BACKGROUND:Orthostatic Tremor (OT) is a rare movement disorder characterized by a sensation of unsteadiness while standing and associated with high frequency tremors. Patients with OT commonly report a fear of falling and significant limitations in everyday activities. The prevalence of psychiatric comorbidities in OT patients has not been well-studied.METHODS:Subjects were evaluated by trained psychiatry researchers using the Mini International Neuropsychiatric Interview (M.I.N.I.). The M.I.N.I is a validated screening tool for psychiatric disorders. A standardized history covering previous psychiatric symptoms and illnesses was also obtained.RESULTS:29 OT subjects were evaluated. The mean age was 67.7 years with female preponderance (89.3%). The average disease symptom duration was 18.2 years. 58.6% of the subjects had seen a mental health professional during the course of their OT illness. 24.1% of the subjects had a past history of depression, and 10.3% reported a family history of any psychiatric condition. 37.9% of the subjects screened positive for agoraphobia. Two of 29 subjects (6.9%) were classified as having a current major depressive episode and one subject (3.4%) was at risk for suicide.CONCLUSIONS:Psychiatric comorbidities are highly prevalent in OT patients, especially anxiety-spectrum disorders. Further studies are needed to understand if psychiatric disorders appear as a secondary response to the patient's symptoms, or are a primary non-motor manifestation of OT.
To evaluate Psychiatric comorbidities in Orthostatic Tremor patient population using the Mini International Neuropsychiatric Interview (M.I.N.I.).
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To the Editor: Priapism is a prolonged, painful, and persistent penile erection usually not associated with sexual stimulation. Priapism results from an obstruction in the venous drainage of the corpora cavernosa of the penis sparing the glans penis and corpora spongiosa; thus, only the corpora cavernosa are turgid without affecting the other 2 components. It is this finding that distinguishes priapism from a normal penile erection.1 Priapism is a relatively rare condition, but due to its potentially serious and long-term consequences and its potential as an adverse effect of many common medications, it is a matter of serious concern for clinicians. Impotence may occur in 50% of patients with an episode of priapism,2 and it is considered a urologic emergency. We present a case of a patient who developed priapism during treatment with risperidone, an atypical antipsychotic medication, and the treatment decisions that followed. Case report. Mr A, a 31-year-old African American man, had a 10-year history of schizophrenia, chronic, paranoid type, diagnosed using the DSM-IV criteria. The patient had been followed at our outpatient clinic since 1997 and had been compliant with the treatment recommendations. His symptoms of schizophrenia were under fairly good control with risperidone. There was no history of psychiatric inpatient hospitalization. The patient had never been married and had no children. He lived by himself and worked 1 day a week doing newspaper advertising inserts. He had been attending a community-based day program 1 day a week for 10 years. He was a high school graduate with some community college training in computers. The patient was a nonsmoker and a nondrinker and had no history of any illicit drug use. His medical history was significant for obesity, hypercholesterolemia, keloid on his neck, and tonsillectomy at age 6 years. His only medication was risperidone 2 mg in the morning and 3 mg at bedtime. The patient presented to the emergency room in 2005 with a 10-day history of a persistent and painful penile erection. It was sudden in onset while the patient slept, and he awoke with a painful erection. The patient was not sexually active; there was no history of penile, genital, or pelvic trauma; and there was no evidence of any infection or malignancy. There was no change in his current medications and no reported use of any over-the-counter medication or any herbal preparation. The patient had a similar complaint 2 years earlier, but it resolved within a few hours and he did not seek medical care. On this occasion, the erection persisted, and on the 10th day he presented to the emergency room. Routine laboratory tests were performed that included complete blood count, basic metabolic profile, and a coagulation study, and all the results were within normal limits. A diagnosis of priapism was made, and the urology service was consulted. They performed irrigation with normal saline followed by an injection of phenylephrine to the corpora cavernosa to reduce the priapism. There was some improvement in the patient's priapism, and