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Background: The threat of the potential spreading of the SARS epidemic caused significant stress to many individuals from non-affected countries. In this study, we investigated whether the SARS threat affected the subjective mood and behavior of Israeli patients with schizophrenia and compared their reactions with those noted in their clinical staff., Methods: Subjects were evaluated with a specially designed questionnaire and a modified form of the Spielberger Scale for State Anxiety., Results: As compared to staff, patients had higher scores on the Modified Spielberger State Anxiety Scale. However, many responses (e.g., dysphoria) to the SARS threat did not differ from staff. Patients felt more protected by the authorities and some perceived the epidemic in a psychotic manner., Conclusions: It seems that patients attempt to reduce the effect of external stressors by living in an "autistic bubble" (in which outside threats cannot enter) or by denying the significance of these stressors and over-emphasizing the power of medical authorities to protect them. On the other hand, some patients also psychotically interpreted these stressors.

The assessment of various symptoms in schizophrenia has received much interest, although few studies have compared evaluations by clinicians to those of their patients. Self-report tools may improve service delivery, data collection, and possibly also treatment adherence. We constructed the Positive and Negative Symptoms Questionnaire (PNS-Q), a self-report measure, after items from the Scale for Assessment of Positive Symptoms (SAPS) and the Scale for Assessment of Negative Symptoms (SANS). The PNS-Q contained 68 items and was administered to 61 schizophrenic inpatients. We examined its psychometric properties and utility as a self-report tool in schizophrenia. The PNS-Q exhibited high internal consistency for both its positive and negative subscales. External validity with the SAPS and SANS was low. The positive symptoms subscale correlated significantly with the SAPS ( r = .341, P < .01), whereas the negative symptoms subscale did not correlate at all with the SANS ( r = -0.086, P > .1). The correlation between patients' insight and scores of the PNS-Q was mixed. A partial correlation analysis failed to confirm a relationship between the rating of the patients' level of insight (measured by the Amador Scale to Assess Unawareness of Mental Disorders [SUMD]) and the disparity between the PNS-Q and the SAPS and SANS. However, the PNS-Q correlated highly with McEvoy's Vignettes, a measure of self-perception of symptoms. The results of this study are discussed in light of current research and methodologic issues. The PNS-Q reflects schizophrenics' self-perception, an important, yet neglected, aspect of schizophrenia. Using this new measure, we believe that clinicians and researchers will be able to gain insight to the inner world of these patients and improve their condition, as well as enhance patients' involvement in treatment planning.

During a period of four years, multidrug-resistant Escherichia coli of particular serotypes have been isolated from 255 elderly (>65 years) patients from four hospitals in central Israel. 83% of the isolates belonged to one of four predominant serotypes (O153:H31, O101:H-, O2:H42, and O102:H6). All isolates were producers of extended spectrum beta-lactamases and resistant to ciprofloxacin. To our knowledge, the involved serotypes have hitherto not been reported as etiological agents of extraintestinal human infections (MEDLINE). Pulsed-field gel electrophoresis of isolates from one of the most frequent serotypes indicated a clonal relationship between them. Further investigation of these strains and analysis of their virulence factors may help to confine their spread.

Objective: To compare long-term lithium patients who developed renal insufficiency (RI) with those who did not, and to examine what characterized these groups., Method: One hundred fourteen subjects with DSM-IV bipolar, major depressive, or schizoaffective disorder who had been taking lithium for 4 to 30 years from 1968 to 2000 were studied retrospectively. Subjects with blood creatinine levels > or = 1.5 mg/dL were defined as RI patients, and creatinine levels < 1.5 mg/dL indicated no renal insufficiency (NRI). Ninety-four unmedicated subjects, matched for sex and age, served as a comparison group and had 2 measures of creatinine with a mean interval of 11.88 years., Results: Twenty-four (21%) of the lithium-treated patients were defined as RI patients. These subjects exhibited the "creeping creatinine" phenomenon as their creatinine levels increased progressively. The NRI subjects showed no increase of creatinine levels in up to 30 years and remained comparable to the comparison group. RI was associated with episodes of lithium intoxication and diseases or medicines that could affect glomerular function, but not with sex, psychiatric diagnosis, age at onset of diagnosed disorder, duration of lithium therapy, serum lithium concentration, and cumulative lithium dose., Conclusions: Long-term lithium therapy did not influence glomerular function in an overwhelming majority of patients. However, about 20% of long-term lithium patients exhibited "creeping creatinine" and developed renal insufficiency.

