Faculty Bibliography

Posttraumatic stress disorder (PTSD) may develop after exposure to severe stress, such as combat, accidents, assaults, and natural disasters. Pharmacotherapy can be a useful adjunct in the comprehensive treatment of these patients. The presence of comorbid conditions, including depression, panic disorder, substance abuse, and traumatic brain injury, should be carefully evaluated. Symptoms of PTSD that are associated with central nervous system hyperarousal or reexperiencing of the traumatic event appear to be the most responsive to pharmacotherapy. Social withdrawal and dulled responsiveness have not been shown to be alleviated through standard pharmacologic interventions. A therapeutic strategy is proposed that is based on the patient's symptoms and initial response to medication.

The Observer's Assessment of Alertness/Sedation (OAA/S) Scale was developed to measure the level of alertness in subjects who are sedated. This scale was tested in 18 subjects in a three-period crossover study to assess its reliability and its criterion, behavioral, and construct validity. After receiving either placebo or a titrated dose of midazolam to produce light or heavy sedation, each subject was administered two sedation scales (OAA/S Scale and a Visual Analogue Scale) and two performances tests (Digit Symbol Substitution Test and Serial Sevens Subtraction). Two raters individually evaluated the subject's level of alertness on each of the two sedation scales. The results obtained on the OAA/S Scale were reliable and valid as measured by high correlations between the two raters and high correlations between the OAA/S Scale and two of the three standard tests used in this study. The OAA/S Scale was sensitive to the level of midazolam administered; all pairwise comparisons were significant (p less than 0.05) for all three treatment levels at both test periods.

Depression occurs frequently in patients with neurologic disorders. Current research in traumatic brain injury, stroke, Parkinson's disease, multiple sclerosis, epilepsy, and brain tumors indicates that affective symptomatology can be a specific sequel of these illnesses that is related to the resultant impairment in brain functioning. Because of the cognitive and emotional deficits that neurologic disorders can cause, the clinician must be aware of the complicated presentation of depression in these patients. Psychopharmacologic treatments are safe and efficacious in the treatment of depression in patients with neurologic illness.

Issues related to the epidemiology, nosology, and differential diagnosis of organic aggressive disorders in the elderly are discussed. Rating and monitoring of aggressive events using the Overt Aggression Scale are reviewed. The management of acute aggression with antipsychotic agents and benzodiazepines is presented, as well as an approach for using beta-blockers, anticonvulsant agents, and serotonin-specific antidepressants and an antianxiety agent for the treatment of chronic aggression.

Five patients with chronic psychosis and episodic aggressive dyscontrol were treated with electroconvulsive therapy (ECT). Four patients also demonstrated clinical evidence of seizure disorder. ECT resulted in marked reduction of both episodic aggressive dyscontrol and clinical seizures, with modest improvement of psychosis. No patient developed clinical signs of organic brain syndrome during ECT. Albeit in a small number of patients, our findings indicate that ECT may have short-term therapeutic effects on episodic aggressive dyscontrol in patients with chronic psychoses.