Medicine and Health Sciences Commons^™

Sudden Cardiac Death With Clozapine And Lorazepam Combination, Sriram Ramaswamy, Susan J. Boust, Prizada S. Sattar, Subhash C. Bhatia, Frederick Petty

Jefferson Journal of Psychiatry

Objective: To report a case of sudden cardiac death in a patient taking a combination of clozapine and lorazepam.

Case summary: A 31-year-old white man with schizophrenia was found dead at his apartment. His medication regimen included clozapine 500 mg at bed time, lorazepam 0.5 mg three times daily and levothyroxine 75 mcg once a day. Autopsy studies revealed cardiac hypertrophy, pulmonary congestion and edema.

Discussion: Clozapine therapy may cause cardiomyopathy and reduction in heart rate variability (HRV) indices. Benzodiazepines can reduce vagal tone and increase sympathetic activity. This combination can have an enhanced potential for sudden cardiac death.

Conclusions: …

Using Transcranial Magnetic Stimulation (Tms) To Compare Cortical Excitability Among Depressed Patients, Sleep-Deprived Controls, And Rested Controls, Rajani Rajan, Paul A. Zarkowski, Pedro L. Delgado

Jefferson Journal of Psychiatry

Objective: To compare cortical excitability among sleep-deprived and rested controls, and depressed subjects.

Methods: 3 controls and 4 depressed patients (average HAM-D 19) wererecruited. Sleep-deprived controls were instructed to sleep <=4 hours the previous night. TMS-produced motor evoked potentials (MEPs) were measured before and after subjects engaged in sets of non-fatiguing manual exercise.

Results: Post-exercise MEP increased 71+1-19% for rested controls, 28+1-32% for sleep deprived controls, and 8+1-15% for depressed patients. This increase, "facilitation," was significantly greater in rested controls than in depressed patients (p=0.011). No significant difference in facilitation was found between sleep-deprived controls and depressed patients.

Conclusion: Sleep-deprivation may partially account for reduced cortical excitability in depressed patients.

Antidepressant Pharmacotherapy: Prescription Practices In Psychiatric Resident Care, Rachel Dew, W. Vaughn Mccall

Jefferson Journal of Psychiatry

Background: Research on treatment of depression has raised concerns regarding adequacy of medication trials and rationality of drug choice. Little data exists regarding pharmacotherapy by psychiatric residents. As practice habits begun in training will likely persist after graduation, examination of residents' antidepressant use may ultimately improve treatment by psychiatrists.

Methods: Charts of new patients presenting to the Wake Forest University Psychiatry Resident Clinic were reviewed. Survey was made of medications prescribed to 112 patients diagnosed with major depression, dysthymia, depressive disorder NOS, adjustment disorder with depressed mood, or bipolar disorder with a documented depression during the studied period. Drug choice …

The Duty To Warn/Protect Doctrine And Its Application In Pennsylvania, Clarence Watson

Jefferson Journal of Psychiatry

Despite the almost universal familiarity of mental health professionals with the Tarasoff case, many questions regarding its associated legal requirements often arise when evaluating potentially dangerous patients. The principles of the duty to warn/protect, while appearing nebulous at times, contain key concepts that the clinician must consider in the face of potential danger to third parties. This article reviews the landmark decision of the Tarasoff case and outlines its key concepts. In addition, given that state jurisdictions vary in treatment of Tarasoff-like cases, this article explores the Pennsylvania Supreme Court decision, Emerich v. Philadelphia Center for Human Development, Inc.

Editor's Note, Anika Vaughn-Cooke

Jefferson Journal of Psychiatry

No abstract provided.

Electroconvulsive Therapy: A Review Of Its Current Status, Tyler Kenning, Ranjnish Mago, Steven Huege, Kenneth Certa, Rodney Pelchat

Jefferson Journal of Psychiatry

This article presents an overview of the current knowledge and practice of ECT. It provides a brief history of the development of ECT followed by a discussion of the accepted indications for ECT in psychiatric practice, including major depression, bipolar disorder (mania and depression), and schizophrenia. Moreover, a description of the technique of performing ECT is given. Also examined are the use of ECT in medically ill patients and the risks associated with ECT. In conclusion, with the aid of advances in anesthesia and the delivery of ECT, electroconvulsive therapy is a safe and effective treatment of mood and psychotic …

The Efficacy And Toxicity Of Bupropion In The Elderly, William T. Howard M.D., M.S., Julia K. Warnock M.D., Ph.D.

