Richard C. W. Hall

BRIEF COMMUNICATION: Tricyclic Exacerbation Of Steroid Psychosis

Four patients in a series of 14 cases of steroid psychosis where steroids were used to treat disease not effecting the central nervous system, are reported. All demonstrated a predominantly affective mood change prior to initiation of treatment with tricyclic antidepressants by the primary physician. In each case, the patients mental state deteriorated rapidly following initiation of tricyclics in mid-dose range (i.e., 100 to 150 mg q.d.). These agents produced a qualitative change in the nature of the patients psychosis rather than simply aggravating pre-existent features. All patients experienced visual hallucinations within 4 days of tricyclic administration. Persistent auditory hallucinations (two cases) became threatening, accusatory, and constant. The exacerbated psychosis cleared rapidly with the discontinuation of the antidepressant and the addition of a phenothiazine. Phenothiazines, in doses of 400 to 800 mg q.d., were necessary to reverse the symptoms of these patients. Phenothiazines were also required to produce a salutary effect in the 10 patients who did not receive tricyclics, but at an average dose of only 200 mg. Steroids raise the effective blood level of tricyclics and alter central catecholamine movement across membranes. These changes may represent the mechanism for exacerbation of steroid psychoses.

Categorization of Types of Medical/Psychiatry Units Based on Level of Acuity

Medical/psychiatry units can be categorized by the level of acuity of medical and psychiatric illness. Type I units are categorized as those that primarily provide psychiatric care with a low level of medical acuity. Type II units include general medicine or medical subspecialty units that are associated with a psychiatric liaison service and provide low levels of psychiatric care to those admitted to the general medical setting. Type III and Type IV units are characterized by a true departure from the current ward settings and care for patients who have concurrent and more severe medical and psychiatric problems in a unified setting. Both of these units require special physical changes in the ward structure, additional nurse training, and coordinated physician coverage to function effectively.

A computerized biochemical profile for detection of alcoholism.

Abstract The authors present a seven-item biochemical and hematologic profile which, when used in a computerized linear discriminant analysis procedure, correctly identified 79% of alcoholic patients and 80% of nonalcoholic patients in their study group. The profile is adaptable for use in automated initial screening for covert alcoholism.

Psychiatric manifestations of Hashimoto's thyroiditis

Abstract The mental symptoms associated with Hashimotos thyroiditis may precede the full-blown, classic picture of hypothyroidism. The psychiatric symptoms include various mental aberrations, depression, irritability, and confusion. Indeed, patients may be mislabeled as having psychotic depression, paranoid schizophrenia, or the manic phase of a manic depressive disorder. The workup must include a thorough evaluation of thyroid function, including tests for autoantibodies. Patients usually respond favorably to thyroid replacement hormone therapy.

Anticholinergic psychosis: differential diagnosis and management.

Abstract The central anticholinergic syndrome occurs frequently but is often unrecognized because many patients’ symptoms do not appear in a well-defined pattern. Symptoms range from confusion and agitation to coma. Two brief case reports illustrate the presentation and diagnosis of the syndrome. Its management, including psychological support and the administration of physostigmine, is discussed.

Covert Outpatient Drug Abuse Incidence And Therapist Recognition

One hundred ninety-five consecutive psychiatric outpatients were surveyed for covert drug abuse by a standardized technique for determining opiates, cocaine, barbiturates, and amphetamines in urine samples. On the basis of demographic variables, diagnostic information, and treatment course, patterns of abuse were defined for the 13.3 per cent with positive test results. Covert abusers demonstrated a higher incidence of adverse drug reactions and a less favorable therapy course than controls. Covert abuse was meaningfully related to misdiagnosis, management problems, and therapists response.Demographic variables and patient reports of previous abuse were not found to be reliable predicators of covert drug abuse. Urine screening for drug use is recommended as an aid to proper diagnosis of psychiatric outpatients that present diagnostic questions.

Hypomagnesemia in Patients with Eating Disorders

One hundred seventy-five patients, admitted to the Eating Disorder Unit of Florida Hospital, Altamonte, were evaluated for electrolyte disorders, with particular reference to hypomagnesemia. Careful physical examination conducted by an internist, three separate histories, an eating-disorder questionnaire, psychometric testing, and the Beck and Zung scales for rating depression were used. The symptoms reported in the medical literature associated with hypomagnesemia were evaluated by the patients blind for the presence of this condition, using an analogue scale. Following treatment, improvement in symptoms was noted. One hundred eating-disorder patients with normal magnesium levels were used as controls. The study demonstrated an incidence of hypomagnesemia of 25%. When the hypomagnesemic patients were compared to controls and electrolyte balance, eight symptoms statistically defined the hypomagnesemic group. These included muscular weakness, cramping of the extremities, restlessness, parasthesias, diminished concentration, cardiac arrythmias, hypertension, and diminished recent memory. Magnesium replacement over several weeks was usually necessary to correct the imbalance when replacement was by the oral route. Hypomagnesemia is an important and often overlooked electrolyte abnormality that occurs in eating-disorder patients. Consequently, it should be routinely evaluated in eating-disorder patients on admission to hospital.

Differential diagnosis of somatopsychic disorders

Abstract A substantial number of patients who present with psychiatric symptoms are suffering from underlying or unrecognized medical illnesses. Only by an awareness of differential diagnostic factors and a high index of suspicion can the clinician avoid misdiagnosis and inappropriate treatment of these somatically ill patients. The authors discuss some of the general characteristics that can help differentiate medical illness from primary psychiatric illness, and outline the psychiatric findings commonly associated with a number of physical illnesses.

The role of the nurse on a consultation-liaison team

Abstract The authors report on the role and functions of a nurse-consultant on an expanding psychiatric consultation-liaison service. One hundred consecutive requests for intervention by a nurse were compared with 100 consecutive requests for psychiatric intervention. Psychiatrists saw 3½ times as many patients on critical care units as did the nurse-consultant. Patient withdrawal and depression were the prime reasons stated for requesting consultation with the nurse, but 24% of the cases seen by the nurse focused on issues of death and dying or on the need for staff or family support, areas in which formal psychiatric intervention was not routinely requested.

Drug-induced psychosis: Emergency diagnosis and management

Abstract In evaluating a patient with toxic psychosis, the clini cian should distinguish between a schizophreniform reaction with excessive sympathetic activity suggestive of amphetamine or co caine overdose and a sensory-distorted reaction more likely to accompany hallucinogen ingestion. Toxic psychosis due to exces sive anticholinergic intake is marked by abrupt onset, dilated pupils, and blurred vision. The basic principles of poison man agement should be followed, with close patient observation and conservative treatment.