Rumination is a rare and complex disorder to treat. It involves repeated regurgitation, rechewing and reswallowing of food and occurs mainly among infants and mentally retarded children. Among adolescents and adults it is rather rare, but still might cause significant sequelae (depression, other eating disorders and social problems). We provide a detailed psychodynamic formulation in a non-retarded adolescent with rumination (over a four year period). A multidisciplinary approach involving individual insight-oriented psychotherapy, group therapy, pharmacological therapy and a nutritional intervention has proved successful in abating the patient's symptoms. We propose that among adolescents and adults, childhood issues of neglect and feeding problems may be reactivated through the rumination symptom. The focus of this report is to address the importance of rumination, as well as the role of a multidisciplinary approach to such cases.

Enteroaggregative Escherichia coli (EAEC) is a newly diarrheagenic agent wherein several predominant serotypes are reported. We studied the association between those serotypes, as clonal indicators, and the trait of enteroaggregative adherence to host cells, tested by polymerase chain reaction. We also evaluated the clinical manifestations of infection in 17 hospitalized children by our most common EAEC serotype, O126:H27.

Background: Depression is a common, under-recognized disorder that causes a great burden on the individual, the family and the community. Depressive symptomatology has serious effects on the psychological and medical condition of patients, and also disrupts their well-being and daily activities. The aim of the present study was to investigate the prevalence of depressive symptomatology in the Israeli population, and its relation to demographic variables and perceived health., Methods: A random sample of 937 Israeli adults filled out the Beck Depression Inventory (BDI) together with a demographic questionnaire., Results: 21.5% scored positively for depressive symptomatology (BDI > 9). 3.8% reached a BDI score in the range of severe depression. Female gender, old age, lower education, immigrant status, manual work and lower income were associated with increased rates of depressive symptomatology. Poor perceived health was also associated with depressive symptomatology., Conclusions: The rates of depressive symptomatology in this study are similar to those found in other studies, performed mostly in Western countries. Despite several methodological limitations, we conclude that the rate and the demographic risk factors of depression in Israel are similar to that of other developed and Western countries.

The current psychiatric literature emphasizes the important risk factors of suicide and parasuicide, which include the following: age, family status, psychopathology, substance abuse, biological markers and so forth. Recently, more emphasis has been placed on the yearly distribution of suicide and parasuicide. This distribution includes parameters such as national and religious holidays, birthdays, anniversary days, the lunar cycle and weather. It has been suggested by many researchers that this distribution is an important precipitant to a cumulative and complicated psycho-pathological process, terminating in suicidal behavior. Analysis of theories and research findings regarding these topics are provided, together with suggestions for research and prevention.

Antiepileptic drugs might be effective in the treatment of patients with Posttraumatic Stress Disorder, a condition with unmet pharmacologic needs. We review the literature on the efficacy and tolerability of antiepileptic drugs in Posttraumatic Stress Disorder, both case reports and open studies, as well as controlled studies if available. The results of the studies will be presented together with their methodological limitations (e.g., open trials, use of additional medications, and lack of use of standardized scales for Posttraumatic Stress Disorder). The effects of antiepileptic drugs on kindling, a suggested pathogenesis for Posttraumatic Stress Disorder are overviewed, and suggestions for further research are raised.

