Diagnosis of personality disorders: a case study

In this article, I report a case highlighting diagnostic uncertainty about psychopathology on both Axes I and II. It concerns in part the problem of comorbidity in relation to diagnostic classification of Axis II personality disorders. After commenting on these uncertainties in relation to categorical and dimensional models, I also consider a psychoanalytic explanation to illustrate an example in which a theoretical model informs diagnostic interviewing. I emphasize how the clinical information that unfolds from an interview based on this theoretical model generates inferences about psychopathology that extend clinical understanding beyond the formal diagnostic assessment of Axes I and II disorders and assessment by self-report.     

Childhood multiple sclerosis: a review

Multiple sclerosis (MS) is an autoimmune demyelinating disorder of the central nervous system (CNS) that is increasingly recognized as a disease that affects children. Similar to adult-onset MS, children present with visual and sensory complaints, as well as weakness, spasticity, and ataxia. A lumbar puncture can be helpful in diagnosing MS when CSF immunoglobulins and oligoclonal bands are present. White matter demyelinating lesions on MRI are required for the diagnosis; however, children typically have fewer lesions than adults. Many criteria have been proposed to diagnose MS that have been applied to children, mostly above 10 years of age. The recent revisions to the McDonald criteria allow for earlier diagnosis, such as after a clinically isolated event. However, children are more likely than adults to have monosymptomatic illnesses. None of the approved disease-modifying therapies used in adult-onset MS have been approved for pediatrics; however, a few studies have verified their safety and tolerability in children. Although children and adults with MS have similar neurological symptoms, laboratory (cerebrospinal fluid) data, and neuroimaging findings, the clinical course, pathogenesis, and treatment of childhood onset MS require further investigation.     

Acquired aphasia with convulsive disorders in children: a case study with a seven-year follow-up.

In a 7-year follow-up a case of the “syndrome of acquired aphasia with convulsive disorder” is described. In particular, attention is paid to EEG patterns and linguistic analysis. Although seizures have been controlled medically and EEG abnormalities have tended to improve, no close parallel improvement has been observed in the patient's language disorders.     

Adjustment to multiple sclerosis: application of a stress and coping model.

This study examined the use of a stress and coping model of adjustment to multiple sclerosis (MS). A total of 122 MS patients were interviewed and completed self-administered scales at Time 1 and 12 months later, Time 2 (n = 96). Predictors included stressful life events, illness (duration, severity, and disability), social support, appraisal (threat and control/challenge), and coping (problem focused and emotion [wishful thinking, self-blame, and avoidance] focused). Adjustment outcomes were Time 2 depression, global distress, social adjustment, and subjective health status. Results from hierarchical regression analyses indicated that after controlling for the effects of Time-1 adjustment, better Time-2 adjustment was related to less disability, greater reliance on problem-focused coping, and less reliance on emotion-focused coping. There was limited support for the stress buffering effects of coping and social support. Findings offer some support for the use of a stress and coping model of adaptation to MS.     

Degree of malignancy in multiple sclerosis: clinicopathologic mortality study

Basing on the neuropathologic findings (acute, subacute resp. chronic demyelination) in 58 cases with multiple sclerosis (MS) the determination of the degree of defect in relation to the duration of working capacity and disability has been carried out in comparison with an index made up for progression and malignancy of the disease. In the final phase of illness an acute exacerbation was noteworthy from the morphological point of view in 48.3% of the patients; in these cases was established a hightened index of malignancy. Differences of sex distribution a. o. pointed to a longer lasting defective (chronic) stage in women. The assessment of progression after a five-year period of examination by a limiting malignancy-index allows a probable prognosis to the chances and the risk of the developing process of disease and may be of importance for care.     

Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) groups disorders into diagnostic classes on the basis of the subjective criterion of "shared phenomenological features." There are now sufficient data to eliminate this rational system and replace it with an empirically based structure that reflects the actual similarities among disorders. The existing structural evidence establishes that the mood and anxiety disorders should be collapsed together into an overarching class of emotional disorders, which can be decomposed into 3 subclasses: the bipolar disorders (bipolar I, bipolar II, cyclothymia), the distress disorders (major depression, dysthymic disorder, generalized anxiety disorder, posttraumatic stress disorder), and the fear disorders (panic disorder, agoraphobia, social phobia, specific phobia). The optimal placement of other syndromes (e.g., obsessive-compulsive disorder) needs to be clarified in future research.     

Controlled prospective study of postpartum mood disorders: psychological, environmental, and hormonal variables

Demographic, psychiatric, social, cognitive, and life stress variables were used to determine the etiology of depression in childbearing (CB; n = 182) and nonchildbearing (NCB; n = 179) women. Hormonal variables in postpartum depression were also evaluated. In the CB group predictors of depression diagnosis were previous depression, depression during pregnancy, and a Vulnerability (V) x Life Stress (LS) interaction; predictors of depressive symptomatology were previous depression, depressive symptoms during pregnancy, life events, and V x LS. Only estradiol was associated with postpartum depression diagnosis. In the NCB group V X LS was the only predictor of depression diagnosis; depressive symptoms during pregnancy and life events were predictors of depressive symptomatology. Previous findings about depression vulnerability were replicated. The significant V x LS interactions support the vulnerability-stress model of postpartum depression.     

