Response to Propranolol and Diazepam in Somatic and Psychic Anxiety

A total of 12 chronically anxious psychiatric outpatients were treated with racemic propranolol (Inderal), diazepam (Valium), and placebo for one week each, using a balanced cross-over experimental design. Six patients had predominantly somatic anxiety, complaining mostly of bodily symptoms, and six had mainly psychic anxiety, complaining primarily of psychological symptoms. Clinical ratings of anxiety were made by patient and psychiatrist after each treatment. Though diazepam was in general more effective than propranolol or placebo in relieving anxiety, propranolol was more effective than placebo in patients with somatic anxiety but not in those with psychic anxiety. We suggest that propranolol should be reserved for patients whose anxiety symptoms are mainly somatic.     

Psychologically mediated abdominal pain in surgical and medical outpatients clinics.

Ninety-six patients complaining of recurrent or persistent abdominal pain were referred consecutively to a surgical clinic and a medical clinic, respectively. They were examined psychiatrically after their initial physical investigation. The psychiatric examination included rating scales for depression and anxiety, a personality inventory, life-events schedule, scale of verbal expressivity, and family and personal patterns of pain and invalidism. Only 15 patients (15-6%) had organic disorders that could be responsible for their symptoms. In the remainder, psychiatric factors were considered primarily responsible for their abdominal pain: 31 were depressed; 21 had chronic tension; in 17 hysterical mechanisms were prominent; and 12 were found to be unrecognised alcoholics. Follow-up at three and six months and recognition by 80% of the psychogenic group that a psychological explanation was plausible, confirmed the diagnoses, and over half responded favourably to psychiatric management. Features distinguishing the organic and psychogenic groups were delineated. Psychiatric assessment has a place among the investigations of non-acute abdominal pain; certainly it should not be condisered simply as "a last resort."     

Resolution of Pulmonary Embolism

To assess restoration of pulmonary perfusion after pulmonary embolism serial lung scans were carried out on 74 patients. Of these, one-third showed almost complete recovery, one-third improved, and the remainder either failed to improve or became worse. Perfusion was most rapidly restored in the first few days after the embolus and more slowly during the next two to three weeks.Untreated patients improved less often and had more new defects in perfusion than patients treated with anticoagulant therapy, no difference occurring in either the amount of improvement or in the rate of recovery of perfusion between patients treated with different anticoagulant regimens. There was evidence of further pulmonary emboli in 35% of treated patients, 82% of these occurring within two weeks of the initial embolus. Patients with defects in perfusion greater than 30% showed considerable improvement but recovered less well than those with smaller defects.     

Psychosocial stress and abdominal pain in adolescents

Children and adolescents may express psychiatric symptoms via somatic complaints. Likewise, children with chronic somatic illnesses are likely to experience psychiatric sequelae. We report three cases of adolescents who were admitted to general paediatrics services for abdominal pain and/or nausea and vomiting with a negative medical workup. In each case, a clear psychosocial stressor was evident. It is possible that somatic symptoms without clear medical causes may reflect psychosocial stress, but it is difficult to discern whether the psychosocial issues preceded the somatic complaints or were a result of them. Making an accurate diagnosis is difficult, and broaching such a subject with patients and their families is a delicate matter. More research is needed to determine appropriate screening tools for identifying cases where psychosocial stress may play a relevant role in symptom presentation, as well as potential treatment modalities for such cases.     

HYPERVENTILATION SYNDROME—A Clinical and Physiological Evaluation

There is a chronic hyperventilation syndrome which is much more common, of greater medical significance and far more difficult to diagnose than the better-known acute hyperventilation attack. This chronic syndrome tends to mimic grave organic disease with which it frequently is associated or superimposed.Studies on 250 patients with chronic hyperventilation patterns revealed the rapidity with which biochemical and physiological changes can occur and the characteristics of the resultant symptoms and signs, with particular reference to the heart and lungs.Once the diagnosis is suspected and appropriately confirmed, it is possible to “cure” over 70 per cent of such patients by means of simple therapeutic measures.     

Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms

Objective: To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms. Design: Follow up study. Setting: National Hospital for Neurology and Neurosurgery, London—a secondary and tertiary referral hospital for neurological disorders. Subjects: 73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia). Main outcome measures: Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview—the schedule for affective disorders and schizophrenia—conducted by a psychiatrist. Results: Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up. Conclusions: Unlike Slater’s study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients’ symptoms or disability was found. However, a high level of psychiatric comorbidity existed.