Background: Schizophreniform disorder (SFD) has an unclear diagnostic and prognostic status within the psychotic spectrum., Method: We studied 36 inpatients admitted to our ward between 1983 and 1993 due to SFD. The patients were contacted an average of 12 years after index hospitalization, and we noted the course of their illness, as well as their present diagnosis., Results: Of the sample, 84% had additional, mostly psychotic, episodes during the follow-up, and 70% had diagnoses in the schizophrenic spectrum (that is, schizophrenia and schizoaffective disorder). A survival analysis revealed that confusion and the presence of at least 2 good prognostic factors (GPF) at index hospitalization predicted better outcome., Conclusions: SFD seems to be an early manifestation of schizophrenia. Only a few of those sampled did not experience additional relapses--a pessimistic finding at 12-year follow-up. The findings of this study accord with DSM-IV criteria and the literature regarding the long-term prognosis of SFD and the importance of the GPF.

To evaluate the prevalence of suicidal behavior in patients with panic disorder (PD) and to study the role of alexithymia (AL), an affect component, as a predictor of suicidal behavior in PD, we compared 42 patients with PD with or without agoraphobia with 24 healthy controls with regards to depression, AL and suicide risk. Only 5% of the PD patients reported previous suicide attempts. A higher frequency of positive AL (score > 73) was found among the PD patients (39% v 4% among the controls). PD patients had a higher suicide risk and AL as compared to controls, but only the increased suicide risk reached statistical significance. AL subjects had higher suicide risk scores as compared to non-AL subjects. Significant correlations were found between the AL score and suicide risk, although the most significant correlation was, as expected, between the depression level and the suicide risk. A low rate of previous suicide attempts was found in the PD group, perhaps reflecting the low comorbidity in our sample. We suggest that AL may have a role in the causation of suicidal behavior in PD patients, although further studies should re-examine this issue with larger samples., (Copyright 2001 by W.B. Saunders Company)

Preventive intervention after exposure to traumatic events is a subject of increasing interest among mental health professionals. Psychological debriefing, which aims to reduce the risk of posttraumatic stress disorder and other psychopathological sequelae of traumatic experiences, is an example of such an intervention. The authors review the history of psychological debriefing and examine its efficacy. They conclude that psychological debriefing might be an effective intervention after extreme stress, although more support from controlled studies is required.

The objective of this study was to determine the efficacy of pindolol as an augmentor of fluoxetine in treatment-resistant panic disorder (PD). Twenty-five outpatients having PD with or without agoraphobia were included. These patients had not responded to two different trials with antidepressants and an 8-week trial of fluoxetine 20 mg/day. Treatment-resistant PD was defined as a less than 20% reduction in score on the Panic Self-Questionnaire (number of attacks per week) (PSQ) and the Clinical Anxiety Scale With Panic Attacks (CAS+PA). These patients continued to receive fluoxetine 20 mg/day and were randomly assigned to additionally receive either pindolol (2.5 mg three times daily) or placebo for the following 4 weeks. Evaluations were performed weekly using the Hamilton Rating Scale for Anxiety, the Hamilton Rating Scale for Depression (HAM-D), the CAS+PA, the NIMH Anxiety Scale, the PSQ, and the Clinical Global Impression Scale. The data were analyzed using a repeated-measures analysis of variance (ANOVA) and a t-test for independent samples. Patients treated with the combination of pindolol and fluoxetine (N = 13) demonstrated a significant improvement over the patients treated with fluoxetine and placebo on all rating scales, with the exception of HAM-D. The statistical differences were shown using the repeated-measures ANOVA (baseline, week 2, week 4) and also with t-tests from the second week of the trial. These preliminary results demonstrate that pindolol has an augmenting effect on fluoxetine in patients with treatment-resistant PD.

Kleptomania is characterized by an irresistible impulse to steal objects not needed for personal use or for their monetary value. Several recent case reports have shown that Serotonin Specific Reuptake Inhibitors (SSRIs) could be effective in the treatment of kleptomania just as it is in other obsessive-compulsive spectrum disorders. We report five cases of kleptomania patients who were successfully treated with fluoxetine or paroxetine in combination with a psychotherapeutic intervention. In one case, the discontinuation of the medication repeatedly led to the resurgence of the kleptomanic behavior. Our case series illustrates the effectiveness of SSRIs in kleptomania. It thus supports the assumption that this syndrome involves a dysfunctional serotoninergic mechanism.

