Quentin R. Regestein

Basis for recurring ventricular fibrillation in the absence of coronary heart disease and its management.

A 39-year-old man twice experienced ventricular fibrillation and exhibited numerous ventricular premature beats. Coronary arteries were normal, and no impaired cardiac function was found upon catheterization. Evidence was adduced that the ventricular premature beats were related to higher nervous activity. The patient had serious psychiatric problems; the ventricular premature beats were provoked by psychophysiologic stress, increased during REM sleep, were reduced by meditation, and were controlled by beta-adrenergic blockade, phenytoin and digitalization. We conclude that psychologic and neurophysiologic factors may predispose to life-threatening cardiac arrhythmia in the absence of organic heart disease. Effective management of the recurrent ventricular arrhythmia involved; acute drug testing for assessing antiarrhythmic efficacy; use of programmed trendscription to provide on-line information on drug action; a treatment program involving more than one agent; and use of measures to reduce sympathetic nervous activity.

Subjective hypnotic efficacy of trazodone and zolpidem in DSMIII–R primary insomnia

Trazodone is an antidepressant which is used at low doses as a hypnotic. The hypnotic efficacy of trazodone in non‐depressed insomniacs is unknown, especially in comparison to hypnotic medications such as zolpidem. Following a placebo screening week, DSM‐IIIR defined primary insomniacs were randomized into a parallel‐group, double‐blind, 14‐day comparison of trazodone 50 mg, zolpidem 10 mg and placebo. Patients completed daily morning questionnaires and weekly office visits. Self‐reported sleep latencies were compared by the Cox proportional hazards regression technique; self‐reported sleep duration by ANOVA. During treatment Week 1, both drugs produced significantly shorter self‐reported sleep latencies and longer self‐reported sleep durations than placebo. Self‐reported sleep latency was significantly shorter with zolpidem than with trazodone. During Week 2, only the zolpidem group maintained a significantly shorter sleep latency than the placebo group, and self‐reported sleep duration did not vary significantly among groups. The incidence of adverse events was low in all groups. Both trazodone and zolpidem improved self‐reported sleep latency and duration of non‐depressed, primary insomniacs; zolpidem was somewhat more efficacious at the doses studied.

Sleep debt and depression in female college students.

The objective of the study was to evaluate relationships between sleep habits and depressive symptoms. Pilot study data were collected about sleep schedules, related factors and depression in female college students to find whether their sleep schedules correlate with affective symptoms. In the subsequent main study, similar information was collected under more controlled conditions. Depression was measured using the CES-D (Center for Epidemiologic Studies Depression Scale) and HAM-D-3 (modified Hamilton Depression Rating Scale). Response rates were 31.3% of eligible students for the pilot survey and 71.6% for the main study. Both studies showed that about 20% of students reported weekday sleep debts of greater than 2 h and about 28% reported significantly greater sleep debt and had significantly higher depression scores (P<0.0001) than other students. Melancholic symptoms indicated by high CES-D scores (>24), were observed in 24% of students. Sleep problems explained 13% of the variance for both the CESD scale and the HAM-D-3 scale. Among female college students, those who report a sleep debt of at least 2 h or significant daytime sleepiness have a higher risk of reporting melancholic symptoms than others.

Self-reported hyperarousal traits among insomnia patients

Hyperarousal Scale scores for certain self-reported behaviors reportedly correlate with EEG arousal measures. We tested whether an insomnia subject group had different Hyperarousal Scale scores compared with hypersomnia, delayed sleep phase syndrome, procrastinator or normal subject groups. Compared with 139 normal subjects, mean scores for a group of 256 insomnia subjects was significantly 1.2 S.D. higher on Hyperarousal total scale score, 0.82 S.D. higher on React subscale score and 0.85 S.D. higher on Introspectiveness subscale score. The insomnia group median Extreme score was 2.25 times that of the normal group. These self-report findings suggest that insomnia subjects may be more responsive generally. All sleep disorder groups had increased total Hyperarousal scores, although these increases were accounted for by different scale items. The procrastinator group had Hyperarousal score patterns that generally differed from those of the other groups.