Key messages

• Motor symptoms that remain unexplained medically despite thorough investigation are a common clinical problem, but the emergence of a subsequent organic explanation for these symptoms is rare
• The prevalence of coexistent affective and anxiety disorders is high and many patients also have a personality disorder
• Patients with a shorter duration of symptoms and coexistent anxiety or depression are likely to do better at follow up
• Reinvestigation of these patients is both expensive and potentially dangerous and should be avoided where no clear clinical indication exists

     

Psychiatric assessment of patients with “20th-century disease” (“total allergy syndrome”)

“Twentieth-century disease”, or “total allergy syndrome”, is a condition attributed to hypersensitivity to the environment that may sometimes be seen as so serious that the patient is incapable of living in the modern world. Although the popular media frequently carry stories about it, there is little scientific literature. It is diagnosed by clinical ecologists, who maintain, among other theories, that susceptible individuals experience an overload in assaults by artificial materials in the environment. The patients usually have multiple ill defined symptoms for which no organic cause can be found, but they vigorously resist psychiatric referral, as they attribute their symptoms to allergy. A group of 18 patients who were purportedly suffering from 20th-century disease were referred to a university psychiatric consultation liaison service. They virtually all had a long history of visits to physicians, and their symptoms were characteristic of several well known psychiatric disorders. The case histories and management of three of them are presented. Although this group of patients may have been atypical in that they had more severe psychologic symptoms, the experience indicates that a psychiatric diagnosis ought to be considered. The symptoms of 20th-century disease have much in common with other conditions known to physicians for centuries.     

Health status and anxiety in the elderly. A longitudinal perspective

The prognostic value of physical health for changes in anxiety symptoms in older people was investigated in a prospective longitudinal study design with data from the Longitudinal Aging Study Amsterdam (LASA). In a sample of 2165 older (> 55 yrs.) respondents anxiety symptoms were measured twice over a three year interval with the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A). Utilizing a cut-off value of 4 on the HADS-A, subjects were considered as anxious or as non-anxious. Based on the first assessment two groups were formed: subjects with and subjects without anxiety symptoms. In the non-anxious cohort the effect of physical health on the development of anxiety symptoms was studied; in the anxious cohort the same factors were evaluated on their predictive value for chronicity of anxiety. Indices of physical health included the presence of chronic diseases, functional limitations, and self-perceived health at the first assessment and changes on these variables over time. Results revealed that poor self-perceived health was predictive of incidence (OR = 1.5; 95% CI = 1.3-1.8) and chronicity of anxiety (OR = 1.2; CI = 1.0-1.5). Regarding chronic diseases, the results showed that suffering from more than one chronic disease predicted becoming anxious and chronicity of anxiety (OR = 1.7; CI = 1.2-2.5 and OR = 2.2; CI = 1.3-3.6, respectively). Specific chronic diseases were not strongly related to a change in anxiety levels. Thus, somatic diseases not only lead to depression, a finding reported in numerous studies, but also increase the likelihood of anxiety symptoms at a later point in time.     

Detecting psychogeriatric problems in primary care: factors related to psychiatric symptoms in older community patients

Objective The aim was to determine the relationship and influence of different variables on the psychiatric symptomatology of older people who reside in the community, as detected by family practitioners.Design A cross-sectional and multi-centre study.Setting Twenty-eight general practices and two psychiatric practices in Huesca, Spain, from 19 primary care health centres.Subjects A sample of 324 patients aged over 65 years, representative of the older people who reside in the community in the province of Huesca.Main outcome measures Symptoms of depression (Yesavage GDS), cognitive impairment (MMSE), anxiety (GADS), psychotic symptoms, obsessive symptoms and hypochondriacal ideas (GMS) were measured by family practitioner and were detected following specific questions from the Geriatric Mental State (GMS-B) examination, following DSM-IV criteria, being defined as 'concern and fear of suffering, or the idea of having a serious disease based on the interpretation of somatic symptoms'. Sociodemographic, physical and somatic, functional and social data were evaluated. Analysis was carried out in three phases: univariate, bivariate and multivariate with logistic regression.Results At the time of the study, 46.1% of the older people studied suffered from some psychiatric symptom; 16.4% had cognitive impairment, 15.7% anxiety, 14.3% depression, 6.1% hallucinations and delusions, 7.2% hypochondriacal ideas and 4.4% obsessive symptoms. Female gender was significantly associated with depression (prevalence ration (PR) 3.3) and anxiety (PR 3.9). Age was a factor associated with cognitive impairment (PR 4.4). Depression was significantly related to severity of the physical illness (PR 61.7 in extremely severe impairment). Isolation (PR 16.3) and being single (PR 13.4) were factors which were strongly associated with anxiety; living in a nursing home was associated with psychotic symptoms (PR 7.6).Conclusions Severity of physical illness, isolation, living in a nursing home and female gender, among others, are related to psychiatric symptoms in community-residing older people identified in primary healthcare centres.     