Jefferson Journal of Psychiatry

Bupropion is an antidepressant with excellent tolerability and few side effects or drug interactions. These characteristics suite it well for use both in the elderly and in the medically ill. However, early reports of seizures with bupropion therapy in patients with bulimia limited its use. The pharmacology, efficacy, toxicity, and side effect profile of both the immediate release (IR) and the recently available sustained release (SR) formulations of bupropion are reviewed. Bupropion SR is associated with a reduced seizure incidence (0.1%) compared to that found with the IR formulation (0.4%). Recent reports, however, demonstrate that the half-life of bupropion is …

The Malingering Of Psychotic Disorders, Michael R. Harris M.D.

Jefferson Journal of Psychiatry

The phenomenon of malingered psychosis is examined through a review of the available literature. Possible motivations for malingering are discussed, and clinical indicators of feigned psychotic symptoms are reviewed. The methods discussed focus on the inpatient evaluation of suspected malingerers and include discussions of interview techniques and psychometric testing to supplement clinical impressions. A differential diagnosis is presented, and techniques for confronting a malingering patient are reviewed.

Lilliputian Hallucinations And Marijuana Dependence In A Bipolar Patient, Matthew L. Bush M.S. Iv, Saurabh Gupta M.D.

Jefferson Journal of Psychiatry

Lilluputian hallucinations are rarely seen in manic patients. Here we present a case of isolated lilluputian hallucinations against a backdrop of psychosis and marijuana use. The phenomenon is interesting and worth following up with. The patient recovered and a brief literature search is included.

A New Onset Paranoid Psychosis Associated With Fluoxetine And Bupropion: A Case Report, Vassili V. Arkadiev M.D., Stephen L. Ruedrich M.D.

Jefferson Journal of Psychiatry

No abstract provided.

Current Methodological Issues In Candidate Gene Association Studies In Psychiatric Disorders, Leo Sher M.D.

Jefferson Journal of Psychiatry

One of the most rapidly emerging areas of neuroscience research is the study of genetic approaches to complex psychiatric disorders. The author discusses potential benefits and pitfalls of candidate gene association studies. Association studies search for correlations in the population between a DNA marker and a disorder. The so-called candidate gene approach is frequently used in association studies. Candidate gene studies are usually based on hypotheses about relationships between specific known loci and particular phenotypes. The aim of molecular genetic studies of behavioral disorders includes the development of predictive and diagnostic testing for psychiatric disorders that can help to establish …

Addiction Professionals' Attitudes Regarding Treatment Of Nicotine Dependence, Baljit S. Gill M.D., Dwayne L. Bennett M.D., Mohammad Abu-Salha M.D., Lisa Fore-Arcand Ed.D.

Jefferson Journal of Psychiatry

The objectives of this study were: to establish the extent to which addiction professionals are willing to treat nicotine addiction concurrently with other addictions, and to evaluate what factors affect their attitudes.

A 21-item questionnaire was developed and distributed to therapists, physicians and other mental health workers in different treatment settings in Southeastern Virginia.

CD staffers own smoking histories were significantly related to: their perceptions of the impact of nicotine use, and how likely they were to intervene in patients' nicotine use. Intervention in CD staffers own smoking behavior may increase the treatment of nicotine dependence in their patients.

Psychosis In Azheimer's Disease, George M. Strickland M.D., Thomas F. Ditzler Ph.D.

Jefferson Journal of Psychiatry

Much of the basic science literature on Alzheimer's Disease (AD) reflects ongoing research into pathophysiology and neuropathology. Yet, despite reports of the association between psychotic symptoms and Alzheimer's disease, relatively little is known about why such symptoms develop in certain patients and not in others. Neuroimaging and genetic studies may provide greater understanding of this association and allow clinicians and researchers to prevent, predict and treat the onset of psychotic symptoms in the future. This paper will review the current literature on the topic of psychosis in Alzheimer's disease and focus on current recommendations for interventions by clinicians and caregivers.

Neuroleptic Malignant Syndrome: Review, Diagnostic Critique, Khurram K. Durrani M.D.