Treatment of delayed sleep phase syndrome

Delayed sleep phase syndrome (DSPS) is a common but little reported cause of severe insomnia. Affected individuals complain of difficulty falling asleep and difficulty awaking at socially acceptable hours. It results from a dysregulation of the circadian sleep-wake cycle. DSPS presents in clinically heterogenous ways as modulated by motivation, psychopathology, drug status, and treatment compliance factors. Patients respond variably to the range of possible treatments. Bright light treatment potentially corrects the circadian abnormality of DSPS. Other treatments reported to relieve some DSPS patients include schedule shifts, drugs, and vitamin and hormone treatments. The safety and efficacy of light treatment have not been conventionally defined, but available information suggests that it is ophthalmologically safe. At present, DSPS must be managed empirically by various methods.

Pedophilia Occurring After Onset Of Cognitive Impairment

Four married patients are reported who first manifested pedophilia and other signs of disinhibition after sustaining illnesses that led to cognitive impairments. Although pedophilia may often be related to a long-standing inadequacy of sexual functioning, the onset of pedophilia in an individual without a previous history of sexual perversion may indicate the presence of recently sustained cognitive impairments.

A case of prolonged, reversible dementia associated with abuse of electroconvulsive therapy.

Standards for the use of electroconvulsive therapy (ECT) are being considered in Massachusetts. While the relative safety of ECT is sometimes used to justify its extensive use, ECT is abused in some cases, causing prolonged deficits in sensorium. A case of an ECT-induced, prolonged, reversible dementia is presented as an example of present abuses and the need for standards.

Daily sleep patterns observed among institutionalized elderly residents.

The sleep/wake patterns of 16 institutionalized demented women were visually monitored hourly for 14 consecutive days. Individual mean total sleep time varied markedly from 5.0 to 12.1 hours per 24 hours. Unexpectedly, amounts of day sleep and night sleep correlated positively, suggesting a general sleep tendency manifested throughout the 24‐hour day. Consistent individual sleep patterns and high inter‐day correlations were found. A high degree of individuality in the sleep/wake patterns was also found, contrary to expectations that elderly obtain less sleep than others. Night sleep in the institutionalized elderly was not lessened by daytime sleep. Visual monitoring of sleep/wake patterns generated reliable data.

Neuropsychological Effects of Methyltestosterone in Women Using Menopausal Hormone Replacement

To observe the effects of androgen replacement on neuropsychological measures in menopausal women, healthy menopausal women already using replacement estrogen were studied in a randomized, double-blind, active placebo-controlled, crossover comparison between two 8-week periods of treatment with (1) 0.625 mg oral esterified estrogen (E) alone and (2) in combination with 1.25 mg oral methyltestosterone (meT). After an initial baseline session, data were gathered at the end of two treatment periods. Scores on standardized psychological tests and computerized reaction times were compared between treatments, as was an overall outcome score that combined all measures. Added meT significantly improved scores on a test of complex information processing, the Switching Attention Test, but not on other tests. Mean outcome score showed no net change and wide variation. Fourteen subjects had outcome scores >1 SD from the mean, and 21 had no change. In the estrogen alone condition, three measures predicted favorable outcome with added meT: surgically compromised ovarian function, fewer physical symptoms, and higher score on a self-image measure of creativity. Added meT treatment may improve complex information processing. Despite wide disparities in outcome, an increased chance of overall improvement may be predicted by specific pretreatment measures.

Relationship among estrogen-induced psychophysiological changes in hypogonadal women.

&NA; Estrogen treatment of 16 hypogonadal women showed lessening of gonadotrophins, vasomotor symptoms, psychometrically measured aggression, and average sleep latency, but more Rapid Eye Movement sleep in a 100‐day cross‐over, double‐blind comparison with placebo treatment. Of eight insomniac subjects, four showed decreased, but four showed increased insomnia scores and sleep latencies. Clinical rank of psychological intactness correlated with sleep latency and with total sleep time during the estrogen condition. Although estrogen altered both physiological and psychological states, such effects were characterized by different time courses and different degrees of consistency among the subjects.