Psychosocial effects of radiotherapy after mastectomy.

Psychosocial morbidity was measured in 47 patients who received postoperative radiotherapy and in 38 who received no further treatment after mastectomy. Roughly one third of all patients experienced depression or anxiety. One month after operation, before radiotherapy, there were no significant differences between the two groups in any of the measures of psychosocial morbidity. Knowledge of impending treatment did not seem to influence morbidity. At three months patients who had completed radiotherapy had significantly more somatic symptoms and social dysfunction than those not so treated. At six months the radiotherapy group continued to show more somatic symptoms, but a year after operation there were no significant differences between the groups. Although several patients who received radiotherapy were upset by their treatment, the study failed to confirm that depression and anxiety were commoner among those given radiotherapy than among patients given no further treatment.     

Fibrinolysin Therapy of Thrombophlebitis and Pulmonary Embolism: A Double-Blind Study

Thrombophlebitis and pulmonary embolism are major causes of disability and death in both medical and surgical patients. Etiological factors are still poorly understood. Preventive measures as currently practised are non-specific and based on questionable premises. Diagnostic measures to predict the silent fatal embolus are inadequate. Currently accepted treatment measures are designed to prevent extension of the thrombus but have no effect on the existing clot. Theoretically, thrombolytic preparations now being marketed offer some hope for dissolution of preformed thrombi. An experimental study was carried out on artificially induced thrombi in jugular and femoral veins of mongrel dogs. Human fibrinolysin (Actase, Ortho) was infused locally and systemically in varying doses. No thrombi were successfully lyzed by either method. Thirty-six cases of acute deep thrombophlebitis in the leg, one of axillary thrombosis, three of chronic postphlebitis of a lower limb with massive edema and eight of pulmonary emboli were observed and carefully documented clinically. All these patients received anticoagulants unless there was a contraindication. Fibrinolysin infusions in varying dosages were administered to 27 patients; 10 served as controls. The observers were unaware of the identity of those receiving the actual drug or of those given the placebo until completion of the study. Progress of the disease was judged by the rate of dis-appearance of symptoms and signs. No significant benefit could be noted in the treated as compared to the control group, in terms of rate of recovery or incidence of embolus.     

Molecular analysis of velo-cardio-facial syndrome patients with psychiatric disorders.

Velo-cardio-facial syndrome (VCFS) is characterized by conotruncal cardiac defects, cleft palate, learning disabilities, and characteristic facial appearance and is associated with hemizygous deletions within 22q11. A newly recognized clinical feature is the presence of psychiatric illness in children and adults with VCFS. To ascertain the relationship between psychiatric illness, VCFS, and chromosome 22 deletions, we evaluated 26 VCFS patients by clinical and molecular biological methods. The VCFS children and adolescents were found to share a set of psychiatric disorders, including bipolar spectrum disorders and attention-deficit disorder with hyperactivity. The adult patients, >18 years of age, were affected with bipolar spectrum disorders. Four of six adult patients had psychotic symptoms manifested as paranoid and grandiose delusions. Loss-of-heterozygosity analysis of all 26 patients revealed that all but 3 had a large 3-Mb common deletion. One patient had a nested distal deletion and two did not have a detectable deletion. Somatic cell hybrids were developed from the two patients who did not have a detectable deletion within 22q11 and were analyzed with a large number of sequence tagged sites. A deletion was not detected among the two patients at a resolution of 21 kb. There was no correlation between the phenotype and the presence of the deletion within 22q11. The remarkably high prevalence of bipolar spectrum disorders, in association with the congenital anomalies of VCFS and its occurrence among nondeleted VCFS patients, suggest a common genetic etiology.     

Recognition of organic mental disorders by physicians.

To test the ability of nonpsychiatrist physicians to correctly diagnose organic mental disorders in patients who present with psychiatric symptoms a multiple-choice questionnaire was distributed. Given six brief case histories, little more than half (55%) of the respondents made the right choice even half of the time. The results strongly suggest a need among physicians for increased familiarity with the psychiatric manifestations of medical-surgical conditions.     