Jefferson Journal of Psychiatry

Neuroleptic malignant syndrome (NMS) can be defined as an idiosyncratic and potentially fatal reaction to neuroleptic agents that consists of fever, mental status changes, muscle rigidity, autonomic dysfunction, respiratory distress and rhabdomyolysis. The pathogenesis of NMS is still not fully understood. The diagnosis presents a challenge and the diagnostic criteria need further refinement. The presentation and course of NMS are quite variable and can range from a progressive, fulminating, downhill course to a relatively benign and self-limiting course. Despite great improvements in the management of the syndrome, prevention and early diagnosis are the most important aspects of treatment.

Treatment Response Of Opium Smoking Hmong Refugees To Methadone Maintenance, Muhammad Waqar Azeem M.D., Gregory A. Carlson B.A., Chomehanh Soudaly Lpn

Jefferson Journal of Psychiatry

Objective: To examine the outcome of methadone maintenance in opium dependent Hmong refugees.

Methods: Medical records were searched for Hmong patients in methadone treatment between 01/1995 and 09/1997. Patient's progress was assessed over nine months.

Results: 44 Hmong patients were found. Data was available on 40 patients, mean age of 47.7 years, 33 males/7 females. At admission 100% met the DSM-IV criteria for Opium Dependence, 75% Major Depressive Disorder and 68% PTSD. Patients showed marked improvement by having mostly negative urine drug screens, improvement on Addiction Severity Index and 70% being highly successful on outcome criteria modified by Drug Abuse …

Editor's Note, Manoj Mohata M.D.

Jefferson Journal of Psychiatry

No abstract provided.

Psychiatric Training: The Culture And Its Contradictions By T.M. Luhrmann, Carolyn Myers M.D.

Jefferson Journal of Psychiatry

No abstract provided.

Methylphenidate, Bupropion, And Ssri Triple Therapy, William Bobo M.D.

Jefferson Journal of Psychiatry

Methylphenidate and bupropion have been demonstrated as being effective adjuncts to serotonin reuptake inhibitors in the treatment of depression (1,2). The use of these medications in case of a depressed patient whose condition was resistant to several forms of monotherapy, monotherapy with "standard" augmentation and ECT. After only a partial response to fluoxetine and methylphenidate, bupropion was added, resulting in full, sustained remission.

Severe Generalized Edema Associated With Phenelzine, William Bobo M.D., Cheryl A. Hemme M.D.

Jefferson Journal of Psychiatry

Rabkin, et al. describes a 4% incidence of phenelzine-induced edema, which appears to be due to increased capillary permeability (1,2). This adverse effect is not further characterized in the literature and is not readily mentioned as one of the many drug effects that could result in severe physical morbidity. We present the case of a depressed patient who developed a generalized edema severe enough to deserve an extensive medical workup. Once the drug was tapered, the edema and its associated symptoms rapidly resolved.

Personality Traits In Juvenile Delinquents: Associations With Peer And Family Relations, Jeffrey J. Wilson M.D., Sharon E. Willams Ph.D., Evan Garner M.D., Elaine Duxbury B.A., Hans Steiner Dr. Med. Univ.

Jefferson Journal of Psychiatry

Objective: To establish family and peer correlates of personality traits shown to be predictive of future criminal recidivism.

Method: 137 incarcerated boys aged 13-18 (x = 16 ± 1.2), 35% black, 21% Hispanic, 43% white, and 1% other completed the Weinberger Adjustment Inventory (WAI) and a psychosocial history obtained by a social worker. Records were summarized using two raters who assigned numerical ratings to dimensions of family and peer relations.

Results: As expected, observer ratings of family and peer relationships were correlated with the personality characteristics of distress, denial and restraint as measured by the WAI.

Conclusion: Family and peer …

Folie A Famille Associated With Amphetamine Use, Kevin P. Hill B.A., Ashwin A. Patkar M.D., Stephen P. Weinstein Ph.D.

Jefferson Journal of Psychiatry

Shared Psychotic Disorder involving an entire family (folie a famille) is extremely rare. Only two cases of Shared Psychotic Disorder linked to stimulant abuse have been documented in the literature. We report a case of folie a famille that involved 5 members of a family, and was associated with amphetamine use in the primary individual. Our case shares many clinical and etilogical factors with previously reported cases of shared psychotic disorders. A wide variety of psychotic manifestations are associated with amphetamine use and clinicians should be aware of this uncommon syndrome among stimulant-using population, particularly due to the recent increase …

Countertransference In Two Settings: A Case Report, Randi L. Plotkin M.D.

