February 2016

Vol. 28. No. 1


The issue of (maybe) treating too much

Recent editorials in the British Medical Journal (BMJ) about “too much medicine and too little caring”1-3 caught my attention and led me to contemplate how often psychiatrists treat patients “too much.” The BMJ editorials focus mostly on overtreatment due to overdiagnosis, 1 the culture of “more is better,”1 changing the disease definition, and shifting the dividing line between normal and abnormal.2 They point out that, “we are now so busy managing the proliferation of risk factors, ‘incidentalomas,’ and the worried well that we lack the time to care properly for those who are seriously ill.”2 One editorial3 focuses solely on psychiatry and the DSM system with its continuous increase in the number of diagnoses and “medicalization of ordinary experience.” That may be true, but there are many other ways of treating our patients “too much.” 



Quetiapine’s effect on the SCL-90-R domains in patients with borderline personality disorder

Susanne S. Lee, PhD | Jeff Allen, PhD | Mary C. Zanarini, EdD | S. Charles Schulz, MD

BACKGROUND: This study aimed to examine the impact of quetiapine on the symptom and distress domains measured by the Symptom Checklist-90-Revised (SCL-90-R) in patients with borderline personality disorder (BPD).

METHODS: Ninety-five participants meeting DSM-IV diagnostic criteria for BPD were randomly assigned to low-dosage (quetiapine, 150 mg/d; n = 33), moderate-dosage (quetiapine, 300 mg/d; n = 33), or placebo (n = 29). SCL-90-R was administered weekly over the course of an 8-week double-blind treatment phase. We used a mixed-effects model to analyze subscale scores of the SCL-90-R.

RESULTS: Results showed that both dosages of quetiapine were effective in reducing levels of overall psychological distress, interpersonal sensitivity, depression, and hostility compared with those who received placebo.

CONCLUSIONS: SCL-90-R can be a useful tool that would allow clinicians to collect information in addition to the DSM symptoms to better understand the diagnostic heterogeneity found in patients diagnosed with BPD.


Pathological laughter and crying: A case series and proposal for a new classification

Francisco de Assis Aquino Gondim, MD, MSc, PhD | Florian P. Thomas, MD, MA, PhD, MS | Salvador Cruz-Flores, MD, MPH | Henry A. Nasrallah, MD | John B. Selhorst, MD

BACKGROUND: Disorders of laughter and crying (DLC) are seen in several neuropsychiatric conditions. Their nomenclature remains under debate. 

METHODS: We present the clinical and imaging findings of 17 patients with DLC and introduce a new classification based on phenomenology and pathogenesis. According to intensity and frequency of laughter and crying (observed behavioral output), patients were divided into hypoactive or hyperactive DLC and subdivided into 5 subtypes: sensory (positive and negative), motor (positive and negative), and mixed. The sensory subtype is represented by disorders of “feeling processing,” whereas the motor subtype is represented by disorders of “emotion processing.” “Positive” and “negative” describe elicitation by irritative vs destructive lesions, respectively.

RESULTS: Among the patients studied, DLC resulted from ischemic stroke (n = 12), intracerebral hemorrhage (n = 2), gunshot wound (n = 1), amyotrophic lateral sclerosis (n = 1), or vestibular migraine (n = 1). Ten patients had lesions in the brainstem, 4 in the cerebral hemispheres, and 2 in subcortical-diencephalic structures. Six patients had negative motor DLC, 5 had positive sensory DLC, 4 had negative sensory DLC, and 2 had positive motor DLC. Phenomenology changed or progressed to mixed DLC in 7 patients.

CONCLUSIONS: This novel phenomenological and pathomechanistic nomenclature explains all subtypes of DLC in neurologic, medical, and psychiatric conditions. Future studies are needed to validate it prospectively.


Psychiatric disorders after terrorist bombings among rescue workers and bombing survivors in Nairobi and rescue workers in Oklahoma City

Gus Zhang, MD | Betty Pfefferbaum, MD, JD | Pushpa Narayanan, MBBS, DCH, MA, MPH | Sungkyu Lee, PhD | Samuel Thielman, MD, PhD | Carol S. North, MD, MPE

BACKGROUND: To examine the prevalence of psychopathology in 52 male rescue workers responding to the 1998 U.S. Embassy bombing in Nairobi, Kenya, comparing them with 176 male rescue workers responding to the 1995 Oklahoma City, Oklahoma, bombing and with 105 directly exposed male civilian survivors of the Nairobi bombing.

METHODS: The Diagnostic Interview Schedule/Disaster Supplement assessed pre-disaster and post-disaster psychiatric disorders and variables related to demographics, exposure, disaster perceptions, and coping in all 3 disaster subgroups.

RESULTS: The most prevalent post-disaster disorders were posttraumatic stress disorder (PTSD) (22%) and major depressive disorder (MDD) (27%) among Nairobi rescue workers, which were more than 2 and 4 times higher, respectively, than among Oklahoma City rescue workers. Alcohol use disorder was the most prevalent pre- and post-disaster disorder among Oklahoma City rescue workers. Nairobi rescue workers had a prevalence of PTSD and MDD not significantly different from Nairobi civilian survivors.

CONCLUSIONS: Nairobi rescue workers were more symptomatic than Oklahoma City rescue workers and were as symptomatic as Nairobi civilian survivors. The vulnerability of Nairobi rescue workers to psychological sequelae may be a reflection of their volunteer, rather than professional, status. These findings contribute to understanding rescue worker mental health, especially among volunteer rescue workers, with potential implications for the importance of professional status of rescue workers in conferring protection from adverse mental health outcomes. 


An assessment of concurrent drug and alcohol use among patients seeking treatment for hepatitis C

Omar T. Sims, PhD | David E. Pollio, PhD | Barry A. Hong, PhD | Mamta K. Jain, MD, MPH | Geri R. Brown, PhD | Carol S. North, MD, MPE

BACKGROUND: The purpose of this study was to assess the one-year prevalence of drug use and of concurrent alcohol use among hepatitis C (HCV) patients seeking treatment from specialty HCV clinics.

METHODS: Patients with confirmed HCV RNA considering HCV treatment (N = 309) were recruited from university-affiliated and Veterans Affairs medical centers.

RESULTS: The prevalence of current drug use in the last year was 65% (201/309) among patients considering HCV treatment. More than one fourth of the sample used drugs at some time in their lives but none in the last year. Only 7% (22/309) of patients reported no lifetime drug use. The prevalence of concurrent drug and alcohol use in the last year was 72% (145/201) and 52% (105/201) in the last month.

CONCLUSIONS: More than half of current drug users were still consuming alcohol in the last month despite the fact that they had all been informed of the potential for accelerated liver damage from continued alcohol use. This finding suggests that achieving abstinence from drug use does not necessarily imply that abstinence from alcohol has been obtained. Integration of substance treatment and HCV treatment into a unified disease management approach might increase treatment eligibility and compliance and improve disease outcomes.