Psychopathological symptoms in patients with primary hyperaldosteronism--possible pathways

A close comorbidity between endocrine diseases and psychopathological symptoms has been described in the literature. Until now only a few studies have reported about an increased anxiety and depressive symptoms in patients with primary hyperaldosteronism (PHA). The exact pathways of psychiatric comorbidities have not been totally clarified yet, although the renin-angiotensin-aldosterone-system has gained more attention in research on anxiety and depression. There are several structures and factors, which could mediate anxiety or a depressive symptomatology. Additionally a possible influence of the standardised treatment with a mineralocorticoidreceptor (MR) antagonist or adrenalectomy should be investigated as they have been shown to affect mood. Psychiatric comorbidities are not only an additional burden in these patients, but as depression and anxiety are additional risk factors in patients with cardiovascular diseases. Possible pathomechanisms in the relation between PHA and psychiatric symptoms should be more closely investigated. For the clinical practice a regular screening for psychiatric comorbidities and an adequate treatment are required.     

The Psychosomatic Emergency

Many psychiatric problems present themselves under the guise of physical rather than mental symptoms.These occur in several categories: (1) Psychological problems which work in conjunction with definitive organic pathology, such as the fear of death. (2) Symptoms produced by altered physiology or biochemistry resultant from an acute orchronic stress state. (3) A combination of A and B above. (4) Patients with an intense disease, such as hypochondriasis. (5) Psychiatric symptoms, such as depression, anxiety or apathy which develop antecedent or subsequent to a fearfully anticipated illness or procedure.These patients have certain characteristics in common. (1) They manifest a disproportionate concern over symptoms. (2) The symptoms are inconsistent with the usual pattern of organic disease. (3) The onset is concurrent with states of conflict. (4) There is usually a personal and family history of psychic and psychosomatic disorders. (5) Other psychiatric disorders are usually present. (6) Secondary gain is usually evident.These patients can be successfully treated within the hospital setting and within the framework of psychiatric consultation and psychotherapy.     

Platelet serotonin concentration in dialysis patients with somatic symptoms of depression

Platelet serotonin (5-HT) concentration was measured in 65 male and 45 female chronic renal patients on hemodialysis (HD) with different somatic symptoms of depression (crying spells, irritability, sleep disturbance, fatigability, loss of appetite, weight loss, somatic preoccupation and loss of libido), to find out the relationship between the severity of symptoms and platelet 5-HT concentration. Male and female patients had significantly lower platelet 5-HT concentration than 62 male and 38 female healthy subjects. Gender-differences in platelet 5-HT values observed in healthy subjects were not found in patients. Platelet 5-HT concentration differed in the groups of patients with the different scores of particular somatic symptoms (loss of appetite and loss of libido), but was similar in patients with other somatic symptoms. There was no relationship between platelet 5-HT concentration and the severity of somatic symptoms, or between platelet 5-HT concentration and age of the patients. Gender-related differences in the occurrence of somatic symptoms were detected in patients with the different degrees of weight loss, somatic preoccupation and loss of libido. Our results suggest that platelet 5-HT concentration could not be used as a biological marker for the severity of somatic symptoms in chronic renal patients on HD.     

PSYCHOSOMATIC PROBLEMS IN UROLOGY

The intimate relationship between the urinary and genital systems permits stimuli in one system to influence the other. At least 15 per cent of women with symptoms of cystitis have no organic basis for their complaints. In psychiatric studies it has been noted that sexual conflict is the primary etiological factor in these patients. In some cases, continuance of the disorder leads to irreversible organic change. Urinary symptoms such as frequency, urgency, burning or retention are most common in women and become an automatic response to anxiety-provoking or sexual stimuli.In men, functional urinary symptoms are relatively infrequent. Often they indicate problems of genital dysfunction. Complaints of impotence, penile pain, testicular pain, or non-specific urethritis stem back to difficulties in their sexual lives. Many of the patients have symptoms of a generalized anxiety tension state due to sexual problems.A purely organic consideration of genitourinary disorders will lead to erroneous conclusions and unsatisfactory therapeutic results. The psychosomatic approach—that is, considering both physical and psychological aspects—will explain many hitherto difficult cases.     

Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis

Deep venous thrombosis and pulmonary embolus are known risks of surgery. However, the incidence of these conditions in face lift is unknown. In this study, the incidence of deep venous thrombosis/pulmonary embolus after face lift is studied and factors associated with thromboembolic complications are evaluated. One-third of the active members of the American Society for Aesthetic Plastic Surgery were randomly selected. Participating surgeons completed a one-page survey providing information on face-lift procedures during a 12-month study period. A response rate of 80 percent was achieved, with 273 of the 342 surgeons responding to the survey. A total of 9937 face-lift procedures were reported in the 1-year study period. There were 35 patients with deep venous thrombosis (0.35 percent), 14 patients with pulmonary embolus (0.14 percent), and 1 patient death in the series. Although 43.5 percent of patients underwent face lift under general anesthesia, 83.7 percent of deep venous thrombosis/pulmonary embolus events occurred with general anesthesia. For prophylaxis for deep venous thrombosis/pulmonary embolus, 19.7 percent of the surgeons used intermittent compression devices, 19.6 percent used thromboembolic disease hose or Ace wraps, and 60.7 percent used no prophylaxis. Of patients developing deep venous thrombosis/pulmonary embolus, 4.1 percent were treated prophylactically with intermittent compression devices, 36.7 percent with thromboembolic disease hose/Ace wraps, and 59.2 percent with no prophylaxis. It was found that deep venous thrombosis/pulmonary embolus after face lift is a measurable complication experienced by one of nine surgeons surveyed. Deep venous thrombosis/pulmonary embolus is more likely to occur when the procedure is performed under general anesthesia. The majority of plastic surgeons surveyed used no prophylaxis for deep venous thrombosis when performing face-lift procedures. Intermittent compression devices were associated with significantly fewer thromboembolic complications, whereas Ace wrap/thromboembolic disease hose afforded no protection against deep venous thrombosis/pulmonary embolus when used alone. In conclusion, aesthetic surgeons should consider adopting intermittent compression devices when performing face lift under general anesthesia.     

Cysteamine attenuates the decreases in TrkB protein levels and the anxiety/depression-like behaviors in mice induced by corticosterone treatment

Objective

Stress and glucocorticoid hormones, which are released into the circulation following stressful experiences, have been shown to contribute significantly to the manifestation of anxiety-like behaviors observed in many neuropsychiatric disorders. Brain-derived neurotrophic factor (BDNF) signaling through its receptor TrkB plays an important role in stress-mediated changes in structural as well as functional neuroplasticity. Studies designed to elucidate the mechanisms whereby TrkB signaling is regulated in chronic stress might provide valuable information for the development of new therapeutic strategies for several stress-related psychiatric disorders.

Materials and Methods

We examined the potential of cysteamine, a neuroprotective compound to attenuate anxiety and depression like behaviors in a mouse model of anxiety/depression induced by chronic corticosterone exposure.

Results

Cysteamine administration (150 mg/kg/day, through drinking water) for 21 days significantly ameliorated chronic corticosterone-induced decreases in TrkB protein levels in frontal cortex and hippocampus. Furthermore, cysteamine treatment reversed the anxiety and depression like behavioral abnormalities induced by chronic corticosterone treatment. Finally, mice deficient in TrkB, showed a reduced response to cysteamine in behavioral tests, suggesting that TrkB signaling plays an important role in the antidepressant effects of cysteamine.

Conclusions

The animal studies described here highlight the potential use of cysteamine as a novel therapeutic strategy for glucocorticoid-related symptoms of psychiatric disorders.     

Perfusion Lung Scans Provide a Guide to Which Patients With Apparent Primary Pulmonary Hypertension Merit Angiography

There is hesitancy, based on the perceived risk, to do pulmonary angiography in patients believed to have primary pulmonary hypertension. Yet pulmonary hypertension due to major-vessel, chronic thromboembolism mimics primary pulmonary hypertension clinically and on standard laboratory tests. Because thromboembolic pulmonary hypertension is potentially remediable by thromboendarterectomy and primary pulmonary hypertension is not, differentiating between these disorders is essential. Angiography is required in patients with thromboembolic pulmonary hypertension to define the anatomic location of the thrombi. In evaluating perfusion lung scans of 110 patients with pulmonary hypertension to determine whether the scan might provide a guide to selecting those patients who merit angiography, no segmentalsize perfusion defects were noted on the scans of 64 patients with primary pulmonary hypertension, whereas all 46 patients with thromboembolic hypertension had one or more defects that were segmental in size or larger. These data indicate that a perfusion lung scan should be done in patients with pulmonary hypertension of uncertain cause and that those with one or more segmental or larger defects merit pulmonary angiography before being diagnosed as having primary pulmonary hypertension.