Somatic Disorders

VIENNA – Childhood trauma was an independent predictor of coronary heart disease and major depression later in life in a study with 360 men.

“Childhood trauma can have important consequences, but it is a risk factor that physicians don't usually think about,” Dr. Viola Vaccarino said while presenting a poster at the annual congress of the European Society of Cardiology.

“Once a person is identified with a history of childhood trauma, that person needs to be monitored very closely. Our data [suggest] that childhood trauma may be a key history to ask about,” said Dr. Vaccarino, a professor of medicine and epidemiology at Emory University, Atlanta.

The study by Dr. Vaccarino and her associates used 360 male twins (180 pairs, either mono- or dizygotic) who were born in 1946–1956 and were enrolled in the Vietnam Era Twin Registry. The participants were all interviewed at Emory University. They were assessed using the Early Trauma Inventory (ETI), a measure of traumatic events occurring before age 18 years, and the Late Trauma Inventory (LTI), a measure of traumatic events that occur when a person is aged 18 years or older. Physical health was assessed by examination, and mental health was assessed with the Structured Clinical Interview for Psychiatric Disorders. In all, 33 participants were diagnosed with coronary heart disease (CHD), 82 were diagnosed with major depressive disorder, and 23 had posttraumatic stress disorder.

The participants were divided into quartiles based on their ETI scores.

The analysis showed that the men in the three lowest ETI quartiles had a 6% prevalence of CHD compared with an 18% rate in the quartile with the highest ETI score. When adjusted for age and smoking history, the men in the highest quartile for childhood trauma had about a twofold increased rate of CHD, compared with men with lower ETI scores, a statistically significant difference. (See box.)

A second analysis showed that men in the quartile with the greatest childhood trauma were also about twice as likely to have major depression, compared with men with lower ETI scores, also a significant difference, said Dr. Vaccarino, who is also director of EPICORE (Emory Program in Cardiovascular Outcomes Research and Epidemiology).

Initially, an excess of CHD and depression was also seen in men who had high scores on the LTI. But when the LTI analysis was adjusted for the prevalence of early trauma, the link between the LTI score and CHD and depression disappeared. In contrast, a strong link was also seen between high LTI scores and posttraumatic stress disorder, but this link was not affected by adjustment for ETI scores.

Childhood trauma can occur in the form of physical abuse, emotional abuse, sexual abuse, or general trauma, which is caused by events such as earthquakes and car accidents.

These findings suggest that primary care physicians should routinely ask patients about their trauma exposures as children. They may even want to administer the ETI, which has recently been streamlined to a single-page questionnaire, Dr. Vaccarino said in an interview.

ELSEVIER GLOBAL MEDICAL NEWS

VIENNA – Childhood trauma was an independent predictor of coronary heart disease and major depression later in life in a study with 360 men.

“Childhood trauma can have important consequences, but it is a risk factor that physicians don't usually think about,” Dr. Viola Vaccarino said while presenting a poster at the annual congress of the European Society of Cardiology.

“Once a person is identified with a history of childhood trauma, that person needs to be monitored very closely. Our data [suggest] that childhood trauma may be a key history to ask about,” said Dr. Vaccarino, a professor of medicine and epidemiology at Emory University, Atlanta.

The study by Dr. Vaccarino and her associates used 360 male twins (180 pairs, either mono- or dizygotic) who were born in 1946–1956 and were enrolled in the Vietnam Era Twin Registry. The participants were all interviewed at Emory University. They were assessed using the Early Trauma Inventory (ETI), a measure of traumatic events occurring before age 18 years, and the Late Trauma Inventory (LTI), a measure of traumatic events that occur when a person is aged 18 years or older. Physical health was assessed by examination, and mental health was assessed with the Structured Clinical Interview for Psychiatric Disorders. In all, 33 participants were diagnosed with coronary heart disease (CHD), 82 were diagnosed with major depressive disorder, and 23 had posttraumatic stress disorder.

The participants were divided into quartiles based on their ETI scores.

The analysis showed that the men in the three lowest ETI quartiles had a 6% prevalence of CHD compared with an 18% rate in the quartile with the highest ETI score. When adjusted for age and smoking history, the men in the highest quartile for childhood trauma had about a twofold increased rate of CHD, compared with men with lower ETI scores, a statistically significant difference. (See box.)

A second analysis showed that men in the quartile with the greatest childhood trauma were also about twice as likely to have major depression, compared with men with lower ETI scores, also a significant difference, said Dr. Vaccarino, who is also director of EPICORE (Emory Program in Cardiovascular Outcomes Research and Epidemiology).

Initially, an excess of CHD and depression was also seen in men who had high scores on the LTI. But when the LTI analysis was adjusted for the prevalence of early trauma, the link between the LTI score and CHD and depression disappeared. In contrast, a strong link was also seen between high LTI scores and posttraumatic stress disorder, but this link was not affected by adjustment for ETI scores.

Childhood trauma can occur in the form of physical abuse, emotional abuse, sexual abuse, or general trauma, which is caused by events such as earthquakes and car accidents.

These findings suggest that primary care physicians should routinely ask patients about their trauma exposures as children. They may even want to administer the ETI, which has recently been streamlined to a single-page questionnaire, Dr. Vaccarino said in an interview.

ELSEVIER GLOBAL MEDICAL NEWS

VIENNA – Childhood trauma was an independent predictor of coronary heart disease and major depression later in life in a study with 360 men.

“Childhood trauma can have important consequences, but it is a risk factor that physicians don't usually think about,” Dr. Viola Vaccarino said while presenting a poster at the annual congress of the European Society of Cardiology.

“Once a person is identified with a history of childhood trauma, that person needs to be monitored very closely. Our data [suggest] that childhood trauma may be a key history to ask about,” said Dr. Vaccarino, a professor of medicine and epidemiology at Emory University, Atlanta.

The study by Dr. Vaccarino and her associates used 360 male twins (180 pairs, either mono- or dizygotic) who were born in 1946–1956 and were enrolled in the Vietnam Era Twin Registry. The participants were all interviewed at Emory University. They were assessed using the Early Trauma Inventory (ETI), a measure of traumatic events occurring before age 18 years, and the Late Trauma Inventory (LTI), a measure of traumatic events that occur when a person is aged 18 years or older. Physical health was assessed by examination, and mental health was assessed with the Structured Clinical Interview for Psychiatric Disorders. In all, 33 participants were diagnosed with coronary heart disease (CHD), 82 were diagnosed with major depressive disorder, and 23 had posttraumatic stress disorder.

The participants were divided into quartiles based on their ETI scores.

The analysis showed that the men in the three lowest ETI quartiles had a 6% prevalence of CHD compared with an 18% rate in the quartile with the highest ETI score. When adjusted for age and smoking history, the men in the highest quartile for childhood trauma had about a twofold increased rate of CHD, compared with men with lower ETI scores, a statistically significant difference. (See box.)

A second analysis showed that men in the quartile with the greatest childhood trauma were also about twice as likely to have major depression, compared with men with lower ETI scores, also a significant difference, said Dr. Vaccarino, who is also director of EPICORE (Emory Program in Cardiovascular Outcomes Research and Epidemiology).

Initially, an excess of CHD and depression was also seen in men who had high scores on the LTI. But when the LTI analysis was adjusted for the prevalence of early trauma, the link between the LTI score and CHD and depression disappeared. In contrast, a strong link was also seen between high LTI scores and posttraumatic stress disorder, but this link was not affected by adjustment for ETI scores.

Childhood trauma can occur in the form of physical abuse, emotional abuse, sexual abuse, or general trauma, which is caused by events such as earthquakes and car accidents.

These findings suggest that primary care physicians should routinely ask patients about their trauma exposures as children. They may even want to administer the ETI, which has recently been streamlined to a single-page questionnaire, Dr. Vaccarino said in an interview.

ELSEVIER GLOBAL MEDICAL NEWS

Social anxiety stemming from acne or other skin conditions might keep people from exercising, say results of a survey of 50 adults selected from an acne support group.

Exercise is important for overall health and skin health, but data from previous studies have shown that people are often inclined to avoid participating in sports and other activities because of anxiety about their appearance.

To examine the link between skin-related social anxiety and the intention to play sports or exercise, Tom Loney, a Ph.D. student at the University of Bath (England) and his colleagues surveyed 20 men and 30 women with an average age of 33 years (J. Health Psychol. 2008;13:47–54).

The participants responded to questionnaires that addressed dermatologic social anxiety, intention to participate in sports and exercise, self-esteem, and quality of life related to skin conditions.

Based on responses to dermatologic social anxiety statements such as, “When in a bathing suit, I often feel nervous about the appearance of my skin,” the average score was 3.97 on a scale of 1 (not at all) to 5 (extremely).

The average score for intent-to-exercise statements such as “I am determined to exercise/play sport at least three times a week during the next month” was 4.04 on a scale of 1 (very unlikely) to 7 (very likely). For self-esteem statements such as “I feel that I have a number of good qualities,” the average response was 1.56 on a scale of 1 (strongly disagree) to 4 (strongly agree).

Finally, the average score on the Dermatology Life Quality Index, which includes 10 items such as, “Over the last week, how much has your skin affected any social or leisure activities?” was 0.99 on a scale of 3 (very much) to 0 (not at all).

Statistical analyses of the responses yielded significant negative relationships between skin-related social anxiety and each of three variables: intention to exercise, self-esteem, and dermatologic-related quality of life.

“Participants who experience greater levels of skin-related social anxiety report lower intention to participate in sport and exercise, experience lower self-esteem,” and have a poorer quality of life related to skin conditions, Mr. Loney and his associates wrote.

The extent to which people are apprehensive about having their skin evaluated by others has implications for the intention to participate in sports and exercise and for self-perception, but more studies are needed to determine the impact of skin-related social anxiety within specific sports and exercise settings, they said. For example, team sports or group exercise settings might cause more anxiety than exercising alone, and people with high skin-related social anxiety might avoid those situations.

Although the results were limited by the use of a global perception of acne severity rather than symptom-specific ratings, the data support findings from previous studies and contribute to the limited field of research involving both physical and psychological health, Mr. Loney and his colleagues said. None of the researchers disclosed any conflicts of interest.

Social anxiety stemming from acne or other skin conditions might keep people from exercising, say results of a survey of 50 adults selected from an acne support group.

Exercise is important for overall health and skin health, but data from previous studies have shown that people are often inclined to avoid participating in sports and other activities because of anxiety about their appearance.

To examine the link between skin-related social anxiety and the intention to play sports or exercise, Tom Loney, a Ph.D. student at the University of Bath (England) and his colleagues surveyed 20 men and 30 women with an average age of 33 years (J. Health Psychol. 2008;13:47–54).

The participants responded to questionnaires that addressed dermatologic social anxiety, intention to participate in sports and exercise, self-esteem, and quality of life related to skin conditions.

Based on responses to dermatologic social anxiety statements such as, “When in a bathing suit, I often feel nervous about the appearance of my skin,” the average score was 3.97 on a scale of 1 (not at all) to 5 (extremely).

