Ronald L. Martin

Obsessive-compulsive disorder, trichotillomania, and anorexia nervosa: A case report

We report a case study of an 18-year-old female who presented with symptoms associated with several discrete diagnostic syndromes: obsessive-compulsive disorder, trichotillomania, major depression, and anorexia nervosa. Improvement in each occurred after treatment with the serotonin selective reuptake inhibitor, fluoxetine, suggesting that such syndromes share a common serotonin neurotransmitter disturbance. Furthermore, the combined effects of medication and psychotherapy resulted in improvement in assertiveness, sense of security, self-worth, flexibility, and self-regulation. We discuss the pharmacological and psychotherapeutic implications of possible psychophysiologic similarities among the previously mentioned syndromes.

Anticholinergic Toxicity Masquerading as Neuroleptic Malignant Syndrome: A Case Report and Review

Patients who present with acute neuropsychiatric syndromes pose difficult diagnostic and treatment challenges. A history of psychiatric illness and treatment with psychotropic medication may be valuable clues to diagnosis and management of such patients. However, this information may also tempt a clinician to focus on a premature diagnosis, excluding other important possibilities. A case of a 42-year-old male with recurrent psychotic illness who developed an abrupt deterioration in mental and physical status is presented. Despite an initial good response to physostigmine, he was diagnosed with neuroleptic malignant syndrome and did not receive subsequent treatment with cholinesterase inhibitors. The patient expired within hours of arriving in the emergency room. The postmortem benztropine level was elevated, leading to the attribution of death to anticholinergic toxicity. This case serves to illustrate the difficulties in distinguishing features of anticholinergic toxicity and neuroleptic malignant syndrome.

The Longitudinal Course of Alcoholism among Women Criminals: A Six-Year Follow-up

To date, little has been reported concerning the longitudinal course of alcoholism in criminal women. Glueck and Glueck [5], in their study of 500 delinquent girls, found that 40 percent “drank to excess” when followed-up as adults. Nineteen women were included in Maddocks’ [9] study of untreated psychopaths. A third of these women used alcohol “to excess” at a five-year follow-up. Maddocks generalized that many “psychopaths” (both men and women) eventually “drifted into” alcoholism, implying that alcoholism was a rather late complication in this group. Neither study, however, included the detailed longitudinal data necessary to evaluate the course of alcoholism in criminal women.

Diagnosis of posttraumatic stress disorder with the MMPI: PK scale scores in somatization disorder

Clinic patients with diagnoses of either major depression or somatization disorder were given the MMPI. Women with somatization disorder had high scores on Keanes MMPI scale (PK) for posttraumatic stress disorder. Following the procedure for the MMPI-2 (46 of the 49 PK items and MMPI-2 norms), 59% of the women with somatization disorder and 21% of the women with major depression would have T scores ≥ 65 on the MMPI-2 scale although none of them were known to have developed psychiatric disorder after exposure to a life threatening event. The PK scale has little use in the differential diagnosis of women patients with somatization disorder.

MMPI Screening Scales for Somatization Disorder

44 items on the MMPI were identified which appear to correspond to some of the symptoms in nine of the 10 groups on the Perley-Guze checklist for somatization disorder (hysteria). This list was organized into two scales, one reflecting the total number of symptoms endorsed and the other the number of organ systems with at least one endorsed symptom. Full MMPIs were then obtained from 29 women with primary affective disorder and 37 women with somatization disorder as part of a follow-up study of a consecutive series of 500 psychiatric clinic patients seen at Washington University. Women with the diagnosis of somatization disorder scored significantly higher on the somatization disorder scales created from the 44 items than did women with only major depression. These new scales appeared to be slightly more effective in identifying somatization disorder than the use of the standard MMPI scales for hypochondriasis and hysteria. Further development is needed.

LATE-LIFE PSYCHIATRIC DIAGNOSIS IN DSM-IV

Age is an important variable in the consideration of psychiatric diagnosis. This applies particularly to the presentation of psychiatric disorders in late life. DSM-IV has made a start but much more could be done, particularly for some disorders. It is hoped that more attention to age, especially late life, will be paid in DSM-V and beyond.