Neurovisceral phenotypes in the expression of psychiatric symptoms

This review explores the proposal that vulnerability to psychological symptoms, particularly anxiety, originates in constitutional differences in the control of bodily state, exemplified by a set of conditions that include Joint Hypermobility, Postural Tachycardia Syndrome and Vasovagal Syncope. Research is revealing how brainbody mechanisms underlie individual differences in psychophysiological reactivity that can be important for predicting, stratifying and treating individuals with anxiety disorders and related conditions. One common constitutional difference is Joint Hypermobility, in which there is an increased range of joint movement as a result of a variant of collagen. Joint hypermobility is over-represented in people with anxiety, mood and neurodevelopmental disorders. It is also linked to stress-sensitive medical conditions such as irritable bowel syndrome, chronic fatigue syndrome and fibromyalgia. Structural differences in 'emotional' brain regions are reported in hypermobile individuals, and many people with joint hypermobility manifest autonomic abnormalities, typically Postural Tachycardia Syndrome. Enhanced heart rate reactivity during postural change and as recently recognised factors causing vasodilatation (as noted post prandially, post exertion and with heat) is characteristic of Postural Tachycardia Syndrome, and there is a phenomenological overlap with anxiety disorders, which may be partially accounted for by exaggerated neural reactivity within ventromedial prefrontal cortex. People who experience Vasovagal Syncope, a heritable tendency to fainting induced by emotional challenges (and needle/blood phobia), are also more vulnerable to anxiety disorders. Neuroimaging implicates brainstem differences in vulnerability to faints, yet the structural integrity of the caudate nucleus appears important for the control of fainting frequency in relation to parasympathetic tone and anxiety. Together there is clinical and neuroanatomical evidence to show that common constitutional differences affecting autonomic responsivity are linked to psychiatric symptoms, notably anxiety

An observational study of patient characteristics and mortality following hypoglycemia in the community

Objectives: Characterize diabetes patients with severe hypoglycemia requiring emergency services intervention at home and investigate 12 month mortality. Research design and methods: Emergency services call-outs for hypoglycemia were recorded between 2005 and 2013 in an area covering 34000 patients with diabetes. Patient characteristics were documented together with capillary blood glucose (CBG), HbA1c and treatment for hypoglycemia. 12 month mortality and variables influencing survival were analysed. Results: In 1835 episodes amongst 1156 patients, 45% had type 1 diabetes (68.2% males), 44% had type 2 diabetes (49.4% males) with a minority unclassified. CBG at presentation (mean±SD) was 1.76±0.72 mmol/L in type 1 diabetes and 1.96±0.68 mmol/L in type 2 diabetes patients (p<0·0001), with higher HbA1c in the former group (8.3±1.52% (67.5±16.4 mmol/mol) and 7.8±1.74% (61.6±19.0 mmol/mol), respectively; p<0·0001). A third of type 2 diabetes patients were not on insulin therapy and displayed lower HbA1c compared with insulin users. Glucagon was used in 37% of type 1 diabetes and 28% of type 2 diabetes patients (p<0.0001). One year mortality was 4.45% in type 1 diabetes and 22.1% in type 2 diabetes. Age and type of diabetes were predictive of mortality in multivariable analysis, whereas CBG levels/frequency of hypoglycemia had no effect. Conclusions: Severe hypoglycemia in the community is common with a male predominance in type 1 diabetes. Severe hypoglycemia in non-insulin treated type 2 diabetes patients is associated with lower HbA1c compared with insulin users. Severe hypoglycemia appears to be associated with increased mortality at 12 months, particularly in type 2 diabetes. KEY MESSAGES Severe hypoglycemia in the community is common, and presents a large burden on both patients and healthcare workers. Using a large database of ambulance call-outs for hypoglycemia this study aimed to characterise those requiring the emergency services for an episode of hypoglycemia, and to investigate factors that may be associated with an increased risk of mortality. We found that a third of type 2 diabetes patients having severe hypoglycemic episodes were not using any insulin, these individuals had a lower HbA1c than those with type 2 diabetes requiring insulin treatment. 12 month mortality following an episode of severe hypoglycemia was high, especially in individuals with type 2 diabetes. More research is required to investigate the cause of death in these patient

Does clozapine improve competency restoration? a case report of schizophrenia patient opined incompetent to stand trial unlikely to be restored

A number of defendants with chronic psychotic disorders are opined incompetent to stand trial and are subsequently committed for competency restoration. To the best of our knowledge, the role of clozapine in restoring competency among defendants suffering from treatment-resistant schizophrenia has not been previously reported. This article reports a defendant with a diagnosis of treatment-resistant schizophrenia, who was treated with clozapine and restored to competency within a short duration. During a subsequent hospitalization, the same patient was treated with different antipsychotic medications and was found “incompetent to stand trial and unlikely to be restored.” Therefore, clozapine may play an important role in restoring competency in patients with chronic psychotic illness. The authors discuss the potential benefits and underutilization of clozapine therapy in competency restoration