Psychiatric Times Vol 24 No 7

Epidemiological studies report a lifetime prevalence rate of 24.9% for (any) anxiety disorder. Feelings of anxiety can also be related to normal fear of pain, loneliness, ridicule, illness, injury, grief, or death. In both these types of situations, anxiety can be difficult to deal with. Consequently, benzodiazepines, which offer almost immediate symptomatic relief for anxiety, can be quite appealing to many persons.

Twenty years after the initial meeting of the International Congress for Schizophrenia Research (ICSR), this year's biennial ICSR remained true to its mission to serve as a venue for active researchers. ICSR hosted investigators in neuroscience, cognitive neuroscience, basic and clinical psychopharmacology, psychosocial interventions, and genetics.

The Casebook of a Residential Care Psychiatrist is knowledgeable, humorous, compassionate, and historical, with a strong plea that the mental health community become more involved in the rehabilitation of patients in RCFs.

One of the major challenges in child psychiatry is teaching the essentials of the field to the general physician or medical school student who needs some understanding of developmental issues and psychopathology. Dorothy Stubbe's contribution to this challenge is a small and well-written handbook published as part of the series, Practical Guides in Psychiatry.

Poetry of the Times

Early intervention in psychiatric disorders such as schizophrenia can have a wide range of effects on patient symptoms and outcome. A recent study published in the Journal of Clinical Psychiatry reported improvements with antidepressants and atypicals in adolescents in the "prodromal" stage of schizophrenia, although a psychotic disorder later developed in a quarter of the adolescents treated with atypicals.

States will come under new pressure to provide mental health data to the FBI gun purchase check system if Congress passes a bill being touted as a response to the Virginia Tech catastrophe in which a student gunman with previous mental health problems shot and killed 32 people. The National Instant Criminal Background Check System (NICS) Improvement Act (HR 297) now seems destined to pass Congress this year. It would provide grants to states to help them provide a variety of data to the FBI’s NICS on whether a person has been convicted of a misdemeanor crime of domestic violence or has been the subject of court orders, mental health adjudications, or commitments.

Although there are many treatments and interventions available for drug abuse and dependence, few persons with substance use disorders actually use them, a new survey reports. The National Epidemiologic Survey on Alcohol and Related Conditions, conducted by scientists from the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, was published in the May 2007 issue of the Archives of General Psychiatry. The survey used face-to-face interviews with over 43,000 US adults aged 18 years or older.

The FDA has ordered the addition of a "black box" warning to antidepressant labeling of increased suicide risk in adults aged 18 to 24 years. The labeling will also note that no increased risk has been seen in older adults and that, in fact, the incidence of suicidal thoughts and behavior has been found to decrease during antidepressant therapy in patients 65 years and older.

In 1980 DSM-III created a new diagnostic entity-posttraumatic stress disorder (PTSD). Although this condition had been described for centuries, it was always within the context of a particular stressor, most often war. The term shell shock was applied to World War I soldiers who seemed to have been struck senseless in the heat of battle. The horrors of World War II produced not only robust psychiatric morbidity in its combatants but also devastating emotional symptoms in the civilian victims of concentration camps and atomic bombs.

I grew up with a neighborhood kid who was a nice guy but burst into tears at even the tiniest of scrapes--heck, even if he fell down--so we always called him a crybaby. He seemed to be very tuned to his sensory environment--in our gang's perspective, overly tuned--hence the epithet for his behavior. The many unjust cruelties of childhood notwithstanding, was that really a fair accusation? There is growing evidence that may supply a solid molecular answer to this question. It may reveal the accusation to be not only emotionally unkind but also biologically unsound.

There are important distortions in the article "Substance Abuse in Women: Does Gender Matter?" (Psychiatric Times, January 2007, page 48). My concerns regard the political assumptions made (rather than those based on science) that put a spin on data rather than letting the data stand alone.

The field of psychopharmacology is evolving rapidly. New research and medications appear, and practice changes. This book was up-to-date when it went to press; however, it does not include the most recent findings from the CATIE, STAR*D study, and CATIE-AD study. There is no mention of paliperidone, intramuscular aripiprazole, selegiline transdermal system, varenicline, or depot inject- able naltrexone. One wonders whether books are becoming obsolete as a medium for communicating the state of the art.

In what was billed as the first randomized controlled study to simultaneously evaluate antidepressant therapy and short-term psychotherapy for depressed patients with coronary artery disease (CAD), treatment with an SSRI led to significant improvement, while addition of interpersonal psychotherapy provided no added benefit.

Patients with severe mental illness (SMI), such as schizophrenia, bipolar disorder, and major depression, are more likely to have experienced trauma in childhood, adolescence, and throughout their adult lives than the general population. This high exposure to traumatic events such as physical and sexual abuse and assault takes a heavy toll.

Traumatic experiences are linked with a continuum of mental disorders and physical complaints. In the United States, posttraumatic stress disorder (PTSD) occurs in approximately 8% of adults during their lifetime, with different trauma types associated with varying rates of illness. PTSD is commonly associated with comorbid mental conditions such as depressive disorders, other anxiety disorders, impulse control disorders, and alcohol abuse.

