Specialist Treatment of Essential Tremor

Botulinum toxin is another option for ET and is usually of greater benefit for tremor of the head or voice compared to its limited effectiveness for the upper limb. For ET of the head, botulinum toxin is most effective when the movement is horizontal. For ET of the voice, it can be injected into the vocal cords although this may cause mild, transient hypophonia or dysphagia, these problems usually resolve within several weeks after the injection. The beneficial effect tends to wane after four...

Why Headache Treatment Fails

Table 12.4 lists 10 reasons why chronic headaches fail to respond to treatment. The first five reasons have been discussed in detail. When patients report unsatisfactory results despite proper attention to these issues, consider the presence of a hidden agenda (e.g., litigation or disability) or other emotional or psychological problems (e.g., depression or family issues) that may be impeding either patients' responses to treatment or their reporting of favorable responses. The importance of...

Schizophrenia and Delusional Disorder Somatic Type

In schizophrenia, the patients complaints center around a delusional belief of ill health. Unlike anxious patients who are fearful of illness, delusional patients (whether with schizophrenia, delusional disorder, or major depression) are convinced they are ill, often with a bizarre or unusual infestation, poisoning, metabolic derangement, or physical malformation. The diagnosis of schizophrenia is suggested by a history of previous episodes of hallucinations or delusions in clear consciousness...

The Prognosis of Anxiety Disorders

Although most patients with anxiety disorders improve with treatment, many need long-term follow-up. The primary care physician should decrease or discontinue medications after patients have been asymptomatic for six months but should vigorously reinstitute treatment at the first sign of relapse. Patients with GAD have been found to be symptomatic for 56 percent of their lives after the onset of symptoms. The risk of relapse in GAD is high up to 25 percent in the first month after...

Primary Writing Tremor

Primary writing tremor is part of a larger category of task-specific movement disorders that are characterized by the appearance of an involuntary movement only or at least predominantly during a specific task. Patients with primary writing tremor experience shaking of the hand when writing, yet, surprisingly, they are able to carry out other equally dexterous tasks and maintain posture with little or no tremor. Closely related is dystonic writer's cramp, a task-specific form of dystonia, which...

Patients Who Complain of Forgetfulness but for Whom No Disorder Is Identified

Eighty-five percent of individuals over 65 report that their memory is not as good as it was when they were younger. Empirical research demonstrates that this assertion is accurate. For most individuals, forgetfulness consists of difficulty coming up with names or words or occasionally misplacing keys and other objects. If no other cause for concern is present (e.g., becoming lost in familiar surroundings or losing a skill such as cooking or balancing a checkbook) and a cognitive examination...

Adjustment Disorder with Depressed Mood

Of course, feelings of sadness are not completely determined by circumstance. Adversity acts on individuals with particular vulnerabilities and strengths of personality that render them more or less predisposed to un-happiness. Thus, a romantic disappointment that dispirits an overly dependent person may provoke far less distress in someone more naturally self-reliant. Physicians who know their patients well will observe that a reaction of sadness depends as much on an individual's personality...

Antidepressant Therapy

As discussed in Chapter 2, patients with major depression should be started on antidepressant medication. It is essential for the primary care physician to keep in mind two risks inherent in treating the suicidal patient with major depression. First, many of the older generation of antidepressants (tricyclic antidepressants like amitriptyline hydrochloride, imipramine hydrochloride, nortriptyline hydrochloride, and doxepin hydrochloride) can be fatal in overdose. If there is a good reason for...

Subsyndromal Anxiety

In the primary care setting, patients sometimes complain of anxiety symptoms that do not meet diagnostic criteria for an anxiety disorder. These patients usually report brief or intermittent anxiety in the setting of stresses such as bereavement, serious illness, marital discord, or financial embarrassment. The patients are often anxiety-prone individuals and describe themselves as worriers at baseline. Treatment of subsyndromal anxiety includes emotional support and medications to control...

Functional Hysterical Numbness

The physician should suspect functional causes if there is a significant discrepancy between the pattern of a patients symptoms and neuroanatomic or neurophysiologic realities. Some clues suggesting functional numbness include the following abrupt change from profound abnormality to normal sensation without an intervening area of partial anesthesia. Such a pattern does not occur in structural lesions because there is always an area of overlap between adjacent nerve territories. Even if a nerve...