Labetalol, a combined alpha- and beta-adrenergic blocker is often used to attenuate the transient increases in heart rate and blood pressure that accompany electroconvulsive therapy (ECT). It has been suggested that labetalol should not be administered during ECT without the protection provided by anticholinergic medications, because of its potential severe bradycardic effects. We present our experience with 32 patients from all age groups who received labetalol without anticholinergic treatment during ECT. None of the patients demonstrated adverse bradycardic effects. We conclude that administration of labetalol during ECT does not routinely require premedication with anticholinergic drugs and does not lengthen asystole.

We present a patient with gradual development of camptocormia, three years before a non-Hodgkin's lymphoma was diagnosed. Lymphomas are known to produce neuromuscular symptoms through several indirect mechanisms. Recent studies regard camptocormia as a primary disease of the paravertebral muscles. To our knowledge this is the first report associating camptocormia with malignancy. The possibility of a paraneoplastic syndrome is discussed.

One of the central tenets of the Druze religion is the transmigration of the soul. In rare cases this belief may be related to psychopathology or cause a temporary inability to function normally. We report on 5 Druze patients whose preoccupation with transmigration was the basis of their pathological behavior. These cases illustrate the interaction between cultural and religious beliefs, and psychopathology, and emphasize the importance of employing a culture-specific psychiatric approach in the management of this type of patients.

Tardive dystonia is a disorder characterized by abnormally sustained posturing associated with the use of dopamine-receptor blocking agents such as antipsychotic drugs. However, the structural pathologic and pathophysiologic features of this disorder are unknown, and no consistently effective pharmacologic treatment is available. Patients with tardive dystonia mostly are young men. We present the case of one substantially improved with treatment by 1200 mg/d (IU) of vitamin E.

Kleptomania, one of the rare impulse-control disorders, is characterized by an irresistible impulse to steal objects not needed for personal use or monetary value. There is a comorbidity between mood disorders, eating disorders, anxiety disorders, personality disorders, and kleptomania. Several recent case reports have suggested that serotonin reuptake inhibitors could be effective in the treatment of obsessive-compulsive spectrum disorders and specifically in kleptomania. We describe three depressed patients who paradoxically experienced kleptomanic behavior during treatment with serotonin selective reuptake inhibitors.

The worldwide prevalence of obsessive-compulsive disorder (OCD) is approximately 2% of the general population. Symptoms of OCD include fear of contamination by dirt or germs; constant checking; repetitive, intrusive thoughts of a somatic, aggressive, or sexual nature; extreme slowness; and an inordinate concern with orderliness and symmetry. Differential diagnosis is sometimes complicated by the overlap between OCD and obsessive-compulsive personality disorder (OCPD). The most common complication of OCD is depression. However, while both serotonergic and nonserotonergic antidepressants are effective in treating patients with depression, only serotonergic medications are effective in treating OCD patients. Because OCD patients often attempt to conceal their symptoms, it is incumbent on clinicians to screen for OCD in every mental status examination, since appropriate treatment can often result in improved quality of life.

Attempted suicide in adolescence is a major health problem and recent reports indicate a dramatic increase in the frequency of attempted and completed suicide among adolescents. The aim of this study was to evaluate the characteristics of adolescent admissions with attempted suicide in a large general hospital. The files of all children and adolescents admitted due to a suicide attempt between the years 1984 and 1994 were examined retrospectively, with regard to age, sex, method of attempt, season, year and length of hospitalization. Four hundred and four admissions with attempted suicide were recorded. The majority (83.7%) were females and drug overdose was the most common (92.8%) method used. Thirty patients (7.5%) repeated the attempt during the study period. No specific time of the year was associated with an increase in adolescent suicide attempt admissions. The most remarkable finding was that younger adolescents had a higher probability of performing a violent suicide attempt. Hypotheses for these trends are examined together with possible ramifications for treatment provision.