Beyond monoamines: glutamatergic function in mood disorders

The monoamine theory has implicated abnormalities in serotonin and norepinephrine in the pathophysiology of major depression and bipolar illness and contributed greatly to our understanding of mood disorders and their treatment. Nevertheless, some limitations of this model still exist that require researchers and clinicians to seek further explanation and develop novel interventions that reach beyond the confines of the monoaminergic systems. Recent studies have provided strong evidence that glutamate and other amino acid neurotransmitters are involved in the pathophysiology and treatment of mood disorders. Studies employing in vivo magnetic resonance spectroscopy have revealed altered cortical glutamate levels in depressed subjects. Consistent with a model of excessive glutamate-induced excitation in mood disorders, several antiglutamatergic agents, such as riluzole and lamotrigine, have demonstrated potential antidepressant efficacy. Glial cell abnormalities commonly associated with mood disorders may at least partly account for the impairment in glutamate action since glial cells play a primary role in synaptic glutamate removal. A hypothetical model of altered glutamatergic function in mood disorders is proposed in conjunction with potential antidepressant mechanisms of antiglutamatergic agents. Further studies elucidating the role of the glutamatergic system in the pathophysiology of mood and anxiety disorders and studies exploring the efficacy and mechanism of action of antiglutamatergic agents in these disorders, are likely to provide new targets for the development of novel antidepressant agents.     

Different patterns of recollection impairment in confabulation reveal different disorders of consciousness: A multiple case study

Recollection is used to refer to the active process of setting up retrieval cues, evaluating the outcome, and systematically working toward a representation of a past experience that we find acceptable.In this study we report on three patients showing different patterns of confabulation affecting recollection and consciousness differentially. All patients confabulated in the episodic past domain. However, whereas in one patient confabulation affected only recollection of events concerning his personal past, present and future, in another patient confabulation also affected recollection of impersonal knowledge. The third patient showed an intermediate pattern of confabulation, which affected selectively the retrieval of past information, both personal and impersonal. We suggest that our results are in favor of a fractionation of processes involved in recollection underling different disorders of consciousness.     

Adjustment modes in the trajectory of progressive multiple sclerosis: a qualitative study and conceptual model

Objective: We examined cognitive and behavioural challenges and adaptations for people with progressive multiple sclerosis (MS) and developed a preliminary conceptual model of changes in adjustment over time.

Design: Using theoretical sampling, 34 semi-structured interviews were conducted with people with MS. Participants were between 41 and 77 years of age. Thirteen were diagnosed with primary progressive MS and 21 with secondary progressive MS. Data were analysed using a grounded theory approach.

Results: Participants described initially bracketing the illness off and carrying on their usual activities but this became problematic as the condition progressed and they employed different adjustment modes to cope with increased disabilities. Some scaled back their activities to live a more comfortable life, others identified new activities or adapted old ones, whereas at times, people disengaged from the adjustment process altogether and resigned to their condition. Relationships with partners, emotional reactions, environment and perception of the environment influenced adjustment, while people were often flexible and shifted among modes.

Conclusions: Adjusting to a progressive condition is a fluid process. Future interventions can be tailored to address modifiable factors at different stages of the condition and may involve addressing emotional reactions concealing/revealing the condition and perceptions of the environment.     

Glutamate-hypothalamic-pituitary-adrenal axis interactions: implications for mood and anxiety disorders

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is a pathologic feature of certain mood and anxiety disorders that results in the increased production and secretion of corticotropin-releasing factor. There is increasing preclinical evidence that glutamate, an excitatory amino acid, plays an important role in the regulation of the HPA axis. Activation of glutamatergic projections to limbic structures such as the amygdala and brainstem structures such as the nucleus tractus solitarius is implicated in the stress response. There are laboratory and clinical suggestions that glutamatergic N-methyl-D-aspartate (NMDA) receptor antagonists function as antidepressants, and that chronic antidepressant treatments have a significant impact on NMDA receptor function. Clinical investigations of glutamate antagonists in patients with mood and anxiety disorders are in their infancy, with a few reports suggesting the presence of mood-elevating properties. Ultimately, HPA axis modulators, serotonin-enhancing agents, and glutamate antagonists might serve to increase neurotropic factors in key brain regions for affective and anxiety regulation, providing a putative final common pathway.     

Epidemiologic study on the etiopathogenesis of multiple sclerosis

A computer-aided evaluation of those affected with multiple sclerosis (n = 90) with regard to the actually discussed hypothesis on the aetiology of this disease results in 10 significant signs. These signs in their majority support the combined hypothesis of a disturbed regulation of infection and immunity. Frequently, as early as in childhood and youth the upper airways are affected, and this is coupled with a severe course of the disease. The incidence also shows familially and territorially frequent occurrences.     

Neuroreceptor imaging of stress and mood disorders

Techniques such as positron emission tomography and single photon emission computed tomography allow for the imaging of neurotransmitter receptors and transporters in the brain. These tools have been used to investigate serotonergic, dopaminergic, and opioidergic function in healthy subjects as well as in patients with major depressive disorder, bipolar disorder, and other mood disorders. Pharmacologic challenges, such as amphetamine challenge, and physiologic stressors, such as pain challenge, have been used to further examine the function of these neurotransmitter systems. Neuroimaging of patient populations before and after medication treatment may be useful to understand changes in neurotransmission that accompany disease remission. As new radiotracers with higher selectivity for the various receptors and transporters are developed, imaging techniques may provide new insights into the pathophysiology of mood disorders, leading to improved diagnosis and treatment.