he was transferred to the internal medicine floor. On the second day, his symptoms worsened, and he was offered a second phenylephrine injection, which he refused due to pain. He was then transferred to the operating room where a Winter shunt was placed between corpora cavernosa and corpora spongiosa to relieve his symptoms. His priapism resolved completely within a few hours with the shunt placement. Sickle cell anemia was a potential cause of his priapism, so a hematology consult was obtained. In the absence of any history of anemia, pain crisis, or blood transfusion, a diagnosis of sickle cell anemia was considered unlikely and was ruled out by testing, but the patient was found to be a carrier. While in the hospital, his risperidone treatment was continued. The patient was discharged to home on the fourth day to be followed up in our outpatient psychiatry clinic. Risperidone was the only known causative factor, and despite its efficacy for this patient, it was discontinued. The patient's treatment was changed to aripiprazole in a cross-tapering manner over 3 weeks. The priapism had not returned when the patient was followed up 2 months later. Although priapism can occur in all age groups, it occurs more frequently in the third and fourth decades, often early in the morning, and is noticed on waking.3 The cause is unknown 50% of the time, and the rate of recurrence is 30%–40%.3 The exact pathophysiology is still unclear, and it is considered to be multifactorial in origin. However, among all the reported cases of priapism, 15%–26% are linked to the use of antipsychotic medications.4 Priapism may occur at any time during the treatment course of psychotropic medications and may occur even without a change in the medication dosage.5 Priapism is a result of an obstruction in the venous drainage from the corpora cavernosa of the penis. Priapism is commonly divided into 2 subtypes,6 high-flow and low-flow priapism. High-flow subtype results from a rupture of a cavernous artery that leads to an abnormal blood flow in the penis. This condition is rare and is usually painless due to lack of ischemia, has a favorable prognosis, and is generally not considered a true emergency.7 In low-flow priapism, there is a reduction or absence of the venous drainage from the emissary venules, which results in hypoxia, acidosis, and ischemia. This subtype is painful, accounts for the majority of the cases, and can lead to irreversible fibrosis of the cavernosal spaces if not treated urgently.7 Low-flow priapism is associated with the use of antipsychotic medications. The exact mechanism underlying antipsychotic-induced priapism is still unclear and is considered multifactorial in origin.7 The histaminic system8 and hypersensitization of the β-adrenergic receptors9 have been proposed as important influences in this phenomenon. The commonly proposed mechanism of antipsychotic-induced priapism is related to the α-adrenergic system. Arterioles in the penis that supply blood to the corpora cavernosa are in a tonic state of contraction during the flaccid state of penis, a condition mediated by the α-adrenergic activity.10 During erection, there is a relaxation of the cavernous and the arteriolar smooth muscle leading to an increase in the blood flow into the sinusoidal spaces.11 Priapism is proposed to be mediated by α receptors located in the corpora cavernosa of the penis,8 and the α-adrenergic antagonist properties found in many psychotropic medications12 could very well explain the mechanism underlying priapism induced by these medications. It has also been proposed that the corpora cavernosa in some men are exceptionally sensitive to α-blocking agents.8,13 Several other causes of priapism include perineal trauma, some antihypertensives, phosphodiesterase type 5 inhibitors, other behavior medications (trazodone), anticoagulants, and hematologic disorders including sickle cell anemia, leukemia, lymphoma, and thrombocytopenia.7 However, the only medication our patient was taking was risperidone, which is known to possess α1- and α2-adrenergic antagonist properties,14 and as there was no indication of any other medical illness or causative factor, we propose his condition of priapism to be related to the use of risperidone. Priapism is a urologic emergency, and treatments, including ice packs, enemas, medications, and anesthesia, generally do not produce consistent results.15 Management usually includes intracavernous injection of an α-adrenergic agonist.7 This patient needed to be maintained on an antipsychotic regimen, which posed a particular problem given the high degree of risk for priapism with these medications. At the time of our patient's follow-up, the only medication not reported to be associated with priapism was aripiprazole.