The average score for intent-to-exercise statements such as “I am determined to exercise/play sport at least three times a week during the next month” was 4.04 on a scale of 1 (very unlikely) to 7 (very likely). For self-esteem statements such as “I feel that I have a number of good qualities,” the average response was 1.56 on a scale of 1 (strongly disagree) to 4 (strongly agree).

Finally, the average score on the Dermatology Life Quality Index, which includes 10 items such as, “Over the last week, how much has your skin affected any social or leisure activities?” was 0.99 on a scale of 3 (very much) to 0 (not at all).

Statistical analyses of the responses yielded significant negative relationships between skin-related social anxiety and each of three variables: intention to exercise, self-esteem, and dermatologic-related quality of life.

“Participants who experience greater levels of skin-related social anxiety report lower intention to participate in sport and exercise, experience lower self-esteem,” and have a poorer quality of life related to skin conditions, Mr. Loney and his associates wrote.

The extent to which people are apprehensive about having their skin evaluated by others has implications for the intention to participate in sports and exercise and for self-perception, but more studies are needed to determine the impact of skin-related social anxiety within specific sports and exercise settings, they said. For example, team sports or group exercise settings might cause more anxiety than exercising alone, and people with high skin-related social anxiety might avoid those situations.

Although the results were limited by the use of a global perception of acne severity rather than symptom-specific ratings, the data support findings from previous studies and contribute to the limited field of research involving both physical and psychological health, Mr. Loney and his colleagues said. None of the researchers disclosed any conflicts of interest.

Social anxiety stemming from acne or other skin conditions might keep people from exercising, say results of a survey of 50 adults selected from an acne support group.

Exercise is important for overall health and skin health, but data from previous studies have shown that people are often inclined to avoid participating in sports and other activities because of anxiety about their appearance.

To examine the link between skin-related social anxiety and the intention to play sports or exercise, Tom Loney, a Ph.D. student at the University of Bath (England) and his colleagues surveyed 20 men and 30 women with an average age of 33 years (J. Health Psychol. 2008;13:47–54).

The participants responded to questionnaires that addressed dermatologic social anxiety, intention to participate in sports and exercise, self-esteem, and quality of life related to skin conditions.

Based on responses to dermatologic social anxiety statements such as, “When in a bathing suit, I often feel nervous about the appearance of my skin,” the average score was 3.97 on a scale of 1 (not at all) to 5 (extremely).

The average score for intent-to-exercise statements such as “I am determined to exercise/play sport at least three times a week during the next month” was 4.04 on a scale of 1 (very unlikely) to 7 (very likely). For self-esteem statements such as “I feel that I have a number of good qualities,” the average response was 1.56 on a scale of 1 (strongly disagree) to 4 (strongly agree).

Finally, the average score on the Dermatology Life Quality Index, which includes 10 items such as, “Over the last week, how much has your skin affected any social or leisure activities?” was 0.99 on a scale of 3 (very much) to 0 (not at all).

Statistical analyses of the responses yielded significant negative relationships between skin-related social anxiety and each of three variables: intention to exercise, self-esteem, and dermatologic-related quality of life.

“Participants who experience greater levels of skin-related social anxiety report lower intention to participate in sport and exercise, experience lower self-esteem,” and have a poorer quality of life related to skin conditions, Mr. Loney and his associates wrote.

The extent to which people are apprehensive about having their skin evaluated by others has implications for the intention to participate in sports and exercise and for self-perception, but more studies are needed to determine the impact of skin-related social anxiety within specific sports and exercise settings, they said. For example, team sports or group exercise settings might cause more anxiety than exercising alone, and people with high skin-related social anxiety might avoid those situations.

Although the results were limited by the use of a global perception of acne severity rather than symptom-specific ratings, the data support findings from previous studies and contribute to the limited field of research involving both physical and psychological health, Mr. Loney and his colleagues said. None of the researchers disclosed any conflicts of interest.

Nearly half of all patients with chronic idiopathic urticaria have Axis I psychiatric diagnoses and 45% have Axis II diagnoses, a new study shows.

Obsessive-compulsive disorder (OCD) and major depression were the most common Axis I diagnoses among 89 consecutive patients with chronic idiopathic urticaria (CIU), and both psychiatric illnesses were significantly more common in the patients than in a control group.

Among the patients, 26% had OCD, compared with 2% of the controls, and 13% had major depression, compared with 3% of the controls, reported Dr. Faruk Uguz and his colleagues at Selcuk University, Konya, Turkey (J. Psychosom. Res. 2008;64:225–9).

Obsessive-compulsive personality disorder and avoidant personality disorder were the most common Axis II diagnoses among the CIU patients, and both were significantly more prevalent in the patients than in the controls. Thirty percent of the patients had obsessive-compulsive personality disorder, compared with 3% of the controls, and 18% of the patients had avoidant personality disorder, compared with 5% of the controls.

Characterized by the rapid appearance of itchy wheals, urticaria is considered chronic when it is recurrent for at least 6 weeks. Few cases have identifiable physical causes, such as infections, reactions to drugs or foods, or vasculitic diseases. But 75% of all cases have no known cause, and these are referred to as chronic idiopathic urticaria.

The study involved 89 consecutive patients with CIU who were seen at an outpatient clinic in Turkey and a control group of 64 hospital employees and their relatives who were matched to the patients' sociodemographic characteristics. The investigators excluded from both groups individuals who were illiterate, and those who had accompanying severe medical illnesses, or had used corticosteroid or psychotropic medications within the prior 4 weeks.

Psychiatrists made Axis I diagnoses using the Structured Clinical Interview for DSM-IV and the Structured Clinical Interview for DSM, Revised Third Edition, Personality Disorders.

In all, 44 of the CIU patients (49%) and 8 of the individuals in the control group (12%) had an Axis I disorder. Forty of the CIU patients (45%) and nine of the controls (14%) had Axis II disorders. Both differences were statistically significant.

The investigators acknowledged that their study could not establish a causal relationship between psychiatric disorders and CIU. Psychiatric disorders could either be a cause or a consequence of CIU.

Nearly half of all patients with chronic idiopathic urticaria have Axis I psychiatric diagnoses and 45% have Axis II diagnoses, a new study shows.

Obsessive-compulsive disorder (OCD) and major depression were the most common Axis I diagnoses among 89 consecutive patients with chronic idiopathic urticaria (CIU), and both psychiatric illnesses were significantly more common in the patients than in a control group.

Among the patients, 26% had OCD, compared with 2% of the controls, and 13% had major depression, compared with 3% of the controls, reported Dr. Faruk Uguz and his colleagues at Selcuk University, Konya, Turkey (J. Psychosom. Res. 2008;64:225–9).

Obsessive-compulsive personality disorder and avoidant personality disorder were the most common Axis II diagnoses among the CIU patients, and both were significantly more prevalent in the patients than in the controls. Thirty percent of the patients had obsessive-compulsive personality disorder, compared with 3% of the controls, and 18% of the patients had avoidant personality disorder, compared with 5% of the controls.

Characterized by the rapid appearance of itchy wheals, urticaria is considered chronic when it is recurrent for at least 6 weeks. Few cases have identifiable physical causes, such as infections, reactions to drugs or foods, or vasculitic diseases. But 75% of all cases have no known cause, and these are referred to as chronic idiopathic urticaria.

The study involved 89 consecutive patients with CIU who were seen at an outpatient clinic in Turkey and a control group of 64 hospital employees and their relatives who were matched to the patients' sociodemographic characteristics. The investigators excluded from both groups individuals who were illiterate, and those who had accompanying severe medical illnesses, or had used corticosteroid or psychotropic medications within the prior 4 weeks.

Psychiatrists made Axis I diagnoses using the Structured Clinical Interview for DSM-IV and the Structured Clinical Interview for DSM, Revised Third Edition, Personality Disorders.

In all, 44 of the CIU patients (49%) and 8 of the individuals in the control group (12%) had an Axis I disorder. Forty of the CIU patients (45%) and nine of the controls (14%) had Axis II disorders. Both differences were statistically significant.

The investigators acknowledged that their study could not establish a causal relationship between psychiatric disorders and CIU. Psychiatric disorders could either be a cause or a consequence of CIU.

Nearly half of all patients with chronic idiopathic urticaria have Axis I psychiatric diagnoses and 45% have Axis II diagnoses, a new study shows.

Obsessive-compulsive disorder (OCD) and major depression were the most common Axis I diagnoses among 89 consecutive patients with chronic idiopathic urticaria (CIU), and both psychiatric illnesses were significantly more common in the patients than in a control group.

Among the patients, 26% had OCD, compared with 2% of the controls, and 13% had major depression, compared with 3% of the controls, reported Dr. Faruk Uguz and his colleagues at Selcuk University, Konya, Turkey (J. Psychosom. Res. 2008;64:225–9).

Obsessive-compulsive personality disorder and avoidant personality disorder were the most common Axis II diagnoses among the CIU patients, and both were significantly more prevalent in the patients than in the controls. Thirty percent of the patients had obsessive-compulsive personality disorder, compared with 3% of the controls, and 18% of the patients had avoidant personality disorder, compared with 5% of the controls.

Characterized by the rapid appearance of itchy wheals, urticaria is considered chronic when it is recurrent for at least 6 weeks. Few cases have identifiable physical causes, such as infections, reactions to drugs or foods, or vasculitic diseases. But 75% of all cases have no known cause, and these are referred to as chronic idiopathic urticaria.

The study involved 89 consecutive patients with CIU who were seen at an outpatient clinic in Turkey and a control group of 64 hospital employees and their relatives who were matched to the patients' sociodemographic characteristics. The investigators excluded from both groups individuals who were illiterate, and those who had accompanying severe medical illnesses, or had used corticosteroid or psychotropic medications within the prior 4 weeks.

Psychiatrists made Axis I diagnoses using the Structured Clinical Interview for DSM-IV and the Structured Clinical Interview for DSM, Revised Third Edition, Personality Disorders.

In all, 44 of the CIU patients (49%) and 8 of the individuals in the control group (12%) had an Axis I disorder. Forty of the CIU patients (45%) and nine of the controls (14%) had Axis II disorders. Both differences were statistically significant.

The investigators acknowledged that their study could not establish a causal relationship between psychiatric disorders and CIU. Psychiatric disorders could either be a cause or a consequence of CIU.

COLORADO SPRINGS – Former nondrinkers who initiated moderate alcohol consumption in middle age experienced a 38% reduction in cardiovascular events over 4 years, compared with continued nondrinkers in the Atherosclerosis Risk in Communities study.

“The current American Heart Association guidelines state that moderate alcohol consumption at this level can be part of a healthy lifestyle, but caution that if you don't already drink, don't start. This research challenges that policy. A 38% lower chance of having an acute MI or stroke is extremely significant. That's a bigger effect than you'd expect with initiation of statin therapy,” said Dr. Dana E. King, who is professor of family medicine at the Medical University of South Carolina, Charleston.

Results were presented at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

Atherosclerosis Risk in Communities (ARIC) is an ongoing National Heart, Lung, and Blood Institute-sponsored prospective epidemiologic study of 15,792 black and white men and women aged 45–64 at entry who are free of known cardiovascular disease and diabetes in four geographically diverse communities across the United States.

