James E. Miles

A comparative psychometric study of anorexia nervosa and obsessive neurosis.

Similarities between anorexia nervosa and obsessive-compulsive disorder have been described by a number of authors but few empirical investigations have been reported. In the current study, 15 female anorexics were compared with 14 age-matched female obsessives on a variety of psychometric tests, psychiatrists ratings and self-rating scales. Obsessives and anorexics obtained similarly high obsessive symptom and trait scores on the Leyton Obsessional Inventory (LOI). Both groups were rated by the psychiatrist as similarly obsessive, and there were no significant group differences in self-ratings of obsessive symptoms. Both groups were characterized by high levels of neuroticism and anxiety and low levels of extraversion. In the anorexic group the 6 abstainers had higher resistance scores on the LOI and higher extraversion scores on the MPI than the 9 bulimics. Findings are discussed with reference to the “sorcerers apprentice” syndrome which appears to characterize both the obsessive and the anorexic.

Psychiatric disorders associated with atypical facial pain.

Atypical facial pain (AFP) patients classically present with a chronic discomfort that is neither anatomic nor dermatomal in distribution. Neuropsychiatric assessment of 68 patients with AFP indicated that 46 (68%) had a specific psychiatric disorder by DSM-III criteria. A wide spectrum of psychiatric disorders was present. The authors emphasize that psychiatric assessment of patients with AFP should be an integral part in early assessments of this disorder, rather than relying on psychiatric opinions after extensive dental and other invasive procedures have been tried in vain and often to the detriment of the patient. Comments on the excellent prognosis in treating the psychiatric syndromes associated with AFP are made.

Ineffective dental and surgical treatment associated with atypical facial pain

Patients with atypical facial pain (AFP) are subject to ineffective dental and surgical procedures for their pain complaints. Twenty-one of fifty-eight patients (36.2 percent) with AFP had sixty-five dental and surgical treatments, with only one patient showing less pain as a result of the treatment. While the majority of patients (69 percent) with AFP suffered from a psychiatric illness, fourteen (24 percent) of the patients referred for AFP had a specific medical or dental disorder that was causal in their pain complaints. There is a trend for the AFP patient with a psychiatric diagnosis to receive more ineffective treatments than those AFP patients for whom a specific medical or dental diagnosis was made. Patients with AFP should receive conservative dental and medical treatment and a psychiatric assessment before dental and surgical procedures are contemplated.

Medical Student Change During a Psychiatry Clerkship: Evaluation of a Program.

The psychiatry clerkship at the University of British Columbia (U.B.C.) emphasizes the teaching model of the student as primary therapist. In the adult program this takes the form of a ward in which clinical clerks are the primary medical agents. In the child program each clerk assesses and treats a new family referral. While the student-ward model has been described previously, this is the first report which attempts to evaluate some aspects of this innovative approach to teaching clinical psychiatry. Student knowledge, attitudes, personality attributes, and expectations were assessed at the beginning and end of the eight-week rotation, and the changes are described. Principal findings included significant differences in the following: psychiatric knowledge, attitudes about psychiatric illness, ratings of the students by the psychiatrist-supervisor, and some student personality characteristics. Most students had rotation experiences which went beyond prior expectations. The changes which occurred were thought to be important, although modest. The implications of the changes are discussed. The level of the patient care in the programs described compared favorably with similar situations in which residents are the primary therapists.

The comparative psychopathology of anorexia nervosa: Obsessive-compulsive disorder or phobia?

The current study investigates the similarities and differences between anorexic restricters, anorexic bulimics, female obsessives, agoraphobics, social phobics, and specific phobics. Measures of psychopathology were self-ratings of adjustment, the IPAT, FSS, MPI, and LOI. Results indicated that persons suffering from anorexia nervosa and bulimia nervosa were more similar to obsessives than to phobics with respect to obsessional personality traits and neuroticism. Additional research is needed in the examination of the central preoccupation in order to understand the differentiation of the various disorders and to what extent anorexia nervosa is a nosological entity.

A Comparison of the Safety and Efficacy of Alprazolam and Desipramine in Moderately Severe Depression

Fifty-four patients (34 outpatients, 20 inpatients)fulfilling Research Diagnostic Criteria for Definite Major Depressive Disorder were enrolled in a double-blind study comparing the antidepressant effects of alprazolam versus desipramine. The mean daily dose of alprazolam and desipramine at study termination was 3.78mg and 208mg respectively. As there were no significant demographic or clinical differences between outpatients and inpatients, both groups were combined in data analysis. Using the Hamilton Depression Rating Scale (HAM-D) both drug groups showed highly significant improvement beginning with the first week of active drug treatment. HAM-D scores continued to decrease through study termination (six weeks of active drug). There were no significant differences when comparing alprazolam and desipramine (outpatients, inpatients, or both groups combined) on any of the subjective or objective psycho-metrics used in this study. Clinically, only twelve of thirty-four outpatients (35.3%) were felt to be “markedly or moderately” improved, suggesting that neither the outpatient alprazolam nor desipramine patients did particularly well with drug treatment. In terms of drug safety there was no difference between the alprazolam and desipramine in the number of excessive or serious drug side effects. However, five of twenty-nine alprazolam patients had to discontinue therapy because of excessive drowsiness, and two of the alprazolam outpatients had motor vehicle accidents directly related to this adverse event. Alprazolam appeared as effective as desipramine in the pharmacotherapy of this group of depressed outpatient and inpatients. Alprazolam appeared well-tolerated by most subjects although drowsiness was a common — and at times serious — medication side effect.

The medical student therapist. Treatment outcome.

Summary Sixty inpatients from a psychiatric ward, where senior medical students function as the sole primary physicians, were matched with 60 inpatients from two other wards in the same hospital who had been attended by psychiatric residents and certified psychiatrists. The problem-oriented medical record was used as a basis for treatment evaluation. Ratings by the patient at discharge, and the patient, a significant other and follow-up professional at three months, showed no significant difference in the treatment outcome between the two groups.

The psychiatric referral in dentistry: Indications and mechanics

Psychiatric consultation is sometimes a part of the diagnostic evaluation of facial pain. The indications for referral arise out of the history. Several brief questions may indicate whether or not a psychiatric illness is present. Patients may hold beliefs or attitudes about their illness or about psychiatric treatment that make referral difficult. Successful referral depends on the relationship that the dentist establishes with the patient. Recommendations to facilitate the referral are presented.

The art of pharmacotherapy in depressed outpatients

There is an art to prescribing medications to depressed patients. Both patient and therapist/actors are important to a successful outcome with appropriate timing and prescribing of treatment. Two case reports are provided as examples. Specific strategies used by experienced clinicians are presented in the discussion.

Neuropsychiatric and electroencephalographic aspects in the diagnosis of complex partial seizures.

The authors review from a psychiatric perspective some of the electroencephalographic techniques that may assist the clinician in diagnosing complex partial seizures (temporal lobe epilepsy). Routine scalp electroencephalograms may not detect temporal lobe EEG abnormalities, leading to the false impression of pseudo or hysterical seizures. Knowledge of the advantages of a sleep recording, specialized EEG electrodes (nasopharyngeal, sphenoidal), and natural or pharmacological activation techniques will increase ones diagnostic acumen. The authors discuss the appropriate use of these methods and their relevance to psychiatry.