The traumatic events surrounding the recent school shootings at Virginia Tech remind us that a disturbing aspect of our current culture is the rate at which America's youth are exposed to violence. Whether it is graphic episodes of violence on television, violent music, aggressive video games, hearing about or witnessing violence in the home or neighborhood, or being the direct victim of violence--violence is a pervasive part of society that disproportionately affects youth.

Rape is a crime that is defined as an unwanted sexual act that results in oral, vaginal, or anal penetration. Generally speaking, there are 2 major types of rape. Forcible rape involves unwanted sexual penetration obtained by the use of force or threat of force. Drug- or alcohol-facilitated rape occurs when the victim is passed out or highly intoxicated because of voluntary or involuntary consumption of alcohol or drugs. Rape can happen to boys and men as well as to girls and women but this article will focus primarily on women.

The addition of an antidepressant to a mood stabilizer did not add any benefit for patients with bipolar depression, according to an NIMH-sponsored research project reported in April in the New England Journal of Medicine. In the multicenter study, adding an antidepressant to the regimen also did not increase affective switching to mania.

Methamphetamine (MA) abuse is not a new problem in the United States, but the current epidemic is more widespread and presents with more pernicious consequences than in the past. MA, frequently called "speed," "crystal," "crank," "ice," or "tina," is a potent psychostimulant that can be swallowed in pill form or administered via intranasal, intravenous, or smoking route.

Up Against the Wall

A major physical illness or procedure, such as a myocardial infarction (MI), a transplant operation, or a life-threatening attack of asthma, can be emotionally traumatic,1,2 but the study of posttraumatic reactions in the medically ill is relatively new. Only in the past 2 decades or so it has been recognized that, in fact, medical illness and its treatment can be traumatic, and only since the publication of DSM-IV in 1994 has medical illness been included as a potentially traumatic event that may lead to the development of posttraumatic symptoms.

Grand mal convulsive seizures are characterized by the sudden loss of consciousness and motor inhibition, followed by tonic flexion and extension, repetitive clonic movements, and motor relaxation and lassitude. Seizures are elicited in all vertebrates that have been tested. The loss of both vigilance and the defenses of fight or flight incur life-threatening risks to the individual. In evolutionary history, we would expect this behavior to be extinguished. Its persistence prompts the query: What are the benefits of seizures?

He was young, schizoid, and had experienced brief periods of psychotic-like disorganization. We worked together in psychotherapy for many years. None of the then available psychotropic agents were helpful. He believed, however, that marijuana was helpful, and, if he smoked a joint in the hours preceding a session, his way of relating to me was different. He was less "there," more deeply into himself. His descriptions of the marijuana experience never varied. "I am," he would say, "at peace. I feel connected to everything. I am part of the universe, part of nature, part of God." He was, I thought, a person with significant ego boundary problems who, for the most part, maintained his basic sense of self by distancing himself from both the world and inner turmoil. Marijuana appeared to lead to the internal experience of greater connectedness and peace, although I felt he was less available to me after using it.

NSAIDs have long been considered first-line treatments for a variety of pain conditions--most notably, musculoskeletal pain. Many NSAIDs are available in over-the-counter preparations, so they are inexpensive and, for better or worse, can be obtained without consulting physicians or health care professionals. For most patients, these drugs were considered safe, except in those who are at risk for GI bleeding or who have renal dysfunction. The most common adverse effect associated with NSAID use is GI distress.

After wading through the initial shock and horror of the murder of 32 students and faculty at Virginia Tech on April 16 by student Seung-Hui Cho, there is a natural impulse to rush to enact laws to prevent this type of tragic event from ever happening again in our schools. As professionals, as parents, as concerned members of a community, we have a felt need for an immediate response to ensure that schools are safe and secure places to learn and grow. Action is demanded. Not only must this opportunity/obligation not be squandered, but we must make sure that by our actions we do not make things worse.

Dr Penelope Ziegler's article was correct in the assertion that treating pain in a patient with a substance use disorder can be very difficult and requires consideration of multiple factors ("Safe Treatment of Pain in the Patient With a Substance Use Disorder," Psychiatric Times, January 2007, page 32); however, I believe several topics discussed require further clarification.

Posttraumatic stress disorder (PTSD) is an anxiety disorder that occurs after severe psychological stress, eg, assault, combat, natural disasters, terrorism, or other stressors.

Four physicians work on the same patient for days at a time, continually returning to a white board, where they list the patient's changing symptoms and their own differential diagnoses. They think inside and outside the box. As data come in from tests and as interventions succeed or fail, they remain flexible in their way of thinking. The attending physician's main lesson to his 3 fellows is to remain unencumbered by preconceived notions and to constantly revise their thinking to fit the data. Only then, he tells his trainees, is there any chance of a correct diagnosis and medical treatment.

In the aftermath of the tragic events at Virginia Tech, we would like to suggest some ways in which psychiatrists, psychologists, and college personnel can help identify and treat students who have severe psychiatric disorders--and perhaps prevent another mass murder.