During the first 6 years, 7,697 enrollees who were nondrinkers at baseline began moderate consumption of alcohol, defined in accord with the AHA and American Diabetes Association as not more than two drinks per day for men and one for women.

An additional 0.4% of former nondrinkers began heavier drinking, Dr. King said 38%.

During the next 4 years of follow-up, the combined rate of fatal and nonfatal cardiovascular events was 6.9% among new moderate drinkers and 10.7% in the continued teetotalers.

After adjustment for age, race, sex, diabetes, hypertension, hyperlipidemia, and physical activity, adoption of moderate alcohol intake remained an independent protective factor against cardiovascular events, with an associated 38% relative risk reduction.

All-cause mortality did not differ significantly between the two groups, perhaps because of the limited number of fatalities, but it trended in favor of the new moderate drinkers, who showed a 29% relative risk reduction.

The new heavy drinkers displayed a nonsignificant trend for more cardiovascular events than did continued nondrinkers over the 4-year period.

The reasons why former nondrinkers in ARIC began consuming alcohol in middle age were not assessed as part of the study. “We would presume that it was for the health benefits, but we don't know,” Dr. King said in an interview.

He added that he would not expect a formal change in AHA policy on the basis of a single study.

However, these ARIC findings “certainly tilt the scale” in favor of physician counselling on a case-by-case basis that patients consider making alcohol part of a heart-healthy diet, provided they don't use certain medications or have a strong family or personal history of problem drinking, liver disease, or selected other health problems.

“It's a small minority of the population that gets in trouble with drinking, and perhaps we should not restrict the benefit of this healthy lifestyle choice in people who don't have a problem with alcohol,” he said.

Follow-up in ARIC will continue. That's important because some possible adverse consequences of new drinking–for example, a potential increase in certain types of cancer–might take longer than 4 years to become apparent.

The ARIC alcohol adoption findings were published simultaneously with Dr. King's presentation at the annual conference (Am. J. Med. 2008;121:201–6).

Current guidelines caution that if you don't drink, don't start. This finding challenges that policy. DR. KING

COLORADO SPRINGS – Former nondrinkers who initiated moderate alcohol consumption in middle age experienced a 38% reduction in cardiovascular events over 4 years, compared with continued nondrinkers in the Atherosclerosis Risk in Communities study.

“The current American Heart Association guidelines state that moderate alcohol consumption at this level can be part of a healthy lifestyle, but caution that if you don't already drink, don't start. This research challenges that policy. A 38% lower chance of having an acute MI or stroke is extremely significant. That's a bigger effect than you'd expect with initiation of statin therapy,” said Dr. Dana E. King, who is professor of family medicine at the Medical University of South Carolina, Charleston.

Results were presented at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

Atherosclerosis Risk in Communities (ARIC) is an ongoing National Heart, Lung, and Blood Institute-sponsored prospective epidemiologic study of 15,792 black and white men and women aged 45–64 at entry who are free of known cardiovascular disease and diabetes in four geographically diverse communities across the United States.

During the first 6 years, 7,697 enrollees who were nondrinkers at baseline began moderate consumption of alcohol, defined in accord with the AHA and American Diabetes Association as not more than two drinks per day for men and one for women.

An additional 0.4% of former nondrinkers began heavier drinking, Dr. King said 38%.

During the next 4 years of follow-up, the combined rate of fatal and nonfatal cardiovascular events was 6.9% among new moderate drinkers and 10.7% in the continued teetotalers.

After adjustment for age, race, sex, diabetes, hypertension, hyperlipidemia, and physical activity, adoption of moderate alcohol intake remained an independent protective factor against cardiovascular events, with an associated 38% relative risk reduction.

All-cause mortality did not differ significantly between the two groups, perhaps because of the limited number of fatalities, but it trended in favor of the new moderate drinkers, who showed a 29% relative risk reduction.

The new heavy drinkers displayed a nonsignificant trend for more cardiovascular events than did continued nondrinkers over the 4-year period.

The reasons why former nondrinkers in ARIC began consuming alcohol in middle age were not assessed as part of the study. “We would presume that it was for the health benefits, but we don't know,” Dr. King said in an interview.

He added that he would not expect a formal change in AHA policy on the basis of a single study.

However, these ARIC findings “certainly tilt the scale” in favor of physician counselling on a case-by-case basis that patients consider making alcohol part of a heart-healthy diet, provided they don't use certain medications or have a strong family or personal history of problem drinking, liver disease, or selected other health problems.

“It's a small minority of the population that gets in trouble with drinking, and perhaps we should not restrict the benefit of this healthy lifestyle choice in people who don't have a problem with alcohol,” he said.

Follow-up in ARIC will continue. That's important because some possible adverse consequences of new drinking–for example, a potential increase in certain types of cancer–might take longer than 4 years to become apparent.

The ARIC alcohol adoption findings were published simultaneously with Dr. King's presentation at the annual conference (Am. J. Med. 2008;121:201–6).

Current guidelines caution that if you don't drink, don't start. This finding challenges that policy. DR. KING

COLORADO SPRINGS – Former nondrinkers who initiated moderate alcohol consumption in middle age experienced a 38% reduction in cardiovascular events over 4 years, compared with continued nondrinkers in the Atherosclerosis Risk in Communities study.

“The current American Heart Association guidelines state that moderate alcohol consumption at this level can be part of a healthy lifestyle, but caution that if you don't already drink, don't start. This research challenges that policy. A 38% lower chance of having an acute MI or stroke is extremely significant. That's a bigger effect than you'd expect with initiation of statin therapy,” said Dr. Dana E. King, who is professor of family medicine at the Medical University of South Carolina, Charleston.

Results were presented at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

Atherosclerosis Risk in Communities (ARIC) is an ongoing National Heart, Lung, and Blood Institute-sponsored prospective epidemiologic study of 15,792 black and white men and women aged 45–64 at entry who are free of known cardiovascular disease and diabetes in four geographically diverse communities across the United States.

During the first 6 years, 7,697 enrollees who were nondrinkers at baseline began moderate consumption of alcohol, defined in accord with the AHA and American Diabetes Association as not more than two drinks per day for men and one for women.

An additional 0.4% of former nondrinkers began heavier drinking, Dr. King said 38%.

During the next 4 years of follow-up, the combined rate of fatal and nonfatal cardiovascular events was 6.9% among new moderate drinkers and 10.7% in the continued teetotalers.

After adjustment for age, race, sex, diabetes, hypertension, hyperlipidemia, and physical activity, adoption of moderate alcohol intake remained an independent protective factor against cardiovascular events, with an associated 38% relative risk reduction.

All-cause mortality did not differ significantly between the two groups, perhaps because of the limited number of fatalities, but it trended in favor of the new moderate drinkers, who showed a 29% relative risk reduction.

The new heavy drinkers displayed a nonsignificant trend for more cardiovascular events than did continued nondrinkers over the 4-year period.

The reasons why former nondrinkers in ARIC began consuming alcohol in middle age were not assessed as part of the study. “We would presume that it was for the health benefits, but we don't know,” Dr. King said in an interview.

He added that he would not expect a formal change in AHA policy on the basis of a single study.

However, these ARIC findings “certainly tilt the scale” in favor of physician counselling on a case-by-case basis that patients consider making alcohol part of a heart-healthy diet, provided they don't use certain medications or have a strong family or personal history of problem drinking, liver disease, or selected other health problems.

“It's a small minority of the population that gets in trouble with drinking, and perhaps we should not restrict the benefit of this healthy lifestyle choice in people who don't have a problem with alcohol,” he said.

Follow-up in ARIC will continue. That's important because some possible adverse consequences of new drinking–for example, a potential increase in certain types of cancer–might take longer than 4 years to become apparent.

The ARIC alcohol adoption findings were published simultaneously with Dr. King's presentation at the annual conference (Am. J. Med. 2008;121:201–6).

Current guidelines caution that if you don't drink, don't start. This finding challenges that policy. DR. KING

Patients with obstructive sleep apnea hypopnea had a greater rate of motor vehicle crashes than did matched controls, and they were three times more likely to be involved in crashes involving personal injury, according to researchers in British Columbia.

“Our data indicate that the increased risk of motor vehicle crash occurs at all levels of OSAH severity,” Dr. Alan T. Mulgrew, of the University of British Columbia, Vancouver, and his colleagues wrote (Thorax 2008 Jan. 30 [Epub doi:10.1136/thx.2007.085464]).

The study involved 783 adult patients who were referred for overnight polysomnography for suspected sleep-disordered breathing. Patients were excluded if they had symptoms of another sleep disorder known to cause daytime sleepiness (periodic limb movement disorder), or if they had another serious medical condition or overt psychiatric disease. They were also excluded if they were already being treated for OSAH.

Overnight polysomnography was performed using conventional instrumentation, and analysis was performed according to the American Academy of Sleep Medicine's recommendations on syndrome definition and measurement techniques. Patients completed a number of surveys on the night of their polysomnography study. Daytime sleepiness was assessed using the Epworth Sleepiness Scale.

All motorists in British Columbia are insured by a single insurance corporation: the Insurance Corporation of British Columbia (ICBC). Objective crash data for patients–including crash severity type–was obtained for 3 years prior to the sleep study.

All patients were matched with an individual control from the ICBC database based on age, gender, type of license, driving experience, and postal region, Dr. Mulgrew said.

Patients were categorized by OSAH severity based on the apnea hypopnea index (AHI): normal polysomnography (AHI of 5 or fewer events per hour), mild OSAH (AHI greater than 5 and up to 15), moderate OSAH (AHI greater than 15 but less than 30), and severe OSAH (AHI of 30 or more per hour).

Most patients (71%) were men, and the average patient age was 50 years. The average AHI was 22.6 events per hour, and the average Epworth Sleepiness Scale score was 10. The mean body mass index (BMI) was 31.8 kg/m

In terms of OSAH severity, 18% of patients had normal polysomnography, 30% had mild OSAH, 26% had moderate OSAH, and 26% had severe OSAH.

In all, there were 374 crashes, of which 251 (67%) happened to patients. In the patient group, 94 of 251 crashes caused minor property damage, 83 crashes caused major property damage, and 74 crashes caused injuries. This compared with 48, 52, and 23 in the control group.

When compared with controls, patients with OSAH had a significantly increased rate of motor vehicle crashes, with relative risks ranging from 1.9 to 2.6. In comparison, patients without OSAH (AHI 0–5 events per hour) were at lower risk of motor vehicle crashes than were patients with OSAH.

The presence of OSAH was linked with a 3.0- to 4.8-fold increase in the rate of more severe motor vehicle crashes.

Within the patient group, there appeared to be a dose-response relationship between OSAH severity and the rate of motor vehicle crashes involving personal injury.

In patients with an AHI of 0–5, motor vehicle crashes involving personal injury accounted for 9% of crashes, compared with 37% in those with an AHI greater than 30.

Compared with patients with an AHI of 0–5, patients with severe OSAH were 6.1 times more likely to be in a crash involving personal injury, the researchers reported.

Patients with obstructive sleep apnea hypopnea had a greater rate of motor vehicle crashes than did matched controls, and they were three times more likely to be involved in crashes involving personal injury, according to researchers in British Columbia.

