Biomedical subjects
D Behar
Publications and source records attributed to D Behar.
Tranquilizer reduction trials in a residential program for persons with mental retardation.
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Mental retardation and psychiatric illness.
Although traditional diagnostic criteria are accepted for use with mentally retarded persons, diagnosis of psychiatric disorders in this population is often complicated by clinicians' ignoring or underestimating such disorders and by patients' communication problems. The revision of DSM-III and changes in policies of third-party payers have sensitized clinicians to the presence of psychopathology among mentally retarded persons. The authors discuss the relationship between mental illness and mental retardation and review recent research on the diagnosis of specific psychiatric disorders in these patients. Some problems, such as behavioral disruptiveness, psychoses, and phobias, are more prevalent among mentally retarded persons than among other populations, whereas other problems, such as alcoholism and suicide, may be less common.
Platelet imipramine binding and serotonin uptake in obsessive-compulsive patients.
Platelet imipramine binding was measured in 16 drug-free nondepressed patients (aged 20-61 years, mean +/- SD 35 +/- 8) suffering from obsessive-compulsive disorder (OCD) and in 16 sex-, race- and age-matched healthy controls. Imipramine binding capacity and affinity were not different in the 2 groups. Platelet serotonin (5-HT) uptake capacity, Vmax, was also measured in 15 of these patients and their matched controls. Vmax was significantly higher in the patients (309 +/- 149 pmol/10(9) cells/min) than in the controls (181 +/- 110). An increase in platelet 5-HT uptake supports the involvement of 5-HT in OCD and may suggest that a hyperactive serotonergic system is present in this disorder.
P.r.n. medications in child psychiatric patients: a pilot placebo-controlled study.
BACKGROUND: The administration p.r.n. (as needed) of sedative medications is a widespread practice in the management of acute dyscontrol of child psychiatric inpatients. Its efficacy, however, has never been tested in a controlled clinical trial. METHOD: Twenty-one male inpatients, aged 5-13 years, participated in a double-blind, placebo-controlled study of the p.r.n. use of diphenhydramine, a sedative antihistaminic often used in child psychiatry wards. The patients' DSM-III-R diagnoses were conduct disorder, attention-deficit hyperactivity, and major depression. Each patient in acute dyscontrol blindly received either oral or intramuscular doses of diphenhydramine 25-50 mg (N = 9) or placebo (N = 12). The Conners Abbreviated 10-Item Teacher Rating Scale and the Clinical Global Impressions scale were completed before and 0.5, 1, and 2 hours after the dose. RESULTS: Repeated measures ANOVA showed significant time effects, but no difference due to drug. The intramuscular route tended to be more effective than the oral, regardless of whether active drug or placebo was given. CONCLUSION: The data indicate that if p.r.n. administrations are effective, this is a placebo effect. Likewise, intramuscular administrations are more effective because of a route effect ("the needle") and not because of a specific pharmacologic activity.
Diagnosis of panic disorder in prepubertal children.
Few reports on panic disorder in children are available, despite the retrospectively documented onset in childhood of about 20% of the cases of adult panic disorder. The authors report on six prepubertal children, aged 8 to 13 years, who met DSM-III-R criteria for adult-type panic disorder. Hyperthyroidism, cardiologic, and respiratory problems were excluded as well as abuse of caffeine or other drugs. The first panic attack occurred between 5 to 11 years of age, with an average interval of 3 years between onset of the disorder and diagnosis. Mitral valve prolapse was documented in two cases. Family history was always positive for panic disorder. Although not common, panic disorder should be considered in children with school phobia and positive family history. As it is in adults, mitral valve prolapse may be associated with panic disorder in children.
Children with panic disorder.
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Subtyping aggression in children and adolescents.
To document the existence of "predatory" (goal-oriented, planned, hidden, or controlled) and "affective" (impulsive, unplanned, overt, or uncontrolled) subtypes of aggression, this study assessed 73 aggressive child and adolescent psychiatric patients for the presence of theoretically predatory and affective behaviors. Cluster analysis, using the reliable items, confirmed the predicted partition, yielding a "predatory" and an "affective" cluster. The scale, with a total score from +5 (fully predatory) to -5 (fully affective), had good internal consistency (alpha = .73). The score distribution tended to be bimodal, with peaks at -3 (predominantly affective) and 1 (mixed). Patients with "affective" aggression were more likely to have lower IQ, to receive neuroleptics or lithium, and to have a chart diagnosis of schizophrenia. History of drug abuse was more frequent among the "predatory" patients.
Reliability of DSM-III diagnoses of hospitalized children.
The reliability of diagnoses of 46 child psychiatric inpatients made using three independent instruments--an unstructured interview with the parent and child that produced the chart diagnosis, a structured interview with the parent, and a structured interview with the child--was assessed. These diagnoses were then compared with a review diagnosis, which was based on all information available at the patient's discharge. Substantial disagreement between the diagnoses resulting from the structured and unstructured interviews was found in one-third of the cases. The review diagnosis disagreed with the chart diagnosis in 33 percent of the cases but disagreed with the diagnosis resulting from the structured interview with the parent in 13 percent of the cases. While structured interviews can contribute to the standardization of diagnoses, the reliability and validity of child psychiatric diagnoses remain problematic.