The frequent use of selective, serotonin reuptake inhibitors has increased the risk of the serotonin syndrome. This condition is related to stimulation of 5HT1A receptors and is characterized by agitation, confusion, tremor, fever and shivering. A 29-year-old woman and a 69-year-old man with the syndrome are reported. The importance of early diagnosis and treatment is emphasized, and aspects of the syndrome in patients with obsessive-compulsive disorder are presented.

Background: A major pitfall in the diagnosis of conversion disorder is the difficulty in ruling out organic causes. METHODS. A 19-year-old female was referred with seizures and the Dandy-Walker syndrome. We continued the medical workup and also treated the patient with psychotherapy., Results: The patient's symptoms gradually abated, however, the headaches remained. No neurologic illness evolved during the follow-up., Conclusions: The diagnosis of pseudoseizures is suggested according to clinical evaluation and follow-up. A multidisciplinary approach is recommended in such cases for efficient diagnosis and treatment.

Objective: To assess the long-term effects of a traumatic bus-train collision and to examine the effect of levels of exposure and immediate reactions on long-term adjustment., Method: Seven years after the accident, 389 subjects, all doing compulsory army service, filled out self-report questionnaires assessing symptoms of posttraumatic stress disorder (PTSD), psychiatric symptomatology, and military functioning. In addition, subjects were questioned about their immediate reactions to the traumatic event., Results: The most highly exposed subjects reported the highest levels of somatization, depression, phobic anxiety, and psychoticism and more PTSD symptoms. Acute stress symptoms and manifestations of fear immediately after the accident were strongly related to long-term maladjustment, Conclusions: The results suggest that the investigation and assessment of long-term adjustment after traumatic events should take into account both contextual factors, such as the level of exposure to the event, and personal factors, such as the victims' immediate reactions.

Valproic acid has been proven to be efficient in the treatment of bipolar affective disorders as an adjunctive agent to lithium and carbamazepine. Recently, its efficacy in rapid cycling states has attracted interest. We present the case of a male patient with bipolar affective disorder who developed an extreme state of ultra-rapid cycling (48-h cycles). Only the addition of valproic acid therapy to prior lithium treatment succeeded in curtailing the ultra-rapid cycling. Several issues regarding ultra-rapid cycling and valproate's efficacy in bipolar disorder are discussed.

Transmigration of souls is one of the central beliefs of the Druze religion and culture. However, in rare cases this belief can represent psychopathology. A case of an 18-year-old Druze soldier suffering from generalized anxiety disorder whose presenting symptom was a belief in transmigration of souls is described. This case illustrates the interaction between cultural and religious beliefs with psychopathology.

Objective: Fluvoxamine, a monocyclic, specific serotonin uptake inhibitor with demonstrated efficacy in obsessive-compulsive disorder (OCD) and depression in adults, is marketed in more than 30 countries worldwide, including Israel. In the United States, where fluvoxamine is available only on an investigational basis, marketing appears imminent. This study evaluates the safety and efficacy of fluvoxamine in adolescents., Method: In an 8-week, open-label trial of fluvoxamine, 20 adolescent inpatients, ages 13 to 18 years, were treated for OCD (n = 14) or major depressive disorder (MDD)(n = 6) with daily doses ranging from 100 to 300 mg. Target symptoms were rated at regular intervals with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS); Suicide Potential Scales (SPS); Beck Depression Inventory (BDI); the Overt Aggression Scale (OAS); and the Children's Global Adjustment Scale (CGAS)., Results: Fluvoxamine proved relatively safe and was especially effective in the patients with OCD; mean Y-BOCS scores decreased significantly (p < .0001) from 28.0 to 19.8 on medication. Although fluvoxamine also appeared effective in decreasing depression and bulimic symptoms, its impact on impulsive, suicidal, and anorectic symptoms was less clear. The commonest side effects (n > or = 3) were dermatitis, insomnia, hyperactivity, excitement, anxiety, tremor, and nausea. Fluvoxamine was discontinued in four patients because of side effects; the most serious side effect occurred in two debilitated anorexic patients, of whom one became delirious and the other developed hallucinations., Conclusion: Preliminary evidence suggests that short-term treatment of adolescents with fluvoxamine is relatively safe and may be effective for OCD and some affective spectrum symptoms.