“Our data indicate that the increased risk of motor vehicle crash occurs at all levels of OSAH severity,” Dr. Alan T. Mulgrew, of the University of British Columbia, Vancouver, and his colleagues wrote (Thorax 2008 Jan. 30 [Epub doi:10.1136/thx.2007.085464]).

The study involved 783 adult patients who were referred for overnight polysomnography for suspected sleep-disordered breathing. Patients were excluded if they had symptoms of another sleep disorder known to cause daytime sleepiness (periodic limb movement disorder), or if they had another serious medical condition or overt psychiatric disease. They were also excluded if they were already being treated for OSAH.

Overnight polysomnography was performed using conventional instrumentation, and analysis was performed according to the American Academy of Sleep Medicine's recommendations on syndrome definition and measurement techniques. Patients completed a number of surveys on the night of their polysomnography study. Daytime sleepiness was assessed using the Epworth Sleepiness Scale.

All motorists in British Columbia are insured by a single insurance corporation: the Insurance Corporation of British Columbia (ICBC). Objective crash data for patients–including crash severity type–was obtained for 3 years prior to the sleep study.

All patients were matched with an individual control from the ICBC database based on age, gender, type of license, driving experience, and postal region, Dr. Mulgrew said.

Patients were categorized by OSAH severity based on the apnea hypopnea index (AHI): normal polysomnography (AHI of 5 or fewer events per hour), mild OSAH (AHI greater than 5 and up to 15), moderate OSAH (AHI greater than 15 but less than 30), and severe OSAH (AHI of 30 or more per hour).

Most patients (71%) were men, and the average patient age was 50 years. The average AHI was 22.6 events per hour, and the average Epworth Sleepiness Scale score was 10. The mean body mass index (BMI) was 31.8 kg/m

In terms of OSAH severity, 18% of patients had normal polysomnography, 30% had mild OSAH, 26% had moderate OSAH, and 26% had severe OSAH.

In all, there were 374 crashes, of which 251 (67%) happened to patients. In the patient group, 94 of 251 crashes caused minor property damage, 83 crashes caused major property damage, and 74 crashes caused injuries. This compared with 48, 52, and 23 in the control group.

When compared with controls, patients with OSAH had a significantly increased rate of motor vehicle crashes, with relative risks ranging from 1.9 to 2.6. In comparison, patients without OSAH (AHI 0–5 events per hour) were at lower risk of motor vehicle crashes than were patients with OSAH.

The presence of OSAH was linked with a 3.0- to 4.8-fold increase in the rate of more severe motor vehicle crashes.

Within the patient group, there appeared to be a dose-response relationship between OSAH severity and the rate of motor vehicle crashes involving personal injury.

In patients with an AHI of 0–5, motor vehicle crashes involving personal injury accounted for 9% of crashes, compared with 37% in those with an AHI greater than 30.

Compared with patients with an AHI of 0–5, patients with severe OSAH were 6.1 times more likely to be in a crash involving personal injury, the researchers reported.

Patients with obstructive sleep apnea hypopnea had a greater rate of motor vehicle crashes than did matched controls, and they were three times more likely to be involved in crashes involving personal injury, according to researchers in British Columbia.

“Our data indicate that the increased risk of motor vehicle crash occurs at all levels of OSAH severity,” Dr. Alan T. Mulgrew, of the University of British Columbia, Vancouver, and his colleagues wrote (Thorax 2008 Jan. 30 [Epub doi:10.1136/thx.2007.085464]).

The study involved 783 adult patients who were referred for overnight polysomnography for suspected sleep-disordered breathing. Patients were excluded if they had symptoms of another sleep disorder known to cause daytime sleepiness (periodic limb movement disorder), or if they had another serious medical condition or overt psychiatric disease. They were also excluded if they were already being treated for OSAH.

Overnight polysomnography was performed using conventional instrumentation, and analysis was performed according to the American Academy of Sleep Medicine's recommendations on syndrome definition and measurement techniques. Patients completed a number of surveys on the night of their polysomnography study. Daytime sleepiness was assessed using the Epworth Sleepiness Scale.

All motorists in British Columbia are insured by a single insurance corporation: the Insurance Corporation of British Columbia (ICBC). Objective crash data for patients–including crash severity type–was obtained for 3 years prior to the sleep study.

All patients were matched with an individual control from the ICBC database based on age, gender, type of license, driving experience, and postal region, Dr. Mulgrew said.

Patients were categorized by OSAH severity based on the apnea hypopnea index (AHI): normal polysomnography (AHI of 5 or fewer events per hour), mild OSAH (AHI greater than 5 and up to 15), moderate OSAH (AHI greater than 15 but less than 30), and severe OSAH (AHI of 30 or more per hour).

Most patients (71%) were men, and the average patient age was 50 years. The average AHI was 22.6 events per hour, and the average Epworth Sleepiness Scale score was 10. The mean body mass index (BMI) was 31.8 kg/m

In terms of OSAH severity, 18% of patients had normal polysomnography, 30% had mild OSAH, 26% had moderate OSAH, and 26% had severe OSAH.

In all, there were 374 crashes, of which 251 (67%) happened to patients. In the patient group, 94 of 251 crashes caused minor property damage, 83 crashes caused major property damage, and 74 crashes caused injuries. This compared with 48, 52, and 23 in the control group.

When compared with controls, patients with OSAH had a significantly increased rate of motor vehicle crashes, with relative risks ranging from 1.9 to 2.6. In comparison, patients without OSAH (AHI 0–5 events per hour) were at lower risk of motor vehicle crashes than were patients with OSAH.

The presence of OSAH was linked with a 3.0- to 4.8-fold increase in the rate of more severe motor vehicle crashes.

Within the patient group, there appeared to be a dose-response relationship between OSAH severity and the rate of motor vehicle crashes involving personal injury.

In patients with an AHI of 0–5, motor vehicle crashes involving personal injury accounted for 9% of crashes, compared with 37% in those with an AHI greater than 30.

Compared with patients with an AHI of 0–5, patients with severe OSAH were 6.1 times more likely to be in a crash involving personal injury, the researchers reported.

SCOTTSDALE, ARIZ. – Even though sleepwalking, night terrors, and other parasomnias are usually benign and do not call for specific interventions, Dr. Teofilo L. Lee-Chiong Jr. urged that they be thoroughly evaluated in children and adults.

Violent and potentially injurious behavior can endanger the person and/or the person's bed partner, according to Dr. Lee-Chiong, head of the sleep medicine section at National Jewish Medical and Research Center in Denver. A recent patient, for example, walked for 4 hours along a busy interstate highway while fast asleep, Dr. Lee-Chiong said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Another concern, he added, is that a patient with REM sleep behavior disorder could have undiagnosed Parkinson's disease or another neurological disorder. Characteristics of this condition include abnormal behavior during REM sleep, REM sleep without atonia, and the enactment of altered, unpleasant, or violent dreams.

“I believe assessment should be extensive,” Dr. Lee-Chiong said, recommending a comprehensive neurological evaluation with EEG and brain MRI in REM sleep behavior disorder cases.

Even if these tests prove negative, he urged that the patient be closely monitored for years afterward in case a neurological disorder is late in emerging.

Dr. Lee-Chiong defined parasomnias as undesirable physical phenomena or behaviors that appear “alongside sleep,” but are not associated with more common complaints such as excess sleepiness or insomnia. “We all seem to know what it is, but deep down we know very little,” he said, adding afterward in an interview, “If you take [posttraumatic stress disorder] away, there really is no psychopathology that predicts the development of parasomnias.”

A variety of factors make evaluation difficult, according to Dr. Lee-Chiong. Patients are unaware of some parasomnias. Descriptions are often inaccurate or misleading. The clinician rarely sees the parasomnia. If it is not related to sleep architecture, then polysomnography may not be useful. Moreover, a single negative test does not rule out infrequent events.

Polysomnography is indicated when an underlying seizure disorder is suspected, someone has been injured, the case has medical-legal implications, or the person presents with REM sleep behavior disorder, according to Dr. Lee-Chiong. EEG electrodes should be used if seizures are a possibility. In REM sleep behavior disorder cases, he also recommends EMG monitoring of the upper extremities. Often four to six studies are required before a diagnosis can be made, he advised, and technicians need to be trained to recognize subtle features.

Dr. Lee-Chiong characterized sleepwalking, sleep terrors, and confusional arousals as disorders of arousal that usually occur in non-REM sleep during the first third of the night. These are four times as common in childhood, he said, with a prevalence of 16% vs. 4% in adults. Febrile illness in children and medications in the elderly are among the predisposing factors, though sleep terrors are uncommon in older people.

Genetics appears to play a role in sleepwalking, according to Dr. Lee-Chiong. Prevalence is 45% if one parent engaged in sleepwalking, and 60% if both parents had the condition. In addition, the DQB1*0501 allele is more common among sleepwalkers.

Treatments can range from proper sleep hygiene and relaxation techniques to pharmacologic agents, including low-dose benzodiazepines, SSRIs, tricyclic antidepressants, and trazodone.

In cases of confusional arousals (waking with disorientation, inappropriate behavior, or inability to be consoled), Dr. Lee-Chiong suggested attempting to break the cycle by waking a child about 15 minutes before the time these usually occur.

REM sleep parasomnias typically occur during early morning hours, he said. Unlike sleepwalkers, people with REM sleep behavior disorder usually keep their eyes closed and can recall their dreams afterward. The condition is more common in men and can include screaming, punching, kicking, jumping, and running. “True intent to harm” should be considered in the differential diagnosis.

A host of medications–for example, alcohol, amphetamines, anticholinergics, antidepressants other than bupropion, biperiden, cocaine, sedative-hypnotics, and selegiline–might precipitate REM sleep behavior disorder, as can withdrawal from alcohol, hypnotic agents, and REM suppressants.

Deciding whether and how to treat can be problematic, according to Dr. Lee-Chiong. Daily medication might be riskier than infrequent parasomnias. Clonazepam has been successful in 87% of cases, he said.

Even if tests prove negative, it makes sense to closely monitor the patient for years afterward. DR. LEE-CHIONG

Tips for Making Bedrooms Safer

Removing weapons such as guns and knives from the bedroom is a given when people present with parasomnias that put them and their bed partners in harm's way.

Yet Dr. Teofilo L. Lee-Chiong Jr. said in an interview that he knows of no cases in which these weapons have caused injury during a parasomnia. Other, less obvious changes are at least as important, he said, offering the following recommendations for a safe bedroom:

▸ Keep the floor very clean. There should be no object on the floor that could cause a person to slide or trip.

▸ Make sure nothing breakable is within reach of the person. Glasses and mirrors might have to be removed from the bedroom.

▸ Exclude sharp objects, including pens.

▸ Pad sharp edges of bedroom furniture.

▸ Close the bathroom door–add a barrier, if necessary–to keep out a person having a parasomnia. The floor is harder, and fixtures can create a dangerous obstacle course for a person who is not fully awake.

▸ Sleep on the first floor if possible. Stairs and upper story windows are hazards.

▸ Use heavy curtains to prevent cuts to the hand and forearm, if a person strikes out and breaks the glass.

