Elective mutism: a case study of a disorder of childhood

This paper reviews a number of treatment strategies utilized in the treatment of a 6-year-old boy with a history of multiple parental separations. When the patient presented to the child psychiatric clinic, he had a history of not speaking in the preceding four months, following the arrival of a stepmother in the household and a move to a new house in a new locality. Developmental and psychometric assessments are presented and their utility in early diagnosis and later prognosis are discussed. Reluctant speech is differentiated from, and compared with, elective mutism.The management of elective mutism is often complicated by these children not speaking to anyone in certain environments, and very frequently the persons with whom they do speak are not available for participation in treatment programs. Consequently, if a child does not speak to anyone who can participate in the early mapping of treatment modalities, the use of treatment strategies such as stimulus fading is impossible. Suggestions for future management to overcome this difficulty are presented and discussed.

[Paramyoclonus multiplex (Friedreich's disease)]

The authors describe a case of benign myoclonic jerks in a man aged 45 years, followed-up during 3 years. The disease had a benign course and a tendency was observed for decreasing intensity of symptoms. Apart from disseminated myoclonic jerks and longer lasting muscle spasms no other neurological abnormalities were found. EMG demonstrated spontaneous and asynchronous discharges of groups of motor units corresponding to the observed myoaclonic jerks but no other pathological findings were elicited. Other laboratory investigations including CT of the brain gave normal results. Taking into account the onset and course of the disease, the objective state and the results of laboratory investigations a functional background of the disease could not be ruled out.

Separation from mother at time of weaning. A rarely discussed aspect of the aetiology of protein energy malnutrition

Weaning is an important factor in the aetiology of protein energy malnutrition (PEM). In the present study it was shown that the psychological aspects of weaning — i.e. separation from the mother — play a more important role in the development of PEM than do physical factors. Of children suffering from PEM, 80.4% were physically separated from the mother at time of weaning, whereas only 32% of a comparable healthy control group had undergone the trauma of separation.

Risk factors for the development of eating disorders in adolescent exchange students: an exploratory survey

A pragmatic approach to the prevention of eating disorders involves the study of individuals at high risk for the development of these disorders. A clinical survey of 14 adolescent exchange students who were diagnosed as eating disorder patients confirms our hypothesis that several of the predisposing or precipitating factors mentioned in the literature must be present for the disorder to occur. It is concluded that the prevention of eating disorders among the high risk population of exchange students should focus on an early detection of adolescent identity problems, relational difficulties and an accentuated sensitivity to weight issues.

Imipramine in adolescent major depression: plasma level and clinical response

Thirty-four adolescents with mean age 14.25 years who met RDC criteria for major depressive disorder as assessed with the K-SADS, were treated for 6 weeks on a fixed schedule of imipramine hydrochloride titrated to a dosage of 5.0 mg/kg/day except as limited by side effects. Mean dose was 246 mg/day (4.5 mg/kg/day). In spite of good indications of compliance with treatment only 44% of the adolescents improved to the level of no or only slight depressed mood or anhedonia, though most had less depressive symptomatology at the end of treatment. There was neither a linear nor curvilinear relationship between total plasma level of IMI plus DMI and clinical response, despite a wide range of both plasma level (77 ng/ml to 986 ng/ml) and outcome. Adolescents with associated separation anxiety had significantly poorer response to treatment of their depressive disorder than those with major depression alone. Poor response was also weakly associated with being female, having endogenous subtype of depression, and having higher plasma IMI (but not DMI) level. In the context of similar studies of IMI on depression in other age groups, it is hypothesized that high levels of sex hormones during adolescence and young adulthood may interfere with IMI's antidepressant effects. It is concluded that other types of antidepressants should be tested in adolescents with major depression.

Stuttering as a complication of strabismus surgery

Children may experience extremely high levels of psychological stress in the operating suite because of anxiety associated with the separation from their parents, the unfamiliar and intimidating environment, the presence of strangers in unusual attire (masks, caps, gowns), the act of being forcibly restrained, and the forceful pressing over the mouth and nose of an anesthetic mask which emits a foul-smelling gas and which seems to restrict breathing in a manner reminiscent of suffocation. High levels of anxiety can lead to regression in a child's mental development, including stuttering, which is a regression to an earlier speech pattern and failure to develop fluent speech. Two cases are reported in which children developed stuttering following inappropriate or abusive treatment by the anesthesia departments of the hospitals in which they had surgery for strabismus. Both patients were four-year-old boys.

Preliminary data on DSM-III associated features of major depressive disorder in children and adolescents

Fifty-nine subjects 5-16 years old with major depressive disorder were assessed for the presence of separation anxiety and antisocial behavior, mentioned in DSM-III as associated features of the disorder in children and adolescents. The findings of the study support the existence of these associated features.

A somaticizing adolescent: an approach to evaluation and therapy

Adolescents may chronically somatize as part of the symptoms of an underlying psychological disorder. Unless the underlying psychological disorder. Unless the underlying psychopathology is recognized by the treating physician, chronic somatization may result in high cost to the health care system due to frequent use and unnecessary biochemical and radiographic evaluation. The case presented is illustrative of the differential diagnosis and management of such a patient.

