Alcohol Abuse

Attention-deficit/hyperactivity disorder (ADHD) is often underappreciated and inadequately treated in adults. Long thought to be a disorder of childhood, ADHD is now believed to persist into adulthood in approximately half of all cases.

At the core of alcoholism is the pathologically increased motivation to consume alcohol at the expense of natural rewards with disregard for adverse consequences. naltrexone and acamprosate represent the first generation of modern pharmacotherapies that target this pathology.

Several months ago, a new psychiatrist came from a prestigious university in the Northeast to work in the VA hospital out West where I practice. During one of our initial conversations, he expressed the emphatic view that "benzodiazepines are only useful for acute alcohol withdrawal or psychiatric emergencies and other than that they have no place in pharmacology." I juxtaposed this position with that of several of our older clinicians, who are equally strong advocates of the generous use of benzodiazepines for a variety of psychiatric symptoms.

Successful intervention for Alzheimer disease requires an early and timely diagnosis. Caregivers of persons with AD often state that an average of 2 years passes from the onset of symptoms to a formal diagnosis.

A great deal of data exists about the dangers of polypharmacy. Persons with psychiatric disorders experience increased risk for adverse drug interactions because of the great frequency with which multiple medications are used.

Essential tremor significantly compromises patients' professional and personal lives.

What is comorbidity? Psychiatric comorbidity refers to the occurrence of 2 or more mental or substance use disorders within a certain period. Research shows that comorbidity of substance use and other psychiatric disorders is common and often worsens the prognosis for each disorder.

Treatment interventions via telephone, Internet, and through other telemedical services are gaining popularity, especially in rural areas where licensed clinicians might not be available. Dr Per Carlbring and colleagues recently evaluated a 10-week, Internet-based, self-help program with weekly telephone calls for patients who had panic disorder with or without agoraphobia. The results were published in the December 2006 issue of the American Journal of Psychiatry.

This study determined the prevalence of at-risk drinking in a psychiatric emergency service (PES) and compared the characteristics and functioning of at-risk drinkers with schizophrenia or bipolar disorder with those of at-risk drinkers with depression or anxiety disorders. Of the adult patients who entered the PES and met study criteria, 148 had schizophrenia or bipolar disorder and 242 had depression or anxiety.

Despite the enormous progress made in stroke diagnosis and treatment in recent years, patients continue to experience stroke-related deficits that clinicians-even those working on stroke rehabilitation units-do not always recognize or record. In a recent study of 53 patients who underwent screening tests within 10 days of admission to a stroke unit, every impaired patient had at least 1 undocumented cognitive or sensory deficit. The authors suggested that without formal testing with standardized assessments, much stroke-related impairment goes unrecognized and perhaps untreated.

Cocaine dependence is a devastating disorder that is associated with a host of medical and psychosocial risks. This complex disorder is made up of distinct clinical components that are interwoven into a cycle of addiction (Figure 1). Cocaine activates ancient pleasure centers that dominate our thoughts, behaviors, and priorities, producing a pleasure-reinforced compulsion to use the drug. Repeated use dysregulates brain pleasure centers and paves the way to addiction through craving and impaired hedonic function.1 Euphoria and craving drive the cycle of addiction through positive and negative reinforcement, respectively, and they provide targets for pharmacological interventions.

Traumatic brain injury (TBI) is one of the most common causes of morbidity and mortality, especially in young adults. Recognition and early accurate diagnosis of neurobehavioral TBI sequelae are important in reducing the severity of postinjury symptoms. Sequelae of TBI include cognitive impairments, personality changes, aggression, impulsivity, apathy, anxiety, depression, mania, and psychosis.

Generalized anxiety disorder (GAD) is characterized by excessive or unrealistic anxiety and worries about life circumstances. In the general population, the prevalence of GAD is 2% to 5%. It is the most frequent anxiety disorder seen in primary care, where 22% of patients complain of anxiety problems.1 DSM-IV lists 6 somatic symptoms associated with GAD: restlessness, increased fatigability, difficulty in concentrating, irritability, muscle tension, and sleep disturbance. These symptoms may present with hyperarousal, hypervigilance, and heightened muscle tension; autonomic symptoms are milder than in other anxiety disorders and can be absent.