SCOTTSDALE, ARIZ. – Even though sleepwalking, night terrors, and other parasomnias are usually benign and do not call for specific interventions, Dr. Teofilo L. Lee-Chiong Jr. urged that they be thoroughly evaluated in children and adults.

Violent and potentially injurious behavior can endanger the person and/or the person's bed partner, according to Dr. Lee-Chiong, head of the sleep medicine section at National Jewish Medical and Research Center in Denver. A recent patient, for example, walked for 4 hours along a busy interstate highway while fast asleep, Dr. Lee-Chiong said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Another concern, he added, is that a patient with REM sleep behavior disorder could have undiagnosed Parkinson's disease or another neurological disorder. Characteristics of this condition include abnormal behavior during REM sleep, REM sleep without atonia, and the enactment of altered, unpleasant, or violent dreams.

“I believe assessment should be extensive,” Dr. Lee-Chiong said, recommending a comprehensive neurological evaluation with EEG and brain MRI in REM sleep behavior disorder cases.

Even if these tests prove negative, he urged that the patient be closely monitored for years afterward in case a neurological disorder is late in emerging.

Dr. Lee-Chiong defined parasomnias as undesirable physical phenomena or behaviors that appear “alongside sleep,” but are not associated with more common complaints such as excess sleepiness or insomnia. “We all seem to know what it is, but deep down we know very little,” he said, adding afterward in an interview, “If you take [posttraumatic stress disorder] away, there really is no psychopathology that predicts the development of parasomnias.”

A variety of factors make evaluation difficult, according to Dr. Lee-Chiong. Patients are unaware of some parasomnias. Descriptions are often inaccurate or misleading. The clinician rarely sees the parasomnia. If it is not related to sleep architecture, then polysomnography may not be useful. Moreover, a single negative test does not rule out infrequent events.

Polysomnography is indicated when an underlying seizure disorder is suspected, someone has been injured, the case has medical-legal implications, or the person presents with REM sleep behavior disorder, according to Dr. Lee-Chiong. EEG electrodes should be used if seizures are a possibility. In REM sleep behavior disorder cases, he also recommends EMG monitoring of the upper extremities. Often four to six studies are required before a diagnosis can be made, he advised, and technicians need to be trained to recognize subtle features.

Dr. Lee-Chiong characterized sleepwalking, sleep terrors, and confusional arousals as disorders of arousal that usually occur in non-REM sleep during the first third of the night. These are four times as common in childhood, he said, with a prevalence of 16% vs. 4% in adults. Febrile illness in children and medications in the elderly are among the predisposing factors, though sleep terrors are uncommon in older people.

Genetics appears to play a role in sleepwalking, according to Dr. Lee-Chiong. Prevalence is 45% if one parent engaged in sleepwalking, and 60% if both parents had the condition. In addition, the DQB1*0501 allele is more common among sleepwalkers.

Treatments can range from proper sleep hygiene and relaxation techniques to pharmacologic agents, including low-dose benzodiazepines, SSRIs, tricyclic antidepressants, and trazodone.

In cases of confusional arousals (waking with disorientation, inappropriate behavior, or inability to be consoled), Dr. Lee-Chiong suggested attempting to break the cycle by waking a child about 15 minutes before the time these usually occur.

REM sleep parasomnias typically occur during early morning hours, he said. Unlike sleepwalkers, people with REM sleep behavior disorder usually keep their eyes closed and can recall their dreams afterward. The condition is more common in men and can include screaming, punching, kicking, jumping, and running. “True intent to harm” should be considered in the differential diagnosis.

A host of medications–for example, alcohol, amphetamines, anticholinergics, antidepressants other than bupropion, biperiden, cocaine, sedative-hypnotics, and selegiline–might precipitate REM sleep behavior disorder, as can withdrawal from alcohol, hypnotic agents, and REM suppressants.

Deciding whether and how to treat can be problematic, according to Dr. Lee-Chiong. Daily medication might be riskier than infrequent parasomnias. Clonazepam has been successful in 87% of cases, he said.

Even if tests prove negative, it makes sense to closely monitor the patient for years afterward. DR. LEE-CHIONG

Tips for Making Bedrooms Safer

Removing weapons such as guns and knives from the bedroom is a given when people present with parasomnias that put them and their bed partners in harm's way.

Yet Dr. Teofilo L. Lee-Chiong Jr. said in an interview that he knows of no cases in which these weapons have caused injury during a parasomnia. Other, less obvious changes are at least as important, he said, offering the following recommendations for a safe bedroom:

▸ Keep the floor very clean. There should be no object on the floor that could cause a person to slide or trip.

▸ Make sure nothing breakable is within reach of the person. Glasses and mirrors might have to be removed from the bedroom.

▸ Exclude sharp objects, including pens.

▸ Pad sharp edges of bedroom furniture.

▸ Close the bathroom door–add a barrier, if necessary–to keep out a person having a parasomnia. The floor is harder, and fixtures can create a dangerous obstacle course for a person who is not fully awake.

▸ Sleep on the first floor if possible. Stairs and upper story windows are hazards.

▸ Use heavy curtains to prevent cuts to the hand and forearm, if a person strikes out and breaks the glass.

SCOTTSDALE, ARIZ. – Even though sleepwalking, night terrors, and other parasomnias are usually benign and do not call for specific interventions, Dr. Teofilo L. Lee-Chiong Jr. urged that they be thoroughly evaluated in children and adults.

Violent and potentially injurious behavior can endanger the person and/or the person's bed partner, according to Dr. Lee-Chiong, head of the sleep medicine section at National Jewish Medical and Research Center in Denver. A recent patient, for example, walked for 4 hours along a busy interstate highway while fast asleep, Dr. Lee-Chiong said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Another concern, he added, is that a patient with REM sleep behavior disorder could have undiagnosed Parkinson's disease or another neurological disorder. Characteristics of this condition include abnormal behavior during REM sleep, REM sleep without atonia, and the enactment of altered, unpleasant, or violent dreams.

“I believe assessment should be extensive,” Dr. Lee-Chiong said, recommending a comprehensive neurological evaluation with EEG and brain MRI in REM sleep behavior disorder cases.

Even if these tests prove negative, he urged that the patient be closely monitored for years afterward in case a neurological disorder is late in emerging.

Dr. Lee-Chiong defined parasomnias as undesirable physical phenomena or behaviors that appear “alongside sleep,” but are not associated with more common complaints such as excess sleepiness or insomnia. “We all seem to know what it is, but deep down we know very little,” he said, adding afterward in an interview, “If you take [posttraumatic stress disorder] away, there really is no psychopathology that predicts the development of parasomnias.”

A variety of factors make evaluation difficult, according to Dr. Lee-Chiong. Patients are unaware of some parasomnias. Descriptions are often inaccurate or misleading. The clinician rarely sees the parasomnia. If it is not related to sleep architecture, then polysomnography may not be useful. Moreover, a single negative test does not rule out infrequent events.

Polysomnography is indicated when an underlying seizure disorder is suspected, someone has been injured, the case has medical-legal implications, or the person presents with REM sleep behavior disorder, according to Dr. Lee-Chiong. EEG electrodes should be used if seizures are a possibility. In REM sleep behavior disorder cases, he also recommends EMG monitoring of the upper extremities. Often four to six studies are required before a diagnosis can be made, he advised, and technicians need to be trained to recognize subtle features.

Dr. Lee-Chiong characterized sleepwalking, sleep terrors, and confusional arousals as disorders of arousal that usually occur in non-REM sleep during the first third of the night. These are four times as common in childhood, he said, with a prevalence of 16% vs. 4% in adults. Febrile illness in children and medications in the elderly are among the predisposing factors, though sleep terrors are uncommon in older people.

Genetics appears to play a role in sleepwalking, according to Dr. Lee-Chiong. Prevalence is 45% if one parent engaged in sleepwalking, and 60% if both parents had the condition. In addition, the DQB1*0501 allele is more common among sleepwalkers.

Treatments can range from proper sleep hygiene and relaxation techniques to pharmacologic agents, including low-dose benzodiazepines, SSRIs, tricyclic antidepressants, and trazodone.

In cases of confusional arousals (waking with disorientation, inappropriate behavior, or inability to be consoled), Dr. Lee-Chiong suggested attempting to break the cycle by waking a child about 15 minutes before the time these usually occur.

REM sleep parasomnias typically occur during early morning hours, he said. Unlike sleepwalkers, people with REM sleep behavior disorder usually keep their eyes closed and can recall their dreams afterward. The condition is more common in men and can include screaming, punching, kicking, jumping, and running. “True intent to harm” should be considered in the differential diagnosis.

A host of medications–for example, alcohol, amphetamines, anticholinergics, antidepressants other than bupropion, biperiden, cocaine, sedative-hypnotics, and selegiline–might precipitate REM sleep behavior disorder, as can withdrawal from alcohol, hypnotic agents, and REM suppressants.

Deciding whether and how to treat can be problematic, according to Dr. Lee-Chiong. Daily medication might be riskier than infrequent parasomnias. Clonazepam has been successful in 87% of cases, he said.

Even if tests prove negative, it makes sense to closely monitor the patient for years afterward. DR. LEE-CHIONG

Tips for Making Bedrooms Safer

Removing weapons such as guns and knives from the bedroom is a given when people present with parasomnias that put them and their bed partners in harm's way.

Yet Dr. Teofilo L. Lee-Chiong Jr. said in an interview that he knows of no cases in which these weapons have caused injury during a parasomnia. Other, less obvious changes are at least as important, he said, offering the following recommendations for a safe bedroom:

▸ Keep the floor very clean. There should be no object on the floor that could cause a person to slide or trip.

▸ Make sure nothing breakable is within reach of the person. Glasses and mirrors might have to be removed from the bedroom.

▸ Exclude sharp objects, including pens.

▸ Pad sharp edges of bedroom furniture.

▸ Close the bathroom door–add a barrier, if necessary–to keep out a person having a parasomnia. The floor is harder, and fixtures can create a dangerous obstacle course for a person who is not fully awake.

▸ Sleep on the first floor if possible. Stairs and upper story windows are hazards.

▸ Use heavy curtains to prevent cuts to the hand and forearm, if a person strikes out and breaks the glass.

SALT LAKE CITY – Narcotic bowel syndrome is a problem that physicians have been sweeping under the rug, and it may be growing in frequency, Dr. Douglas A. Drossman said at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Physicians have ignored this syndrome, since many are loathe to undertake the arduous task of weaning their patients from narcotics, said Dr. Drossman, co-director of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders.

But this reluctance is not necessary, because patients can be helped to break the “vicious cycle,” he said. There is a very effective protocol that can be used to withdraw patients from narcotics, using clonidine for the physical withdrawal symptoms and lorazepam for the anxiety, while switching them to an antidepressant for pain control.

This syndrome was first noted and described in the 1980s, but very little has been written about it, Dr. Drossman said. Since the 1980s, almost nothing has been published on the topic until recently, when Dr. Drossman and his colleagues Dr. David Grunkemeier, Dr. Joseph Cassara, and Ms. Christine Dalton published a paper (Clin. Gastroenterol. Hepatol. 2007;5:1126–39).

He has seen at least 100 patients with narcotic bowel syndrome in his clinic.

