Etomidate during ECT for elderly seizure-resistant patients.
Explore the source record for details and available documents.
Age Factors↗
Biomedical subjects
S N Caroff
Publications and source records attributed to S N Caroff.
Neuroleptic malignant syndrome and malignant hyperthermia: end of a controversy?
Two primary hypotheses have been proposed to explain the pathophysiology of the neuroleptic malignant syndrome (NMS): 1) that NMS is produced by abrupt and extensive central dopamine receptor blockade by neuroleptics, particularly in nigrostriatal and hypothalamic pathways; and 2) that NMS, like malignant hyperthermia (MH), results from a preexisting defect in skeletal muscle metabolism that is unmasked or provoked by neuroleptic exposure. To evaluate these models, the authors review studies published since 1980 of the clinical features, epidemiology, risk factors, laboratory assessment, and relevant animal models of NMS and MH. Data from these studies suggest that although NMS and MH are clinically similar, they are pharmacologically distinct, implying that cross-reactivity between triggering agents is unlikely to occur.
Animals↗
Fatal pulmonary embolism in the catatonic syndrome: two case reports and a literature review.
BACKGROUND: Catatonia is associated with excess early mortality when it is unrecognized or inadequately treated. The characteristics of the lethal catatonia subtype are now well described, but the excess mortality of the remaining patients with catatonic syndrome, particularly from pulmonary embolism, appears to be inadequately recognized. The fatal risk of the catatonic syndrome is reviewed. METHOD: Two new case reports of sudden death from pulmonary embolism in catatonic syndrome are presented. The world literature on morbidity, mortality, and pulmonary embolism in catatonia was reviewed by a search of MEDLINE and PsychInfo from 1966 to the present. Additional older references were discovered by screening bibliographies from articles produced by the searches. RESULTS: Twenty cases of autopsy-confirmed pulmonary embolism were found in patients with catatonic syndrome. Catatonic patients were more likely to die of pulmonary embolism and die earlier than patients with other types of schizophrenia. Death from pulmonary embolism did not occur until after the second week of catatonic symptoms and often occurred without warning. CONCLUSION: Risk of a fatal pulmonary embolism is inherent in persistent catatonic symptoms and may explain the observed excess early mortality. Prompt resolution of the catatonic syndrome with benzodiazepines, barbiturates, or electroconvulsive therapy is the best way to reduce risk of pulmonary embolism. The prophylactic value of physical therapy or anticoagulation merits further investigation. Despite the absence of controlled trials of treatment effectiveness, the catastrophic outcome of acute pulmonary embolism warrants early and vigorous intervention in catatonic patients.
Adult↗
Progression of symptoms in neuroleptic malignant syndrome.
The neuroleptic malignant syndrome (NMS) is a rare but potentially fatal disorder characterized by mental-status changes, muscle rigidity, hyperthermia, and autonomic dysfunction. Systematic examination of early signs and the progression of symptoms in NMS may be worthwhile to facilitate prompt recognition and interventions to abort the syndrome in its incipient stage. The authors present the results of a preliminary review of the temporal sequence of the four predominant signs of NMS as described in 340 clinical reports of NMS in the literature. Of all order implications, 70.5% were consistent with the sequence of mental-status changes, rigidity, hyperthermia, and autonomic dysfunction. Changes in either mental status or rigidity were the initial manifestations of NMS in 82.3% of cases with a single presenting sign and were significantly more likely to be observed before hyperthermia and autonomic dysfunction. Methodological limitations of these data and clinical implications are discussed.
Adolescent↗
Neuroleptic malignant syndrome.