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Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
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Back to table of contents Previous article Next article Book Forum: Models of the MindFull AccessThe Mind: Its Nature and OriginMARK H. FLEISHER, M.D., MARK H. FLEISHERSearch for more papers by this author, M.D., Omaha, Neb.Published Online:1 Jul 2005https://doi.org/10.1176/appi.ajp.162.7.1397AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Given the expansive title of this book, I expected to find a cryptic and complex tome of many hundreds of pages filled with diagrams, positron emission tomography scans, and the most modern three-dimensional images. As it turned out, I was partially correct. The Mind does seem cryptic and complex to me, but it runs under 250 smallish pages and fulfills the promise implied about the nature or origin of one’s mind.I am willing to accept some responsibility for not fully grasping the merits of the book. Perhaps I am too narrowly focused in biologically oriented psychiatric medicine to appreciate this effort. However, some fault must lie with the author and editors for producing a book whose book jacket summary, a reflection of the contents, is so convoluted that it left me and a few colleagues puzzled.The quest, we are told, is to demonstrate how cerebral activities become mental events. On this journey of 21 chapters organized within five parts we revisit Freud, Piaget, and many other revered psychologists and behavioral scientists; engrams; and Gestalt. We are treated to the history of dialectical concepts, beginning with Zeno of Elea in 464 BCE. We are offered dialectical interconnectedness and dialectical triads. We are awash with matrices and fusions as well as complex and simple mnemonics. Part 3, Structures of the Mind, has a chapter titled “Ego, Superego, Id,” and the only other chapter is titled “The Neurophysiology of Dreaming.”The section on Brain, Mind and Body includes six chapters totaling 28 pages. The chapter on the “Mind-Body Problem” is less than four pages long and has three references, from 1950, 1980, and 1985 (by the author), and includes a figure (number 10) of the ubiquitous smiley face and sad face.The section on Psychological and Clinical Implications covers personality formation, psychopathology, and psychotherapy in a brief 40 pages. Although it might fortify the previous chapters, as a clinician I found that it did not offer much to strengthen my practice or pearls to share with residents.Pointing out what I see as flaws in this book does not necessarily mean I found no merit. I look at The Mind as primarily a relatively brief philosophical, psychological, and scientific exploration of concepts. For those wanting to ponder “the mind,” memory, and cognition relative to a historical framework it may well be a very rewarding experience. For those looking for a more useful clinical or teaching tool for psychiatric medicine I do not think this would be a first-line choice.By Christiaan D. van der Velde, M.D. Amherst, N.Y., Prometheus Books, 2004, 242 pp., $28.00. FiguresReferencesCited byDetailsCited ByNone Volume 162Issue 7 July 2005Pages 1397-1397 Metrics PDF download History Published online 1 July 2005 Published in print 1 July 2005
Back to table of contents Previous article Next article Book Forum: GeneticsFull AccessMolecular Genetics and the Human PersonalityMARK H. FLEISHER, M.D., MARK H. FLEISHERSearch for more papers by this author, M.D., Omaha, Neb.Published Online:1 Apr 2003https://doi.org/10.1176/appi.ajp.160.4.802AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This book is a serious and substantially successful effort to discuss areas of modern molecular genetics and human personality. The editors have brought together 35 contributors to create 18 chapters that begin to explore and explain this very complex topic. As one would expect, it is not an easy task to introduce the current state of genetic research as it relates to the convoluted patterns of human behavioral phenotypes.The first chapter introduces some basic topics in genetics and the research methods involved in trying to untangle the epidemiology of complex human traits and behaviors. It is a dense chapter filled with research on the mathematical and theoretical constructs used to explore the relationships between genotypes and their expression in humans.The second chapter explores the concepts of genetics and personality features and their relevance to psychiatry. This chapter explores aspects of normal and abnormal personality features from theoretical and clinical points of view. The author helps to undo a minor criticism I have with the title of this worthy book, which, in my mind, unintentionally tends to minimize its importance and scope. To many readers, “personality” might suggest the veneer of an individual’s uniqueness in terms of behavior, and an entire book on the genetics of personality may put off potential readers. The first two chapters, as well as others in this book, discuss behavioral traits or behavioral phenotypes as elements of personality and clarify the broader range of the editors’ efforts.The next several chapters, all well written, seem to criss-cross through important and interesting topics in a somewhat puzzling order. The chapter on autistic phenotypes is followed by a chapter on animal models of personality, which precedes chapters that weave through the genetics of particular loci, transporter systems, and the potential