Typically, the patient with narcotic bowel syndrome was started on an opiate because of a functional bowel disorder, or after surgery, or even for an acute painful condition. The patient then developed chronic or intermittent colicky abdominal pain, often due to delayed motility.

At first, the narcotic helps this pain, but over time tachyphylaxis and hyperalgesia set in, rendering the narcotic less and less effective and making the patient dependent on ever-escalating doses.

Dr. Drossman likened the situation to using alcohol to treat a patient with delirium tremens. The alcohol relieves the acute symptoms, but it also perpetuates the cycle.

Dr. Drossman, a gastroenterologist who is trained in psychosomatic medicine, said narcotic bowel syndrome often gets pushed to the background. Narcotics are prescribed because that's what the patient wants, and clinics and hospitals pressure physicians to move patients through the system fast.

The doctors do not have the time or the motivation to address such a complex problem in a medical system that dictates quick processing of patients, Dr. Drossman said.

Narcotic bowel syndrome is probably a U.S. phenomenon, since narcotics are not used as frequently in the rest of the world. About 80% of the world's medical use of narcotics occurs in the United States, and physicians here are using opiates more and more, he said.

According to the protocol Dr. Drossman recommends, physicians who want to detoxify a patient should start with a tricyclic antidepressant or a serotonin-noradrenergic inhibitor, which is begun about 2 days before the withdrawal is initiated. Of the tricyclics, desipramine or nortriptyline are better than imipramine or amitriptyline because they have fewer side effects, he said.

A low dose is used for pain control, for example 50 mg per day of desipramine taken at bedtime, which is titrated up to 150 mg per day.

One day before narcotic withdrawal begins, lorazepam is started in order to ease anxiety, at a dose of 1 mg every 6–8 hours, continued throughout the entire withdrawal.

The narcotic can be withdrawn at a rate of 10%–33% per day, meaning the detoxification can take anywhere from 3 to 10 days.

On the second or third day of the withdrawal, clonidine is begun to treat the sympathetic-related symptoms, such as muscle pains and chills. Both the lorazepam and the clonidine can be tapered and discontinued once the withdrawal is complete.

If the patient is constipated, he or she can be treated with polyethylene glycol. The antidepressant is continued indefinitely, as needed, for pain control.

Dr. Drossman is on the speaker's bureau for Sucampo Pharmaceuticals, Takeda Pharmaceutical North America, Novartis, and Microbia.

SALT LAKE CITY – Narcotic bowel syndrome is a problem that physicians have been sweeping under the rug, and it may be growing in frequency, Dr. Douglas A. Drossman said at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Physicians have ignored this syndrome, since many are loathe to undertake the arduous task of weaning their patients from narcotics, said Dr. Drossman, co-director of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders.

But this reluctance is not necessary, because patients can be helped to break the “vicious cycle,” he said. There is a very effective protocol that can be used to withdraw patients from narcotics, using clonidine for the physical withdrawal symptoms and lorazepam for the anxiety, while switching them to an antidepressant for pain control.

This syndrome was first noted and described in the 1980s, but very little has been written about it, Dr. Drossman said. Since the 1980s, almost nothing has been published on the topic until recently, when Dr. Drossman and his colleagues Dr. David Grunkemeier, Dr. Joseph Cassara, and Ms. Christine Dalton published a paper (Clin. Gastroenterol. Hepatol. 2007;5:1126–39).

He has seen at least 100 patients with narcotic bowel syndrome in his clinic.

Typically, the patient with narcotic bowel syndrome was started on an opiate because of a functional bowel disorder, or after surgery, or even for an acute painful condition. The patient then developed chronic or intermittent colicky abdominal pain, often due to delayed motility.

At first, the narcotic helps this pain, but over time tachyphylaxis and hyperalgesia set in, rendering the narcotic less and less effective and making the patient dependent on ever-escalating doses.

Dr. Drossman likened the situation to using alcohol to treat a patient with delirium tremens. The alcohol relieves the acute symptoms, but it also perpetuates the cycle.

Dr. Drossman, a gastroenterologist who is trained in psychosomatic medicine, said narcotic bowel syndrome often gets pushed to the background. Narcotics are prescribed because that's what the patient wants, and clinics and hospitals pressure physicians to move patients through the system fast.

The doctors do not have the time or the motivation to address such a complex problem in a medical system that dictates quick processing of patients, Dr. Drossman said.

Narcotic bowel syndrome is probably a U.S. phenomenon, since narcotics are not used as frequently in the rest of the world. About 80% of the world's medical use of narcotics occurs in the United States, and physicians here are using opiates more and more, he said.

According to the protocol Dr. Drossman recommends, physicians who want to detoxify a patient should start with a tricyclic antidepressant or a serotonin-noradrenergic inhibitor, which is begun about 2 days before the withdrawal is initiated. Of the tricyclics, desipramine or nortriptyline are better than imipramine or amitriptyline because they have fewer side effects, he said.

A low dose is used for pain control, for example 50 mg per day of desipramine taken at bedtime, which is titrated up to 150 mg per day.

One day before narcotic withdrawal begins, lorazepam is started in order to ease anxiety, at a dose of 1 mg every 6–8 hours, continued throughout the entire withdrawal.

The narcotic can be withdrawn at a rate of 10%–33% per day, meaning the detoxification can take anywhere from 3 to 10 days.

On the second or third day of the withdrawal, clonidine is begun to treat the sympathetic-related symptoms, such as muscle pains and chills. Both the lorazepam and the clonidine can be tapered and discontinued once the withdrawal is complete.

If the patient is constipated, he or she can be treated with polyethylene glycol. The antidepressant is continued indefinitely, as needed, for pain control.

Dr. Drossman is on the speaker's bureau for Sucampo Pharmaceuticals, Takeda Pharmaceutical North America, Novartis, and Microbia.

SALT LAKE CITY – Narcotic bowel syndrome is a problem that physicians have been sweeping under the rug, and it may be growing in frequency, Dr. Douglas A. Drossman said at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Physicians have ignored this syndrome, since many are loathe to undertake the arduous task of weaning their patients from narcotics, said Dr. Drossman, co-director of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders.

But this reluctance is not necessary, because patients can be helped to break the “vicious cycle,” he said. There is a very effective protocol that can be used to withdraw patients from narcotics, using clonidine for the physical withdrawal symptoms and lorazepam for the anxiety, while switching them to an antidepressant for pain control.

This syndrome was first noted and described in the 1980s, but very little has been written about it, Dr. Drossman said. Since the 1980s, almost nothing has been published on the topic until recently, when Dr. Drossman and his colleagues Dr. David Grunkemeier, Dr. Joseph Cassara, and Ms. Christine Dalton published a paper (Clin. Gastroenterol. Hepatol. 2007;5:1126–39).

He has seen at least 100 patients with narcotic bowel syndrome in his clinic.

Typically, the patient with narcotic bowel syndrome was started on an opiate because of a functional bowel disorder, or after surgery, or even for an acute painful condition. The patient then developed chronic or intermittent colicky abdominal pain, often due to delayed motility.

At first, the narcotic helps this pain, but over time tachyphylaxis and hyperalgesia set in, rendering the narcotic less and less effective and making the patient dependent on ever-escalating doses.

Dr. Drossman likened the situation to using alcohol to treat a patient with delirium tremens. The alcohol relieves the acute symptoms, but it also perpetuates the cycle.

Dr. Drossman, a gastroenterologist who is trained in psychosomatic medicine, said narcotic bowel syndrome often gets pushed to the background. Narcotics are prescribed because that's what the patient wants, and clinics and hospitals pressure physicians to move patients through the system fast.

The doctors do not have the time or the motivation to address such a complex problem in a medical system that dictates quick processing of patients, Dr. Drossman said.

Narcotic bowel syndrome is probably a U.S. phenomenon, since narcotics are not used as frequently in the rest of the world. About 80% of the world's medical use of narcotics occurs in the United States, and physicians here are using opiates more and more, he said.

According to the protocol Dr. Drossman recommends, physicians who want to detoxify a patient should start with a tricyclic antidepressant or a serotonin-noradrenergic inhibitor, which is begun about 2 days before the withdrawal is initiated. Of the tricyclics, desipramine or nortriptyline are better than imipramine or amitriptyline because they have fewer side effects, he said.

A low dose is used for pain control, for example 50 mg per day of desipramine taken at bedtime, which is titrated up to 150 mg per day.

One day before narcotic withdrawal begins, lorazepam is started in order to ease anxiety, at a dose of 1 mg every 6–8 hours, continued throughout the entire withdrawal.

The narcotic can be withdrawn at a rate of 10%–33% per day, meaning the detoxification can take anywhere from 3 to 10 days.

On the second or third day of the withdrawal, clonidine is begun to treat the sympathetic-related symptoms, such as muscle pains and chills. Both the lorazepam and the clonidine can be tapered and discontinued once the withdrawal is complete.

If the patient is constipated, he or she can be treated with polyethylene glycol. The antidepressant is continued indefinitely, as needed, for pain control.

Dr. Drossman is on the speaker's bureau for Sucampo Pharmaceuticals, Takeda Pharmaceutical North America, Novartis, and Microbia.

PHILADELPHIA – Symptoms of bipolar disorder are prevalent among patients with epilepsy, and are highly associated with depressive symptoms in these patients, an analysis of 54 epilepsy patients at a tertiary care center shows.

Patients with epilepsy and both bipolar and depressive symptoms may have the mood instability of interictal dysphoric disorder, Dr. Alan B. Ettinger and his associates reported in a poster at the annual meeting of the American Epilepsy Society.

They evaluated adult patients who were managed at the Comprehensive Epilepsy Center of Long Island Jewish Hospital in New Hyde Park, N.Y. Using the Mood Disorders Questionnaire (MDQ), they identified bipolar symptoms in seven patients (13%), a prevalence rate that closely matched the 12% rate the researchers had previously reported in a community-based cohort of epilepsy patients.

Six of the seven MDQ-positive patients also had a positive diagnosis on the Bipolar Spectrum Diagnostic Scale, as did another seven of the remaining 47 patients (15%) with epilepsy who were negative on the MDQ. The MDQ-positive patients also showed evidence of increased functional impairment, documented by their scores on the Sheehan Disability Scale, and they perceived themselves as having a reduced quality of life, based on their scores on the Quality of Life in Epilepsy-89 Patient Inventory.

The researchers found a high association between a positive MDQ score and depressive symptoms, measured on the Center for Epidemiologic Studies-Depression Scale. Among the seven patients with positive MDQ scores, six underwent assessment with the depression scale and all six were positive for depressive symptoms, reported Dr. Ettinger, director of the Comprehensive Epilepsy Center at Long Island Jewish Hospital.

But only two of these six patients were also positive on the Neurological Disorders Depression Inventory for Epilepsy. This finding suggests that the type of depression seen in the MDQ-positive patients, with its apparent link to bipolar symptoms, is not the same as the depression that's identified in many other patients with epilepsy.

Interictal dysphoric disorder may affect a minority of epilepsy patients, Dr. Ettinger and his associates concluded.