Patients Who Acknowledge Suicidal Thoughts but Have Not Injured Themselves

An elderly widower mutters, as he is buttoning his shirt after a checkup, that he has been wrestling with the idea of joining his wife. A distraught parent calls to read the suicide note found in a teenager's notebook. A patient in the office requests a prescription refill and then tearfully confides having had thoughts of taking the whole bottle at once. After making a long list of complaints, a patient sighs, Oh, I wish I were dead. A new patient with a chronic illness asks the physician's...

Unrealistic Concerns about Health

Patients who cannot be reassured about their health are some of the most difficult for physicians. Because such patients have somatic complaints that are medically unexplained despite adequate investigation, patients and physicians may be at odds over what the symptoms indicate. Further, some of these patients may insist on surgery, be dependent on narcotics, or threaten lawsuits. Physicians commonly use terms such as psychogenic, functional, psychosomatic, hysterical, or hypochondriacal to...

Mythical Causes of Headaches

Two myths, in particular, pervade headache diagnosis. The first is that of tension or stress headaches. Many clinicians were taught (and still believe) that mild to moderate, nonspecific headaches the vast majority of headaches are caused by emotional or psychological problems leading to excessive contraction of muscles around the head and neck, in turn producing pain. Electromyographic studies, however, have failed to show any consistent relationship between excessive contraction of head and...

The Pitfalls of Rebounding

Rebounding refers to the increased headache tendency that occurs when an analgesic taken for relief of acute headache wears off. If certain remedies for acute headache are overused more than once per week the underlying headache tendency grows. Rebounding is usually not apparent in the short run (i.e., from dose to dose of analgesics) but is played out in the long run, over months and years. Patients gradually experience more frequent and severe headaches, as a result of which they consume more...

The Concepts of Dependence Abuse and Harmful

Traditionally, substance use disorders have been dichotomized into the categories of dependence and nondependent abuse. Distinctions were drawn between psychological and physiologic dependence the former connoting an emotional need or behavioral habit of drug taking the latter, a physical state characterized by the phenomena of tolerance and physiologic withdrawal. On the basis of such logic, it was widely held until the last decade that cocaine and cannabis could not provoke true dependence...

Cognitive Ability The Mini Mental State Examination

Cognitive impairment, which is central to delirium, dementia, and mental subnormality, often is not detected on cursory examination of an affected individual. The most widely used screening tool for assessing a patients cognitive ability is the Mini-Mental State Examination (MMSE). The MMSE is not a diagnostic test and therefore does not indicate the cause of impairment it is designed only to detect the presence of impairment. A perfect score is 30 30, and scores below 24 are regarded as...

Family Psychiatric History

A family history of psychiatric disorder is best elicited at the same time the rest of the family history is obtained. A positive response to a general question such as Has anyone in your family ever had emotional problems should be followed with more specific questions regarding symptoms, diagnoses, and treatments. Supplementary questions such as Has anyone in your family ever tried to harm himself or herself, or has anyone needed psychiatric treatment sometimes elicit important information...

Contracts for Safety

The primary care physician can sometimes decide to send a patient with suicidal thinking home rather than to the emergency room if the patient has low intent, finds it possible to ignore the thoughts, and can be relied on to honor a promise not to act on any suicidal impulses. Patients who cannot give blanket assurances of this sort may at least be able to promise not to act until the next visit, which should be scheduled within a few days, depending on the particulars of the case. Having the...

Psychiatric Referral of Depressed Patients

There are several situations in which the primary care physician should immediately refer patients with major depression to a psychiatrist. Patients with suicidal intent or a plan to kill themselves must be evaluated by a psychiatrist on an emergent basis to assess the need for psychiatric admission. If they refuse such a referral, procedures for involuntary commitment to a psychiatric hospital must be undertaken to prevent suicide, and the primary care physician should contact psychiatric...

The Management of Essential Tremor

The first step in the treatment of ET is education and reassurance. Many patients with ET are worried that they have PD or another serious disorder. They should also be informed that the tremor is not a sign that they are anxious, even though they have probably already observed exacerbation of the tremor when nervous. The physician should emphasize the insidious progression and that ET is not a degenerative disorder. For most but not all affected persons, ET is no more than a nuisance. It is...