Steven Lippmann

Attention Deficit Disorder in Adults

ADHD/ADD, once thought to occur only in children, is now recognized as continuing into adulthood in many people. In order to be labeled as such, signs and symptoms must start before age 7 and are primarily characterized by inattention, distractibility, and impulsiveness. Although the exact mechanism is unknown, a number of associated neurochemical and structural abnormalities have been observed. This disorder can negatively affect the educational, social, and occupational lives of those who suffer from its symptoms. It interferes with the ability to establish and maintain close relationships. Pharmacotherapy remains the primary mode of treatment. Stimulants such as dextroamphetamine and methylphenidate are the main drugs utilized; they are available in immediate and longer duration versions. Bupropion is another important medicinal option, and there are a variety of other miscellaneous medications to consider, including modafinil, venlafaxine, tricyclic antidepressants, and guanfacine. Psychotherapy is shown to help control impulsiveness, form more satisfactory relationships, rear children more effectively, and improve organizational and problem-solving skills.

HAIR LOSS IN PSYCHOPHARMACOLOGY

Medication-induced alopecia is an occasional side effect of many psychopharmaceuticals. Most of the mood stabilizer and antidepressant drugs can lead to this condition. Some antipsychotic and antianxiety agents induce alopecia. Hair loss is also related to hypothyroidism, which can be induced by lithium and other agents. Alopecia might not be reported by some people, but physicians should be aware of this potential problem which may contribute to noncompliance. Lithium causes hair loss in 12–19% of long-term users. Valproic acid and/or divalproex precipitates alopecia in up to 12% of patients in a dose-dependent relationship. Incidences up to 28% are observed with high valproate concentration exposures. These pharmaceuticals also can change hair color and structure. The occurrence of carbamazepine-induced alopecia is at or below 6%. Hair loss is less common with other mood stabilizers. Tricyclic antidepressants, maprotilene, trazodone, and virtually all the new generation of antidepressants may on rare occasions lead to alopecia. The same applies to haloperidol, olanzepine, risperidone, clonazepam, and buspirone, but not to other neuroleptics, benzodiazepines, or barbiturates, selected antihistamines, and antiparkinsonians. Discontinuation of the medication or dose reduction almost always leads to complete hair regrowth. The therapeutic value of mineral supplements remains unclear.

Emotional adjustment to cardiac transplantation

Emotional adjustment to cardiac transplantation is a phasic process. Each step is associated with a milestone in the transplantation protocol. The adjustment process is divided into seven distinct stages: 1) transplant proposal, 2) evaluation, 3) awaiting a donor organ, 4) perioperative period, 5) inhospital convalescence, 6) discharge, and 7) post-discharge adaptation. Patient adjustment to transplantation is influenced by the adaptive task of each stage in the procedure, personality factors, previous experience with illness, and social support. Patients need time to adjust to each stage. Do not pressure them into premature acceptance of transplantation. Verbalization of feelings should be encouraged, and adequate support ensured. Contact with already transplanted patients is helpful to surgical candidates. Psychiatric assistance can greatly aid in patient management and emotional adjustment.

AIDS: Psychological stresses on the family

Abstract Psychological repercussions of AIDS on family members were assessed and treated during psychiatric consultations over 4½ years with 50 relatives of 15 AIDS patients. The most frequent sources of stress were fears of contracting AIDS, the simultaneous revelations of homosexual or bisexual activity and what could prove to be a terminal disease, notoriety, a sense of helplessness, and grieving, especially among parents. Beneficial interventions for relatives include the provision of accurate information, a nonjudgmental approach, grief counseling, and peer-support groups, which in particular combat the sense of isolation felt by the family.

Heart transplant candidates rejected on psychiatric indications:Experience in developing criteria for proper patient selection

Abstract Heart transplantation necessarily involves allocation of a scarce resource. Seventy candidates for the operation were evaluated by a psychiatrist providing consultation for a transplantation team. Thirteen patients were determined to be unsuitable for the surgery owing to psychiatric factors. The psychiatric recommendation to the team for selection or nonselection was based on evaluation of the patients ability to overcome such challenges of transplantation as waiting for a donor, psychological incorporation of the new organ, and, especially, compliance with the medical regimen. Certain DSM-III diagnoses proved to be major impediments to patient selection. Based on their experience, the authors present specific recommendations for assessing candidates.

Psychiatric consultation for acute amputees: Report of a ten-year experience

Abstract Eighty-six patients receiving amputations (59 scheduled surgical amputations and 27 at the accident scene) were referred, usually after the amputation, to the psychiatric consultation service. Reasons for referral included assistance in coping, evaluation for depression, management of pain medication, behavioral problems, and suicidal ideation. Major reactions to amputation included flashbacks to the accident, body-image disturbances, a sense of helplessness, and grieving. Successful treatment interventions included psychotherapy, appropriate psychotropic or pain medication, grief counseling, and peer-group support. Psychiatric consultation also focused on improving the patients relationship with other caregivers, and it reduced the length of hospitalization somewhat.

Divalproex: a Possible Treatment Alternative for Demented, Elderly Aggressive Patients

Elderly, demented people often exhibit behavioral dyscontrol. Divalproex appears to be safe and effective in the management of this presentation. Twelve cases treated with divalproex all responded with improved emotional control. Patients became less verbally and physically disruptive and much more socially appropriate. Divalproex was well tolerated in this population with none of the subjects experiencing significant medicinal side effects. This uncontrolled report suggests that divalproex should be considered as a pharmacotherapy for aggressivity in cognitively impaired, elderly people.

Psychiatric Aspects of Parathyroid Disease

Parathyroid diseases can present with psychiatric symptoms and can be recognized through determinations of serum electrolytes, especially the calcium level. Psychiatric evaluations should include a serum calcium concentration test, which is also essential in reassessment of patients poorly responsive to mental illness treatment. A magnesium and a phosphate assay may also be diagnostically helpful. Abnormality of divalent cation levels may provide evidence for consideration of, or ruling out, parathyroid disorders. Determinations of parathyroid hormone are performed if clinically indicated, and if abnormal divalent cation quantifications are confirmed. If parathyroid disease is identified, corrective endocrine therapies may diminish or even cure psychiatric aspects of parathyroid pathology. Failure to recognize a parathyroid disorder leaves an endocrine-induced mental dysfunction without proper treatment.

Implementation of a smoking ban on a locked psychiatric unit.

The purpose of this study was to measure alterations in the level of disruptive patient activity on a locked psychiatric unit after initiation of a smoking ban. Most of the monitored parameters of disruptive behavior remained stable, and/or changes did not reach statistical significance after the implementation of the smoking prohibition. This is in agreement with previous investigations. The only exception was an increase in the amount of p.r.n. medications dispensed specifically for agitated behavior [t(8 df) = -3.07 (p = 0.015)]. Though major clinical disturbances did not occur, it appeared that patients experienced a small yet documentable increase in agitation. Despite there being no major problems in establishing a smoke-free psychiatric service, abolishing tobacco products may create some minor management difficulties. This may be most commonly observed on locked units that treat large numbers of severely disturbed, involuntarily hospitalized individuals.

Electroconvulsive therapy in the acute poststroke period.

A depressed patient was successfully treated with electroconvulsive therapy approximately 7 to 14 days after a cerebellar stroke. This report documents an uncomplicated use of electroconvulsive therapy that was well tolerated and effective in a course of eight treatments in the acute poststroke period.