PHILADELPHIA – Symptoms of bipolar disorder are prevalent among patients with epilepsy, and are highly associated with depressive symptoms in these patients, an analysis of 54 epilepsy patients at a tertiary care center shows.

Patients with epilepsy and both bipolar and depressive symptoms may have the mood instability of interictal dysphoric disorder, Dr. Alan B. Ettinger and his associates reported in a poster at the annual meeting of the American Epilepsy Society.

They evaluated adult patients who were managed at the Comprehensive Epilepsy Center of Long Island Jewish Hospital in New Hyde Park, N.Y. Using the Mood Disorders Questionnaire (MDQ), they identified bipolar symptoms in seven patients (13%), a prevalence rate that closely matched the 12% rate the researchers had previously reported in a community-based cohort of epilepsy patients.

Six of the seven MDQ-positive patients also had a positive diagnosis on the Bipolar Spectrum Diagnostic Scale, as did another seven of the remaining 47 patients (15%) with epilepsy who were negative on the MDQ. The MDQ-positive patients also showed evidence of increased functional impairment, documented by their scores on the Sheehan Disability Scale, and they perceived themselves as having a reduced quality of life, based on their scores on the Quality of Life in Epilepsy-89 Patient Inventory.

The researchers found a high association between a positive MDQ score and depressive symptoms, measured on the Center for Epidemiologic Studies-Depression Scale. Among the seven patients with positive MDQ scores, six underwent assessment with the depression scale and all six were positive for depressive symptoms, reported Dr. Ettinger, director of the Comprehensive Epilepsy Center at Long Island Jewish Hospital.

But only two of these six patients were also positive on the Neurological Disorders Depression Inventory for Epilepsy. This finding suggests that the type of depression seen in the MDQ-positive patients, with its apparent link to bipolar symptoms, is not the same as the depression that's identified in many other patients with epilepsy.

Interictal dysphoric disorder may affect a minority of epilepsy patients, Dr. Ettinger and his associates concluded.

PHILADELPHIA – Symptoms of bipolar disorder are prevalent among patients with epilepsy, and are highly associated with depressive symptoms in these patients, an analysis of 54 epilepsy patients at a tertiary care center shows.

Patients with epilepsy and both bipolar and depressive symptoms may have the mood instability of interictal dysphoric disorder, Dr. Alan B. Ettinger and his associates reported in a poster at the annual meeting of the American Epilepsy Society.

They evaluated adult patients who were managed at the Comprehensive Epilepsy Center of Long Island Jewish Hospital in New Hyde Park, N.Y. Using the Mood Disorders Questionnaire (MDQ), they identified bipolar symptoms in seven patients (13%), a prevalence rate that closely matched the 12% rate the researchers had previously reported in a community-based cohort of epilepsy patients.

Six of the seven MDQ-positive patients also had a positive diagnosis on the Bipolar Spectrum Diagnostic Scale, as did another seven of the remaining 47 patients (15%) with epilepsy who were negative on the MDQ. The MDQ-positive patients also showed evidence of increased functional impairment, documented by their scores on the Sheehan Disability Scale, and they perceived themselves as having a reduced quality of life, based on their scores on the Quality of Life in Epilepsy-89 Patient Inventory.

The researchers found a high association between a positive MDQ score and depressive symptoms, measured on the Center for Epidemiologic Studies-Depression Scale. Among the seven patients with positive MDQ scores, six underwent assessment with the depression scale and all six were positive for depressive symptoms, reported Dr. Ettinger, director of the Comprehensive Epilepsy Center at Long Island Jewish Hospital.

But only two of these six patients were also positive on the Neurological Disorders Depression Inventory for Epilepsy. This finding suggests that the type of depression seen in the MDQ-positive patients, with its apparent link to bipolar symptoms, is not the same as the depression that's identified in many other patients with epilepsy.

Interictal dysphoric disorder may affect a minority of epilepsy patients, Dr. Ettinger and his associates concluded.

Multiple sclerosis patients who smoke marijuana were more likely to have a history of a mental illness and also performed worse on a test of their mental processing speed and working memory, according to results of a community-based study.

The data “provide the first evidence of the injurious effect of inhaled cannabis on the mentation of patients with MS,” the authors wrote in Neurology.

Ascertaining the effect of cannabis use in MS patients is important because cannabis often is used as a therapeutic agent in the disease, and MS is “by itself a cause of neuropsychological impairment in 40%–65% of patients,” wrote Dr. Omar Ghaffar and his colleague, Dr. Anthony Feinstein, both of the Sunnybrook Health Sciences Centre, Toronto, and the University of Toronto.

The researchers looked at 140 consecutive, community-dwelling MS patients seen at an outpatient clinic in Toronto. Three-fourths were women. The disease was relapse-remitting in 82 patients, secondary progressive in 49 patients, and primary progressive in 9 patients (Neurology 2008 [Epub doi:10.1212/01.wnl.0000304046.23960.25]).

Overall, 10 subjects reported current cannabis use (use of inhaled marijuana purchased on the street in the past month). Users and nonusers differed significantly in age (users had a mean age of about 36 years, vs. nonusers, whose mean age was 44.5 years, P =.001). There were no other differences with respect to disease, duration, disability, education, or gender.

“Since age is a factor that could potentially affect cognition independent of cannabis use, the 10 current cannabis users were each age-matched to 4 subjects who did not use cannabis [total control sample n = 40],” wrote the authors. Subjects were then evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders; the Hospital Anxiety and Depression Scale; and several cognitive assessments.

Overall, the 10 cannabis users were not more likely to have a specific DSM-IV diagnosis (depression, anxiety disorders, alcohol use disorders, etc.), but they were more likely to have had one of those diagnoses in general (P = .04).

There were no differences on the four cognitive measures included in the Neuropsychological Battery for MS. However, on the Symbol Digit Modalities Test (SDMT), cannabis users displayed a significantly slower mean performance time (P = .006). “In the SDMT, nine different symbols, each associated with a number, were presented visually to the subject. Nine symbols at a time were shown to the subject in various orders and the subject had to respond by naming the number that corresponded to each symbol according to the original code,” wrote the authors.

“This test, an index of information processing speed and working memory, has emerged as one of the most sensitive markers of cognitive impairment in MS,” they wrote.

A small sample size was one important limitation to this study. The authors also noted that their reliance on self-reports of cannabis use was not confirmed by urinary toxicology. Finally, cannabis users and nonusers differed slightly in their treatment regimens: More nonusers took disease-modifying treatments while more cannabis users took antidepressants. However, neither of these differences was significant. Furthermore, wrote the authors, “the relation between disease-modifying treatments and cognition remains equivocal, and data [suggest] that patients with MS taking antidepressants are not more impaired on tests such as the SDMT.”

Multiple sclerosis patients who smoke marijuana were more likely to have a history of a mental illness and also performed worse on a test of their mental processing speed and working memory, according to results of a community-based study.

The data “provide the first evidence of the injurious effect of inhaled cannabis on the mentation of patients with MS,” the authors wrote in Neurology.

Ascertaining the effect of cannabis use in MS patients is important because cannabis often is used as a therapeutic agent in the disease, and MS is “by itself a cause of neuropsychological impairment in 40%–65% of patients,” wrote Dr. Omar Ghaffar and his colleague, Dr. Anthony Feinstein, both of the Sunnybrook Health Sciences Centre, Toronto, and the University of Toronto.

The researchers looked at 140 consecutive, community-dwelling MS patients seen at an outpatient clinic in Toronto. Three-fourths were women. The disease was relapse-remitting in 82 patients, secondary progressive in 49 patients, and primary progressive in 9 patients (Neurology 2008 [Epub doi:10.1212/01.wnl.0000304046.23960.25]).

Overall, 10 subjects reported current cannabis use (use of inhaled marijuana purchased on the street in the past month). Users and nonusers differed significantly in age (users had a mean age of about 36 years, vs. nonusers, whose mean age was 44.5 years, P =.001). There were no other differences with respect to disease, duration, disability, education, or gender.

“Since age is a factor that could potentially affect cognition independent of cannabis use, the 10 current cannabis users were each age-matched to 4 subjects who did not use cannabis [total control sample n = 40],” wrote the authors. Subjects were then evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders; the Hospital Anxiety and Depression Scale; and several cognitive assessments.

Overall, the 10 cannabis users were not more likely to have a specific DSM-IV diagnosis (depression, anxiety disorders, alcohol use disorders, etc.), but they were more likely to have had one of those diagnoses in general (P = .04).

There were no differences on the four cognitive measures included in the Neuropsychological Battery for MS. However, on the Symbol Digit Modalities Test (SDMT), cannabis users displayed a significantly slower mean performance time (P = .006). “In the SDMT, nine different symbols, each associated with a number, were presented visually to the subject. Nine symbols at a time were shown to the subject in various orders and the subject had to respond by naming the number that corresponded to each symbol according to the original code,” wrote the authors.

“This test, an index of information processing speed and working memory, has emerged as one of the most sensitive markers of cognitive impairment in MS,” they wrote.

A small sample size was one important limitation to this study. The authors also noted that their reliance on self-reports of cannabis use was not confirmed by urinary toxicology. Finally, cannabis users and nonusers differed slightly in their treatment regimens: More nonusers took disease-modifying treatments while more cannabis users took antidepressants. However, neither of these differences was significant. Furthermore, wrote the authors, “the relation between disease-modifying treatments and cognition remains equivocal, and data [suggest] that patients with MS taking antidepressants are not more impaired on tests such as the SDMT.”

Multiple sclerosis patients who smoke marijuana were more likely to have a history of a mental illness and also performed worse on a test of their mental processing speed and working memory, according to results of a community-based study.

The data “provide the first evidence of the injurious effect of inhaled cannabis on the mentation of patients with MS,” the authors wrote in Neurology.

Ascertaining the effect of cannabis use in MS patients is important because cannabis often is used as a therapeutic agent in the disease, and MS is “by itself a cause of neuropsychological impairment in 40%–65% of patients,” wrote Dr. Omar Ghaffar and his colleague, Dr. Anthony Feinstein, both of the Sunnybrook Health Sciences Centre, Toronto, and the University of Toronto.

The researchers looked at 140 consecutive, community-dwelling MS patients seen at an outpatient clinic in Toronto. Three-fourths were women. The disease was relapse-remitting in 82 patients, secondary progressive in 49 patients, and primary progressive in 9 patients (Neurology 2008 [Epub doi:10.1212/01.wnl.0000304046.23960.25]).

Overall, 10 subjects reported current cannabis use (use of inhaled marijuana purchased on the street in the past month). Users and nonusers differed significantly in age (users had a mean age of about 36 years, vs. nonusers, whose mean age was 44.5 years, P =.001). There were no other differences with respect to disease, duration, disability, education, or gender.

“Since age is a factor that could potentially affect cognition independent of cannabis use, the 10 current cannabis users were each age-matched to 4 subjects who did not use cannabis [total control sample n = 40],” wrote the authors. Subjects were then evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders; the Hospital Anxiety and Depression Scale; and several cognitive assessments.

Overall, the 10 cannabis users were not more likely to have a specific DSM-IV diagnosis (depression, anxiety disorders, alcohol use disorders, etc.), but they were more likely to have had one of those diagnoses in general (P = .04).