Neuroleptic malignant syndrome is a rare but potentially fatal reaction associated with neuroleptic drugs. It occurs in about 0.2% of patients treated with neuroleptics. Risk factors include previous episodes, dehydration, agitation, and the rate and route of neuroleptic administration. Although NMS has been reported in patients with diverse psychiatric diagnoses, as well as in normal subjects, patients with organic brain disorders or mood disorders, particularly when receiving lithium, may be at increased risk. Standardized criteria for the diagnosis of NMS have been developed and emphasize the classic findings of hyperthermia, muscle rigidity, mental status changes, and autonomic dysfunction. The syndrome lasts 7 to 10 days in uncomplicated cases receiving oral neuroleptics. Treatment consists primarily of early recognition, discontinuation of triggering drugs, management of fluid balance, temperature reduction, and monitoring for complications. Use of dopamine agonists or dantrolene or both should be considered and may be indicated in more severe, prolonged, or refractory cases. Electroconvulsive therapy has been used successfully in some cases and is particularly useful in the post-NMS patient. As a result of these measures, mortality from NMS has declined in recent years although fatalities still occur. Neuroleptics may be safely reintroduced in the management of the majority of patients recovered from an NMS episode, although a significant risk of recurrence does exist, dependent in part on time elapsed since recovery and dose or potency of neuroleptics used. Data drawn from clinical observations and basic studies support the primary role of an acute reduction in brain dopamine activity in the development of NMS. Additional studies of facilitating cofactors may lead to innovative risk-reduction strategies and the development of safer neuroleptic drugs.
Age Factors↗
Sleep disturbance as the hallmark of posttraumatic stress disorder.
The reexperiencing of a traumatic event in the form of repetitive dreams, memories, or flashbacks is one of the cardinal manifestations of posttraumatic stress disorder (PTSD). The dream disturbance associated with PTSD may be relatively specific for this disorder, and dysfunctional REM sleep mechanisms may be involved in the pathogenesis of the posttraumatic anxiety dream. Furthermore, the results of neurophysiological studies in animals suggest that CNS processes generating REM sleep may participate in the control of the classical startle response, which may be akin to the startle behavior commonly described in PTSD patients. Speculating that PTSD may be fundamentally a disorder of REM sleep mechanisms, the authors suggest several strategies for future research.
Anxiety↗
Neuroleptic malignant syndrome.
Explore the source record for details and available documents.
Humans↗
Malignant hyperthermia susceptibility in neuroleptic malignant syndrome.
The relationship between neuroleptic malignant syndrome (NMS) and malignant hyperthermia (MH) was investigated using the in vitro skeletal muscle contracture test to screen for MH-susceptibility in NMS patients. The maximum contracture tension which developed following exposure to halothane (1-3%), and incremental doses of fluphenazine (0.2-25.6 mM) was measured in muscle obtained from seven NMS, six MH, and six control patients. Comparison of the cumulative responses to fluphenazine revealed no significant differences among the groups. However, the response (mean +/- SEM) to halothane in the NMS group (1.7 +/- 0.7 g), which was similar to the response in the MH group (1.5 +/- 0.2 g), was significantly greater than the response found in controls (0.2 +/- 0.1 g). In addition, five of seven NMS patients could be diagnosed as MH-susceptible, based on the development of muscle contractures greater than 0.7 g in response to 1-3% halothane. In contrast, none of the controls were MH-susceptible. These findings appear to correlate with clinical evidence suggesting an association between NMS and MH.
Adult↗
Lethal catatonia.
Lethal catatonia, a life-threatening febrile neuropsychiatric disorder, was widely reported in this country and abroad before the introduction of modern psychopharmacologic treatments. A comprehensive review of the world literature indicates that although the prevalence of lethal catatonia may have declined, it continues to occur, now reported primarily in the foreign literature. Lack of recognition probably accounts for the scarcity of recent American reports. Furthermore, lethal catatonia is a syndrome rather than a specific disease and may develop in association with both functional and organic illnesses. Familiarity with the clinical features and varied etiologies is essential for effective management of this catastrophic reaction.
Adolescent↗
Retinopathy, tardive dyskinesia, and low-dose thioridazine.
Explore the source record for details and available documents.
Aged↗
Administration of thyrotropin-releasing hormone at weekly intervals results in a diminished thyrotropin response.
A diminished thyrotropin (TSH) response to the administration of thyrotropin-releasing hormone (TRH) has been widely reported in depressed patients. Repeated TRH administration at short intervals has been shown to produce a diminished TRH response in healthy subjects. In the present study, TRH (400 micrograms) was administered to ten healthy male subjects at weekly intervals for 4 weeks. The TSH response to TRH diminished steadily from 8.2 +/- 1.3 microU/ml on Trial 1 to 6.3 +/- 0.7 microU/ml on Trial 4 (p less than 0.05). No change in the prolactin response to TRH administration was observed over the four trials. Reduction in the TSH response to TRH was not correlated with basal concentrations of thyroxine, triiodothyronine, or cortisol.