Jefferson Journal of Psychiatry

No abstract provided.

Conversion Disorder In A Depressed Patient: The Analysis Of Paralysis, Michael A. Chen Ph.D., David S. Im M.D.

Jefferson Journal of Psychiatry

Patients presenting with neurologic and pseudoneurologic symptoms present both a diagnostic and treatment challenge. This case report describes the ER course of a man who presented with aphonia and paralysis, his medical clearance, transfer to the psychiatric ER and subsequent recovery. The history of conversion disorder and its characteristics are briefly reviewed, and the etiology of this patient's symptoms and a discussion of effective treatment plans are discussed.

Patient Violence In Psychiatric Residency: A Nationwide Survey, Tricia L. Park Ph.D., Thomas L. Schwartz M.D.

Jefferson Journal of Psychiatry

Twenty percent of current psychiatric residents (N = 517) responded to a nationwide survey about patient violence. Thirty six percent of responders reported 630 assaults, with 74% of residents receiving 1,853 threats. While age and training level were correlated to each other (r = .35, p < .001), no correlations were found between gender, age, height, weight number of hours of violence management training and the occurrence of assault and threat. A smaller proportion of first year residents reported assaults and threats, and more males (79%) had been threatened (females = 69%). Sources of study bias are identified and future research directions are outlined.

Editor's Column, Scot R. Maclean M.D.

Jefferson Journal of Psychiatry

No abstract provided.

About The Authors

Jefferson Journal of Psychiatry

No abstract provided.

On The Technical Error Of The Psychotherapist, Satoshi Tamiya M.D., Tetsuro Takahashi M.D.

Jefferson Journal of Psychiatry

The authors present a psychotherapy case where the therapist's countertransference-based technical error and his way of dealing with it remarkably influenced the course of treatment. The authors emphasize that appropriate training, including supervision and personal psychotherapy or psychoanalysis, is imperative, especially so that the beginning therapist can learn to manage countertranference appropriately. Since technical errors cannot always be avoided, it is important for the therapist to deal with them therapeutically, without feeling ashamed or guilty.

Late Onset Tay-Sachs Disease Presenting As A Brief Psychotic Disorder With Catatonia: A Case Report And Review Of The Literature, Osama Saleh M.D.

Jefferson Journal of Psychiatry

This is a case report of late onset Tay-Sachs Disease diagnosed in a 14-year-old male non-Jewish adolescent who presented in a psychotic and catatonic state. The objective is to emphasize that Tay-Sachs disease can present with psychiatric symptoms, with a variety of phenotypes from infancy to adulthood, and can affect individuals other than Ashkenazi Jews. Amphiphilic drugs, including phenothiazine and tricyclic antidepressants, may worsen the course of the illness. Resistant catatonia can respond to an extended trial of high dose lorazepam.

Review Of The Pharmacological Treatment Of Delirium In The Pediatric Population With Accompanying Protocol, Nathan Lavid M.D., Lawrence J. Budner M.D., F.A.A.C.A.P.

Jefferson Journal of Psychiatry

Objective: To review the current state of pharmacological treatment of delirium in the pediatric population and to derive a treatment protocol from our review.

Method: Medline-assisted search of the literature. Articles pertaining to the pharmacological treatment of delirium in children and adolescents were reviewed. Due to the paucity of articles, studies of treatment guidelines for delirium in the adult population were reviewed. Also presented for reference, are studies of optimal dosing regimens of psychotropic agents potentially useful in treating pediatric delirium. Our protocol is extrapolated from previously established guidelines for adult treatment meshed with the current knowledge presented in …

Seasonal Affective Disorder And Seasonality: A Review, Leo Sher M.D.

Jefferson Journal of Psychiatry

Seasonal affective disorder is a condition where depressions in fall and winter alternate with nondepressed periods in the spring and summer. The Degree to which seasonal changes affect mood, energy, sleep, appetite, food preference, or the wish to socialize with other people has been called "seasonality." The author reviews historical aspects, clinical features, epidemiology, genetics, pathophysiology, and treatment of seasonal affective disorder and seasonality. Better understanding of the contemporary concept of seasonal affective disorder, seasonality, and light treatment will improve patient care and promote scientific advances in behavioral sciences.