There were no differences on the four cognitive measures included in the Neuropsychological Battery for MS. However, on the Symbol Digit Modalities Test (SDMT), cannabis users displayed a significantly slower mean performance time (P = .006). “In the SDMT, nine different symbols, each associated with a number, were presented visually to the subject. Nine symbols at a time were shown to the subject in various orders and the subject had to respond by naming the number that corresponded to each symbol according to the original code,” wrote the authors.

“This test, an index of information processing speed and working memory, has emerged as one of the most sensitive markers of cognitive impairment in MS,” they wrote.

A small sample size was one important limitation to this study. The authors also noted that their reliance on self-reports of cannabis use was not confirmed by urinary toxicology. Finally, cannabis users and nonusers differed slightly in their treatment regimens: More nonusers took disease-modifying treatments while more cannabis users took antidepressants. However, neither of these differences was significant. Furthermore, wrote the authors, “the relation between disease-modifying treatments and cognition remains equivocal, and data [suggest] that patients with MS taking antidepressants are not more impaired on tests such as the SDMT.”

LOS ANGELES – Significant numbers of patients with acne have debilitating symptoms normally associated with body dysmorphic disorder, Dr. Whitney P. Bowe said at the annual meeting of the Society for Investigational Dermatology.

In her screening study, 14%–21% of the 128 patients met objective and subjective criteria for a diagnosis of body dysmorphic disorder. The range varied depending on the definition of acne severity.

Body dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance, causes significant disruption in daily functioning. In the general population, 0.7%–3.0% of people are thought to have body dysmorphic disorder, which usually begins in adolescence. The preoccupation typically leads to behaviors such as skin picking and mirror checking.

Patients with body dysmorphic disorder are among the toughest patients to treat, said Dr. Bowe, who conducted the study with associates at the University of Pennsylvania, Philadelphia, while she was a medical student there. She is now an intern at Albert Einstein College of Medicine, New York. Patients with body dysmorphic disorder commonly respond poorly to treatments that do not include psychiatric medications, she explained. They are at increased risk for suicide and are more likely to threaten health care providers both legally and physically, previous reports suggest.

In the current study, the investigators categorized physician assessments of acne severity as clinically significant (which automatically precluded a diagnosis of body dysmorphic disorder) or as clinically insignificant using a stringent or less stringent set of criteria. All patients completed the Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV), which has 100% sensitivity and 92% specificity in surgical settings for detecting preoccupation with defects and at least moderate distress or impairment in functioning.

Only patients with clinically insignificant acne and a positive BDDQ-DV were considered to have body dysmorphic disorder, Dr. Bowe noted.

A total of 49 patients met stringent objective criteria for “minimal or nonexistent acne” (defined as zero or only a few scattered comedones or papules, five or fewer postinflammatory macules, and no scars). Of these, 18 scored positive on the BDDQ-DV, suggesting that 18 (14%) of all 128 patients had the disorder under the stringent criteria.

Using less stringent objective criteria that allowed up to 25% of facial involvement with small papules and comedones, 82 patients were deemed to have “mild acne,” and 27 of these scored positive on the BDDQ-DV. With the less stringent criteria, 27 (21%) of all patients had body dysmorphic disorder.

On the other end of the severity spectrum, among 11 patients who presented with nearly full facial involvement with highly inflammatory lesions and thus were disqualified from a diagnosis of body dysmorphic disorder, nearly half reported levels of preoccupation, distress, and impairment that were commensurate with patients suffering from the disorder. The investigators wondered whether acne patients who screened positive for body dysmorphic disorder are similar to other patients with the disorder, with higher rates of suicide or likelihood to threaten their physicians.

“I don't think so,” Dr. Bowe said. “I think that's a great question that we should look into.”

In particular, patients who have had severe acne that cleared suddenly with treatment like tretinoin can “vividly recall their lives with severe acne, and upon the appearance of even a few papules, are really frightened,” she said. “Are these patients the same as your typical patients with body dysmorphic disorder who have never experienced a severe physical defect that might indeed recur?”

Patients were aged 16–35 years. They were recruited from a general dermatology clinic and a specialty acne clinic at the university, and from a cosmetic outpatient practice in the community.

“Keep in mind that the BDDQ-DV is really meant to be a screening tool, and should not be used in place of a thorough psychiatric examination to ultimately make the diagnosis of body dysmorphic disorder,” Dr. Bowe said.

The BDDQ-DV should not be used in place of a thorough psychiatric examination. DR. BOWE

LOS ANGELES – Significant numbers of patients with acne have debilitating symptoms normally associated with body dysmorphic disorder, Dr. Whitney P. Bowe said at the annual meeting of the Society for Investigational Dermatology.

In her screening study, 14%–21% of the 128 patients met objective and subjective criteria for a diagnosis of body dysmorphic disorder. The range varied depending on the definition of acne severity.

Body dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance, causes significant disruption in daily functioning. In the general population, 0.7%–3.0% of people are thought to have body dysmorphic disorder, which usually begins in adolescence. The preoccupation typically leads to behaviors such as skin picking and mirror checking.

Patients with body dysmorphic disorder are among the toughest patients to treat, said Dr. Bowe, who conducted the study with associates at the University of Pennsylvania, Philadelphia, while she was a medical student there. She is now an intern at Albert Einstein College of Medicine, New York. Patients with body dysmorphic disorder commonly respond poorly to treatments that do not include psychiatric medications, she explained. They are at increased risk for suicide and are more likely to threaten health care providers both legally and physically, previous reports suggest.

In the current study, the investigators categorized physician assessments of acne severity as clinically significant (which automatically precluded a diagnosis of body dysmorphic disorder) or as clinically insignificant using a stringent or less stringent set of criteria. All patients completed the Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV), which has 100% sensitivity and 92% specificity in surgical settings for detecting preoccupation with defects and at least moderate distress or impairment in functioning.

Only patients with clinically insignificant acne and a positive BDDQ-DV were considered to have body dysmorphic disorder, Dr. Bowe noted.

A total of 49 patients met stringent objective criteria for “minimal or nonexistent acne” (defined as zero or only a few scattered comedones or papules, five or fewer postinflammatory macules, and no scars). Of these, 18 scored positive on the BDDQ-DV, suggesting that 18 (14%) of all 128 patients had the disorder under the stringent criteria.

Using less stringent objective criteria that allowed up to 25% of facial involvement with small papules and comedones, 82 patients were deemed to have “mild acne,” and 27 of these scored positive on the BDDQ-DV. With the less stringent criteria, 27 (21%) of all patients had body dysmorphic disorder.

On the other end of the severity spectrum, among 11 patients who presented with nearly full facial involvement with highly inflammatory lesions and thus were disqualified from a diagnosis of body dysmorphic disorder, nearly half reported levels of preoccupation, distress, and impairment that were commensurate with patients suffering from the disorder. The investigators wondered whether acne patients who screened positive for body dysmorphic disorder are similar to other patients with the disorder, with higher rates of suicide or likelihood to threaten their physicians.

“I don't think so,” Dr. Bowe said. “I think that's a great question that we should look into.”

In particular, patients who have had severe acne that cleared suddenly with treatment like tretinoin can “vividly recall their lives with severe acne, and upon the appearance of even a few papules, are really frightened,” she said. “Are these patients the same as your typical patients with body dysmorphic disorder who have never experienced a severe physical defect that might indeed recur?”

Patients were aged 16–35 years. They were recruited from a general dermatology clinic and a specialty acne clinic at the university, and from a cosmetic outpatient practice in the community.

“Keep in mind that the BDDQ-DV is really meant to be a screening tool, and should not be used in place of a thorough psychiatric examination to ultimately make the diagnosis of body dysmorphic disorder,” Dr. Bowe said.

The BDDQ-DV should not be used in place of a thorough psychiatric examination. DR. BOWE

LOS ANGELES – Significant numbers of patients with acne have debilitating symptoms normally associated with body dysmorphic disorder, Dr. Whitney P. Bowe said at the annual meeting of the Society for Investigational Dermatology.

In her screening study, 14%–21% of the 128 patients met objective and subjective criteria for a diagnosis of body dysmorphic disorder. The range varied depending on the definition of acne severity.

Body dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance, causes significant disruption in daily functioning. In the general population, 0.7%–3.0% of people are thought to have body dysmorphic disorder, which usually begins in adolescence. The preoccupation typically leads to behaviors such as skin picking and mirror checking.

Patients with body dysmorphic disorder are among the toughest patients to treat, said Dr. Bowe, who conducted the study with associates at the University of Pennsylvania, Philadelphia, while she was a medical student there. She is now an intern at Albert Einstein College of Medicine, New York. Patients with body dysmorphic disorder commonly respond poorly to treatments that do not include psychiatric medications, she explained. They are at increased risk for suicide and are more likely to threaten health care providers both legally and physically, previous reports suggest.

In the current study, the investigators categorized physician assessments of acne severity as clinically significant (which automatically precluded a diagnosis of body dysmorphic disorder) or as clinically insignificant using a stringent or less stringent set of criteria. All patients completed the Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV), which has 100% sensitivity and 92% specificity in surgical settings for detecting preoccupation with defects and at least moderate distress or impairment in functioning.

Only patients with clinically insignificant acne and a positive BDDQ-DV were considered to have body dysmorphic disorder, Dr. Bowe noted.

A total of 49 patients met stringent objective criteria for “minimal or nonexistent acne” (defined as zero or only a few scattered comedones or papules, five or fewer postinflammatory macules, and no scars). Of these, 18 scored positive on the BDDQ-DV, suggesting that 18 (14%) of all 128 patients had the disorder under the stringent criteria.

Using less stringent objective criteria that allowed up to 25% of facial involvement with small papules and comedones, 82 patients were deemed to have “mild acne,” and 27 of these scored positive on the BDDQ-DV. With the less stringent criteria, 27 (21%) of all patients had body dysmorphic disorder.

On the other end of the severity spectrum, among 11 patients who presented with nearly full facial involvement with highly inflammatory lesions and thus were disqualified from a diagnosis of body dysmorphic disorder, nearly half reported levels of preoccupation, distress, and impairment that were commensurate with patients suffering from the disorder. The investigators wondered whether acne patients who screened positive for body dysmorphic disorder are similar to other patients with the disorder, with higher rates of suicide or likelihood to threaten their physicians.

“I don't think so,” Dr. Bowe said. “I think that's a great question that we should look into.”

In particular, patients who have had severe acne that cleared suddenly with treatment like tretinoin can “vividly recall their lives with severe acne, and upon the appearance of even a few papules, are really frightened,” she said. “Are these patients the same as your typical patients with body dysmorphic disorder who have never experienced a severe physical defect that might indeed recur?”

Patients were aged 16–35 years. They were recruited from a general dermatology clinic and a specialty acne clinic at the university, and from a cosmetic outpatient practice in the community.

“Keep in mind that the BDDQ-DV is really meant to be a screening tool, and should not be used in place of a thorough psychiatric examination to ultimately make the diagnosis of body dysmorphic disorder,” Dr. Bowe said.

The BDDQ-DV should not be used in place of a thorough psychiatric examination. DR. BOWE