Adult↗
Hormonal response to thyrotropin-releasing hormone following rest-activity reversal in normal men.
The prolactin (PRL) and thyrotropin (TSH) response to an intravenous dose (400 micrograms) of thyrotropin-releasing hormone (TRH) was studied in eight healthy young men in the morning (0800 hr), in the evening (2000 hr), and after an acute 12-hr shift of the rest-activity cycle. The PRL and TSH response to TRH was significantly greater in the evening than the morning. The increased PRL and TSH responses observed in the evening were significantly reduced following rest-activity reversal. Our findings underscore the importance of temporal factors in determining response to TRH. These factors may be relevant in clarifying the mechanisms underlying abnormal hormonal responses to TRH in patients with affective disorders.
Adult↗
Multiple hormonal responses to protirelin (TRH) in depressed patients.
The effects of protirelin (thyrotropin-releasing hormone [TRH]) administration on the release of five pituitary hormones (thyrotropin [TSH], prolactin [Prol], growth hormone, luteinizing hormone, and follicle-stimulating hormone [FSH]) were examined in 45 patients with major depressive disorder and 32 healthy volunteers. Although mean pituitary responses to protirelin in depressed patients and controls appeared to be comparable, depressed patients had higher SDs in all cases. Twelve patients (26.7%) but no controls had two or more abnormal hormonal responses to protirelin administration. The use of several nonparametric analyses revealed significant differences in patterns of hormonal response between depressed patients and controls for TSH, Prol, and FSH. These findings support the hypothesis that increased variability of neuroendocrine responsiveness represents a fundamental aspect of physiologic function in patients with endogenous depression.
Adult↗
Improvement in ratings of tension after TRH administration in healthy women.
Administration of thyrotropin releasing hormone (TRH), 400 micrograms i.v., to healthy premenopausal women resulted in improvement in ratings of tension on the 100 mm line test. The max. mean improvement in tension ratings was significantly greater after TRH than after saline (t = 2.27, df = 9, p less than 0.05); after TRH administration, eight of 10 subjects showed greater than 30% improvement in tension ratings, while only three of 10 subjects receiving saline reported a comparable degree of improvement. No significant improvement in ratings of mood state were noted after administration of either TRH or saline. These findings extend previous reports of behavioral effects of TRH in normal subjects. The possibility that the behavioral effects of TRH may be influenced by the state of activity of the CNS is discussed.
Adult↗
The dexamethasone suppression test in outpatients with primary affective disorder and healthy control subjects.
The authors report data on the overnight dexamethasone suppression test (DST) from 64 patients with primary affective disorder (41 unipolar, 17 bipolar-depressed, and 6 bipolar-hypomanic) and 53 healthy control subjects. No difference between the patients and controls was noted in baseline 8:00 a.m. serum cortisol levels or in cortisol levels obtained after the administration of 1 mg of dexamethasone. Sixteen patients and 8 controls had 4:00 p.m. postdexamethasone cortisol levels higher than 5.0 micrograms/dl. The distribution of suppressors and nonsuppressors did not differ significantly between the two groups. Patient nonsuppressors had significantly higher baseline cortisol levels than did patient suppressors (p less than .001). Clinical parameters and family history data did not distinguish patient suppressors from nonsuppressors.
Adult↗
Thyrotoxicosis and mania.
Explore the source record for details and available documents.
Bipolar Disorder↗
The neuroleptic malignant syndrome.
The neuroleptic malignant syndrome (NMS) is an evidently underdiagnosed but potentially lethal consequence of treatment with potent neuroleptics. The author presents a detailed review of the clinical characteristics and differential diagnosis of the NMS as described in the world literature. Further studies of the incidence, etiology and pathogenesis of the NMS may enhance knowledge of neuroleptic pharmacology and produce more effective means of prevention and treatment.
Antipsychotic Agents↗