Delirium is a disorder that lies at the interface of psychiatry and medicine. It is an acute organic syndrome caused by an underlying medical condition and is defined clinically by disturbances in cognitive function, attention, and level of consciousness.1 Delirium is considered a syndrome because of the constellation of signs and symptoms associated with the disorder, coupled with a wide variety of potential etiologies.

The following case histories illustrate some of the clinical aspects of delirium that were described in the preceding article. Each case is followed by a discussion of the diagnosis, identification of the etiology, and subsequent treatment of an episode of delirium.

Although suicidal ideation occurs in roughly 5% to 14% of pregnancies,1 suicide attempts are relatively rare (0.04%) and are associated with substance abuse and poor pregnancy outcome.2 After a suicide attempt, the clinician must first consider the possibility of recurrence of self-destructive behavior by assessing the woman's motivation, her attitude toward the pregnancy, and the severity of her depressive symptoms.

In this issue, Drs Heinrich and Sponagle present a thorough overview of the challenges of detecting and treating delirium in the emergency care setting. They also address the high risks involved when the diagnosis is missed. The difficulties of identifying and appropriately managing delirium are not new. However, the importance of doing so is taking on a greater significance because of certain current and forecasted realities that will affect the nation's emergency departments (EDs).

Pathological gambling (PG) is characterized by persistent and recurrent maladaptive patterns of gambling behavior (eg, a preoccupation with gambling, the inability to control gambling behavior, lying to loved ones, illegal acts, and impaired social and occupational functioning).1 With past-year prevalence rates similar to those of schizophrenia and bipolar disorder,2 it is apparent that PG has become a significant public health issue. The aim of this article, therefore, is to introduce clinicians to the assessment and treatment of PG with the hope that early interventions will reduce the considerable personal and social costs associated with the disorder.

Pharmacotherapy of Acute Schizophrenia

Risk Factors for Suicide in Patients With Schizophrenia

Reading the Ability of a Patient to Change His or Her Life

The Metabolic Syndrome and Schizophrenia: Clinical Research Update

Nonconventional and Integrative Treatments of Alcohol and Substance Abuse (Part 1)

Psychological Therapies for Schizophrenia: Family and Cognitive Interventions

Biological Markers and the Future of Early Diagnosis and Treatment in Schizophrenia

Up to 30% of patients for whom opioids are prescribed for chronic pain show an escalating pattern of opioid abuse characterized by taking more opioids than prescribed, seeking early refills, and finding additional sources of opioids. Although many of these drug-seeking patients are addicted to opioids, some are suffering not from addiction but from inadequate pain management, according to Martha Wunsch, MD, chair of Addiction Medicine and associate professor of pediatrics at Edward Via Virginia College of Osteopathic Medicine (VCOM) in Blacksburg.

The ideal medication for Parkinson disease (PD) would reduce disability and halt or slow disease progression without intolerable adverse effects. Although such an agent is not yet available, current treatments offer significant symptom control for most patients. The decision about when to start therapy is highly individual; however, delaying treatment because of fear of adverse effects may not be in the patient's best interest.

The reason a person has a stroke is no mystery. Results of a Danish study, reported at the 10th Congress of the European Federation of Neurological Societies in Glasgow, Scotland, held September 2 to 5, confirmed that risk factors could be identified in 98.5% of acute ischemic stroke patients.

Persons who have anxiety disorders commonly self-medicate with alcohol and other drugs, a recent survey confirmed. The results were published in the November 2006 issue of The Journal of Nervous and Mental Disease.

Clinical depression is an increasingly well-recognized sequela of epilepsy (see "Optimizing Treatment of Seizures by Addressing Psychiatric Comorbidities," Applied Neurology, August 2006, pages 41-42). Questions are therefore surfacing as to whether patients with epilepsy are being adequately identified and treated.