Disorders of the gastrointestinal tract in children: consultation-liaison experience

Disorders of the gastrointestinal tract are common in children. Fortunately, many are short-lived, related to infection, food intolerance, or specific etiology. Those that persist or recur require greater attention on the part of the physician and can require psychiatric consultation. The frequency of consultation will depend in large part on the psychosocial sophistication and philosophy of care of the referring physician. When consulted, the child psychiatrist can complement the medical care by examination in greater detail of the psychosocial environment of the child, the family, and by psychiatric evaluation of the child. Formulation of these factors may then point the way to more helpful management of the child and treatment. The most serious problems, such as regional ileitis and ulcerative colitis, require not only collaboration of pediatricians and child psychiatrist, but surgeons as well if patients are to receive optimum care.

Pharmacological modification of experimental depression in infant macaques

This study provides evidence that mother--infant separation in macaques is a useful experimental model of depression. At the age of 6--8 months, seven M.fascicularis infants underwent two consecutive separations from their mothers lasting 21 and 15 days, respectively. The frequency and duration of a set of individual and social behaviours were recorded throughout each of the following experimental conditions: baseline, separation, reunion. In response to maternal separation, the infants showed marked increased in frequency of behaviours reflecting distress, self-directed activity or anxiety (e.g. vocalization, locomotion, body play). Both individual and social play behaviours were markedly suppressed in separated infants. During the second separation, one group of subjects was given, in a 'double blind' fashion, daily doses of 5 mg/kg of an antidepressant, desmethylimipramine (DMI), i.m. Treatment with DMI markedly diminished most of the behavioural alterations induced by separation. In particular, the increases in distress and self-directed behaviours as well as the suppression of play activities were prevented or antagonized. Plasma levels of DMI after 5 days of administration were in the range of 50--150 ng/ml.

School phobia: a discussion of aetiology, treatment and evaluation

A discussion of the literature dealing with childhood school phobia has been delineated into five main areas: definition of school phobia and its frequency, aetiology, treatment, follow-up, and methodological appraisal. Throughout the discussion critical comments are offered to illustrate both theoretical and research findings that need greater clarification. Though dynamic theory predominates aetiological concerns, principles of learning theory seem to contribute greatly toward treatment. The basis for both orientations, however, is largely clinical experiences based on case histories. The discussion emphasizes the need to go beyond hypothesis generation and to direct empirical validation.

A hospital play program: helping children with serious illness

Children hospitalized with a life-threatening disease are experiencing a severely stressful situation that is often confusing, frightening, and anxiety-provoking. This paper describes a play-therapy program designed to facilitate the expression of these feelings, enhance the sense of mastery, foster adaptive behavior, and increase cooperation with medical treatment.

Nostalgia: a 'forgotten' psychological disorder

Nostalgia, a psychopathological condition affecting individuals who are uprooted, whose social contacts are fragmented, who are isolated and who feel totally frustrated and alienated, was first described in the 17th century and was a problem of considerable interest to physicians in the 18th and 19th centuries. By the 20th century it seemed to have disappeared, but reappeared under other labels.

Overview of recent research in depression. Integration of ten conceptual models into a comprehensive clinical frame

Disciplinary fragmentation and nosological and semantic controversies have obscured the impressive advances made in the area of depressive disorders during the past decade. This article is an attempt to translate data derived from psychodynamic, sociobehavioral, and neurobiologic research into a clinically meaningful framework. We review ten models of depression with special emphasis on newer models supported by empirical and experimental studies, and present a new model, which incorporates and synthesizes findings from different schools. Depressive illness is conceptualized as the feedback interaction of three sets of variables at chemical, experiential, and behavioral levels with the diencephalon serving as the field of action.

Eyelash pulling: a rare symptom of anxiety

Eyelash pulling, a rare symptom, is described in a multiply placed foster child whose anxieties about death and separation were aroused by two specific events.

Some etiological factors in phobic neurosis

A group of 47 phobic patients (92 percent agoraphobic and 8 percent specific phobics) were matched with the same number of controls on age, socio-economic status and education. All subjects were assessed by two independent psychiatrists, on psychometric tests (IPAT, FSS) and on self-assessment of neurotic symptoms and social maladjustment. Among the control group 40 percent were found to have specific phobias and 5 percent agoraphobia; the severity of both being much below that of the patients. The rate of incidence of other neurotic illness (obsessions, alcoholism, depression, and so on) in the families of phobic patients was higher than in the control group. Mothers of phobic patients had a higher incidence of phobic neurosis and were more frequently described as overprotective than were control mothers. Childhood fears were more frequent among the phobic patients (slightly obsessive, worried persons) long before the onset of the phobic neurosis. On the IPAT anxiety scale and on the FSS, agoraphobic patients scored higher than the specific phobics, who scored higher than the controls. Specific phobias in both patient and control groups seemed to have begun in childhood and persisted until treatment.

On the other hand, agoraphobia developed much later, and half the patients reported temporary remissions. Other neurotic symptoms (hysterical signs, obsessive symptoms, and so on) while clinically unimportant, were still significantly more frequent in the phobies than in the control group. The agoraphobic syndrome showed surprising uniformity from patient to patient.

It was postulated that agoraphobia is due to reactivation of separation anxiety, while specific phobias develop as a conditioned fear response.