global functioning, with incomplete recovery in major depression.     

Identifying chronic affective disorders in outpatients: Validation of the General Behavior Inventory.

The validity of the General Behavior Inventory (GBI) in screening outpatients for chronic unipolar and bipolar affective conditions was evaluated. The GBI was administered to 492 consecutive patients at a university clinic and a community mental health center. Using a stratified random sampling plan, 167 patients were selected and administered blind structured diagnostic interviews. In addition, unipolar depressives were followed up 6 months after the initial evaluation. Overall, the GBI exhibited fair-to-good positive predictive power and good-to-excellent negative predictive power. In addition, GBI scores in the case range were consistently associated with poor outcome at the 6-month follow-up. These findings suggest that the GBI may provide an economical means of screening for chronic unipolar and bipolar affective conditions in outpatient settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Recurrent acute cerebellar ataxia of childhood following nonspecific respiratory tract infection

Acute cerebellar ataxia in childhood following viral infection is a self-limited disease. The disease with recurrent course has rarely been reported. At the Department of Pediatrics, Ramathibodi Hospital, three children with recurrent episodes of acute cerebellar ataxia following nonspecific viral infection were encountered. The age at onset of each patient was 2 years, 18 months and 2 years old. The clinical symptoms were similar and improved rapidly after gluco-corticoid was given. All patients recovered without residual deficit. Six, 5 and 3 recurrent attacks of similar illness were noted in each patient respectively after the first episode. However, no further attack occurred after the age of 5 years and the age of last follow-up was 17, 16 and 14 years old respectively. The pathogenesis of the recurrent episodes is uncertain. The abnormal immunological response is postulated.