Reliability of subtle (soft) neurological signs in children.
Reliability and stability of neurological "subtle" ("soft") signs were assessed in 54 psychiatric patients and 25 normal children, aged 5-17 years, using the revised Neurological Examination for Subtle Signs (NESS). Acceptable interrater reliability (kappa greater than or equal to 0.50, or intraclass correlation coefficient greater than or equal to 0.70) was found for 40 of the 64 items tested. Test-retest reliability at 2 weeks was unsatisfactory for most of the categorically scored items, including some "classic" subtle signs such as overflows or dysrhythmias. Continuous items, such as time needed to perform 20 consecutive movements, remained mostly stable at retest. A practicing effect was evident only in the graphesthesia test. Overall internal consistency was good (Cronbach's alpha = 0.74). Given the poor stability of overflows and dysrhythmias, researchers and clinicians should rely more on subtle signs that can be assessed on continuous scales.
Obsessive-compulsive disorder in mentally retarded patients.
Of 283 mildly to profoundly retarded patients, 10 (3.5%) presented with compulsive behavior that significantly interfered with their daily functioning. Compulsions occurred in the context of obvious cerebral dysfunction and in the absence of anxiety or "ego-dystonic" qualities. The interrater reliability of the differential diagnosis between compulsions, stereotypies, and other repetitive behaviors was good (kappa = .82). A severity rating scale for the compulsive behavior yielded total scores with good interrater reliability (intraclass correlation coefficient = .82). Single items that described observable behaviors had good reliability, while inner resistance and subjective distress were not reliably assessed and contributed little to the total score. The authors suggest that the DSM-III-R diagnosis of obsessive-compulsive disorder be considered in mentally retarded patients, despite the absence of recognizable ego dystonic characteristics. Emphasis should be on the behavioral, externally observable components of the disorder, rather than on inner conflicts and anxiety. Such a diagnostic approach may also benefit nonretarded compulsive patients.
Reliability and validity of the DICA.
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Pharmacokinetics of lithium carbonate in children.
The pharmacokinetics in both serum and saliva of a single oral dose of lithium carbonate 300 mg was investigated in nine children aged 9 to 12 years. The serum and saliva concentration-time curves were parallel and biexponential, with a fast distribution phase after the peak at the second hour and a slow elimination phase starting from the 12th hour. The fast phase half-life was 6.0 +/- 1.8 hour in the serum, and 5.8 +/- 1.9 hour in the saliva. The slow phase half-life was 17.9 +/- 7.4 hour in the serum and 15.6 +/- 8.2 hour in the saliva. Lithium was 2.84 +/- 0.86 times higher in the saliva than in the serum, with a saliva/serum r coefficient of correlation of 0.93. A relatively large error was found in predicting serum levels from saliva. There were significant intersubject differences in the saliva/serum ratio, which point to the need for individual ratios in clinical use. On the whole, the pharmacokinetics of lithium in children had the same features as in adults, with a trend toward a shorter elimination half-life and higher total clearance.
Reduction of (3H)-imipramine binding sites on platelets of conduct-disordered children.
Binding characteristics of tritiated imipramine on blood platelets were determined in daytime hospitalized prepubertal children who had mixed diagnoses of conduct disorder (CD) plus attention deficit disorder hyperactivity (ADDH) and in inpatient adolescents who had a history of aggressive behavior. The number of (3H)-imipramine maximal binding sites (Bmax) was significantly lower in the prepubertal patient group of CD plus ADDH; the dissociation constant (Kd) was not significantly different. There were significant negative correlations between Bmax and the Externalizing or Aggressive factors of the Child Behavior Checklist when the CD plus ADDH prepubertal patients were combined with their matched controls and within the adolescent inpatient group. We propose that a decreased platelet imipramine binding Bmax value, as an index of disturbed presynaptic serotonergic activity, is not specific to depression and may be used as a biologic marker for the lack of behavioral constraint in heterogeneous. populations of psychiatric patients.
Medical findings in child psychiatric inpatients.
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Saliva lithium monitoring.
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Transketolase abnormality in cultured fibroblasts from familial chronic alcoholic men and their male offspring.
We have investigated a thiamine-dependent enzyme, transketolase, in cultured fibroblasts from 41 human subjects, including patients with alcoholism-associated Wernicke-Korsakoff syndrome (n = 3), familial chronic alcoholic males (n = 7), their sons (n = 7), nonalcoholic men (n = 7), their male offspring (n = 7), and three generations of an Amish family (n = 10) without any history of alcoholism. This study was undertaken to delineate whether transketolase abnormality (i.e., high Michaelis Menton constant (Km) for thiamine pyrophosphate), previously reported in patients with Wernicke-Korsakoff syndrome is prevalent among familial chronic alcoholic men and their sons without prior history of alcohol abuse but who are at high risk for alcoholism. Our data suggest that an inborn error (i.e., high Km of transketolase for thiamine pyrophosphate) predisposing to thiamine deficiency diseases similar to those reported in Wernicke-Korsakoff syndrome may occur in the general population. However, for some as yet unexplained reason(s) this variant seems to occur more frequently among familial chronic alcoholic men and their male offspring without any history of alcoholism. The inheritance pattern of this enzyme variant as revealed from an Amish pedigree study may be autosomal recessive as previously suggested.