roles of serotonin and dopamine in human behavior from normal to pathological.The final third of the book is the most interesting from my point of view, with chapters on genetic aspects of cognition, aggression, and childhood temperament. All of these chapters are well written and enlightening and discuss particular behaviors as well as genetic underpinnings.Wisely, the last few chapters of the book are devoted to dissenting opinions and discussion of the social implications of the ideas presented in the earlier chapters. The editors recognize that some of these ideas are not without controversy regarding the degree to which they have been accepted as well as their potential effects on society.Molecular Genetics and the Human Personality is a well-written and generally well-edited book that will be of interest to clinicians in several disciplines—primarily genetics, psychology, and psychiatry. Although it may not have a place on everyone’s reading list, it remains an important book on an area of ever more important interest to physicians, scientists, and ethicists.Edited by Jonathan Benjamin, M.D., Richard P. Ebstein, Ph.D., and Robert H. Belmaker, M.D. Washington, D.C., American Psychiatric Publishing, 2002, 378 pp., $49.00 (paper). FiguresReferencesCited byDetailsCited ByNone Volume 160Issue 4 April 2003Pages 802-802 Metrics PDF download History Published online 1 April 2003 Published in print 1 April 2003
Back to table of contents Previous article Next article Book Forum: Child PsychiatryFull AccessDevelopmental Disability and BehaviourMARK H. FLEISHER, M.D., MARK H. FLEISHERSearch for more papers by this author, M.D., Omaha, Neb.Published Online:1 Jul 2001https://doi.org/10.1176/appi.ajp.158.7.1175AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In this book the editors and contributors have created a very useful review of the important topic of challenging pediatric behaviors. They have assembled an expert group of authors from the fields of child and adolescent psychiatry, pediatric neurology, clinical psychology, neuropsychology, psychotherapy, and community-based pediatric services. The authors write with the clarity and insight that is produced by substantial clinical and teaching experience.The book begins with excellent introductory chapters on disabilities and the management of problem behaviors. The best and most useful chapters that follow review behavior in young people with hearing and visual impairment, traumatic brain damage, behavior analysis, neuropsychological testing, therapeutic interventions for neuropsychiatric disorders, medication management, and psychotherapy for children with developmental disabilities. All of the chapters are well written and provide useful information for clinicians.In a review book such as this it may be surprising to see chapter titles on Rett syndrome and Landau-Kleffner syndrome. Clearly it could be argued that the book would be stronger if it had devoted chapters specifically to some of the more common developmental disorders such as autism or Down’s syndrome. But the contributors use these syndromes to discuss broader behavioral issues and also to highlight distinct or dissimilar features between Rett syndrome and autistiform behaviors as well as the gait and motion symptoms of cerebral palsy.Similarly, the chapter on behavioral aspects of Landau-Kleffner syndrome is constructed to discuss that syndrome and other behavioral presentations as well. Among the primary topics discussed are attention deficit hyperactivity disorder, autistic spectrum disorders, sleep disturbances, aggression, and problematic seizure behavior.A chapter covering ambulatory electronic monitoring in sleep disorders may be a bit eclectic but is nevertheless useful and well written. Sleep disorders seem to be generating more clinical and research interest relative to developmental disabilities, and this chapter will add to our understanding of this topic.It should be iterated that this is an overview of pediatric disorders of development and associated behaviors. It is not meant to explore this large and complex topic comprehensively. Additionally, the editors and some of the other chapter authors recognize that there is no international agreement on terminology, and they are careful to point out the differences. There are several examples of the effort to clarify these confusing conflicts. Internationally it is more common to see the term “mental retardation,” as opposed to “learning disability,” which is the common phrase in the United Kingdom. In the United States, “learning disability” refers to a specific problem of knowledge acquisition within an overall picture of normal intelligence. It can be a maddening discussion, but it is nevertheless necessary for the international community of clinicians, researchers, and authors to communicate effectively.This book has been thoughtfully written and constructed to appeal to the clinical professional who cares for or who has a special interest in pediatric disorders of behavior and development. It will also be especially useful for teachers, psychiatrists, psychologists, and neurologists as an overview text or for use in the instruction of professionals in training.Edited by Christopher Gillberg and Gregory O’Brien. London, Mac Keith Press (New York, Cambridge University Press, distributor), 2000, 189 pp., $64.95. FiguresReferencesCited byDetailsCited byNone Volume 158Issue 7 July 2001Pages 1175-1176 Metrics History Published online 1 July 2001 Published in print 1 July 2001