We assessed eating attitudes and body image using the Eating Attitudes Test-26 (EAT: Garner & Garfinkel, 1979) and a 17-item body image scale in Israeli Jewish female high school populations in five distinct residential settings (kibbutz, moshav, city, and 2 different boarding schools); in five ethnically distinct Arab female high school populations (Muslim, Christian, Druze, Circassian, and Bedouin); and in a group of hospitalized adolescent girls with anorexia nervosa. We hypothesized that the attitudes of the adolescent females most exposed to Western body shape ideals and simultaneously undergoing role conflict between traditional and modern images of the female role would most resemble attitudes of anorectics. This was partly supported by the findings. Ethnic differences also emerged in attitude toward food. All the Arab populations except the Circassian showed strong Western influences in their attitudes toward eating and body image and thus may well be prone to epidemics of anorexia and similar eating disorders in the near future. Kibbutz girls were most similar to the anorectic group.

Hyperemesis gravidarum is a potentially dangerous disorder of pregnancy characterized by severe and protracted vomiting. It is suggested that psychosocial factors may have a role in determining whether the pregnant woman experiences a transient spell of mild vomiting or progresses towards the much rarer but more significant pernicious vomiting. Psychotherapy, hypnotherapy and behavior therapy have been reported to contribute to the treatment of patients with hyperemesis gravidarum. A review of the etiological factors as well as of the therapeutic approaches is presented.

The relationship between anorexia nervosa (AN) and sociocultural factors is examined. Anorexia nervosa was first described in the West and was reported as particularly rare or absent in Eastern cultures. However, the frequency of its presentation has increased worldwide over the past two decades, probably as a consequence of changes in cultural norms and concepts of feminine beauty and an increasing inflow of Western values into other countries. Sociocultural factors are important in the development of AN in psychologically vulnerable young females, although other factors may also be implicated.

A combined plan of action of the Medical Corps in the battle against traffic accidents is described. The plan covers sound medical standards for military driver licensing, disqualification of drivers with medical problems, reporting of problematic drivers (epileptics and others) to the Israeli Ministry of Health, evaluating the driving fitness of drivers involved in traffic accidents, and finally, an education program for all Israel Defence Forces soldiers to be delivered by military physicians. Several medical aspects of traffic safety are highlighted. Scientific research and greater involvement of physicians and psychologists in this area is required if the trauma occurring daily on highways is to be eliminated and acute care hospital costs minimized.

The Ganser syndrome is rare in children and adolescents. Two cases of Ganser syndrome in adolescent brothers, both of whom developed the syndrome while in jail and awaiting trial, are presented. Both brothers subsequently developed signs and symptoms indicative of affective disorder. The differential diagnosis and the management of these two patients are discussed in the light of the nosological controversies surrounding this clinical entity.

Anorexia nervosa is a psychiatric disorder characterized by excessive dieting, severe weight loss, disturbed body image and inexplicable fear of gaining weight. It afflicts mainly upper class women of developed countries. We present a 16-year-old recent immigrant from Russia, where she had developed anorexia nervosa, obsessive-compulsive disorder and depression. The management of this patient is presented in the light of the sociocultural theory of the pathogenesis of anorexia nervosa and the clinical link between eating disorders and depression and obsessive-compulsive disorders.

Coexistence of diabetes mellitus and anorexia nervosa has been noted in the past 2 decades. The nature and treatment of diabetes offer numerous opportunities for the anorectic patient to lose weight. Improper adjustment of the insulin dose, failure to inject insulin, clandestine vomiting and failure to provide urine samples allow the anorectic diabetic to achieve morbid weight loss. The treatment of patients with both conditions is difficult; behavioral management combined with psychotherapy was found to be most effective. An illustrative case is presented.