This is a case report of a 49 year old man admitted to a psychiatric inpatient unit with symptoms of severe depression, who developed hepatic encephalopathy after being started on zolpidem. Zolpidem is an imidazopyridine that is reported to have similar sedative properties to the benzodiazepines but minimal effects as an anxiolytic, muscle relaxant or anticonvulsant. It has a rapid onset, short duration of action and is metabolized in liver through CYP450 system. Zolpidem is extensively used as a hypnotic in short term management of insomnia. There have been reports of hepatic encephalopathy induced by this medication. Hepatic encephalopathy is characterized by confusion, altered level of consciousness and potentially coma and death. It results from liver failure and the accumulation of toxic substances in the blood stream such as nitrogenous waste products, of which ammonia is the most commonly measured. There is increased activity of the inhibitory gamma amino butyric acid (GABA) system and the energy supply to other brain cells is decreased. The diagnosis of hepatic encephalopathy is a clinical one and serum ammonia levels are elevated in 90% of patients.
Throughout the ages, treatment of the mentally ill has evolved with distinct periods of progression, stagnation and regression. These differences in time mirrored how society understood mental illness and the mentally ill person on both a biological and interpersonal level. At various points in history, treatment of the mentally ill included cruel and inhumane acts, while at other times, consisted of compassionate and benevolent care. What follows is a brief comparison of how mental illness was conceptualized and how persons with mental illness were treated in the pre-moral and moral eras of medicine. The pre-moral era is from the end of the classical period to the middle 1700's, while the moral era is considered to be from the middle 1700's to the late 1800's. This review highlights how personal, religious and scientific philosophies weigh heavily in creating a paradigm to conceptualize and treat mental illness.
We present the case of an 8 year-old-girl with a 3-week history of visual conversion, inability to walk, intermittent urinary incontinence, and non-epileptic seizures. Although she had a history of shaken baby syndrome that resulted in hydrocephalus requiring bilateral ventriculoperitoneal (VP) shunt placement at 3 months of age, this current episode could not be attributed to any organic causes and hence she was diagnosed with conversion disorder with mixed presentation. In the absence of published recommendations for treatment of childhood conversion disorder, our multidisciplinary treatment team designed a biopsychosocial approach to improve her symptoms, strengthen family dynamics and provide her parents with guidance for a more stable home environment after discharge. She made substantial improvements in her ability to walk, resolution of urinary incontinence & seizure-like events, and a return to baseline personality; however, her visual conversion was not resolved. In summary, a combination of psychotropic medications, behavioral modifications and brief family psychotherapy was used in an inpatient setting for the treatment of childhood conversion disorder with mixed presentation.
Objective: To report on the successful merger of a civilian and military psychiatry residency. Methods: The reasons for and the history of the merger between the University of Texas Health Science Center at San Antonio and Wilford Hall Air Force Medical Center psychiatry residencies is described. Results: After some false starts, a bottom-up approach was implemented by first merging seminars, then rotations. Conclusions: Combining two psychiatry residencies in order to capitalize on both their strengths can yield a product even greater than the sum of their two programs and the key to a lasting merger is to start with two independently successful programs with different and complementary strengths.
Transformed migraine is one of the subtypes of chronic daily headache (CDH), and is similar to chronic migraine, described in the new International Headache Society (IHS) classification 2004. The term CDH refers to the Headache disorders experienced 15 or more days a month and includes headaches associated with medication overuse. CDH can be divided into primary and secondary varieties. Primary CDH is not related to a structural or systemic illness. It includes diseases such as Transformed migraine (TM). Chronic tension-type headache (CTTH), new daily persistent headache (NDPH), and hemicrania continua (HC). Secondary CDH has an identifiable underlying cause, including post-traumatic headache, cervical spine disorders, vascular disorders, nonvascular intracranial disorders and headaches associated with temporomandibular joint disorders, sinus infections, chronic meningitis, low and high intracranial pressure. In this study we have adopted the 1996 definition of TM proposed by Silberstein and Lipton in preference to the new discredited 2004 IHS criteria for chronic migraine.
