Sindromul catatonic

Sindromul catatonic este caracterizat prin urmatoarele elemente semiologice

Stereotipia de pozitie si miscare, tonusul muscular crescut, flexibilitatea ceroasa-
catalepsia, negativismul si sugestibilitatea,...
Modalitatile de manifestare ale acestor semnepot fii cuprinse intre doua extreme ,
reprezentate de stuporul catatonic si agitatia catatonica
In stuporul catatonic pacientul estee complet nemiscat, pastrand o postura rigida,
stereotipia de pozitie. Aceasta postura poate avea o anumita semnificatie simbolica sau
nu- pacient rastignit in semnul crucii, perna psihica...
Un exemplu este semnul pernei psihice, in care persoana sta intinsa in pat si chiar poate
dormi tinand capul ridicat deasupra patului cu aproximativ 10-20 de centimetri, ca si cum
ar avea o perna – dar nu o are- si doarme, sau sta in aceasta pozitie cuminte, ore, fara a se
plange de redoare de ceafa. Pentru a pastra aceasta postura rigida musculatura pacientului
este incordata, prezentand tonus muscular crescut iar in cazul in care cineva ar incerca sa-
i schimbe pozitia ar constata efortul ce trebuie sa-l depuna pentru a reusi.

Complianta – Aderenta la tratament

Complianta la tratament reprezinta comportamentul pacientului conform cu sfaturile

medicului, in ce masura comportamentul unui pacient corespunde cu sfatul medicului.
O definitie formala a compliantei: gradul in care utilizarea de catre o persoana a
medicamentelor coincide cu indicatia medicului. Nu exista inca o definitie general
valabila in ceea ce priveste capacitatea pacientului de a urma un tratament indicat.
Complianta la tratament joaca un rol fundamental in succesul sau esecul final al oricarui
tratament. Dintre aspectele noncompliantei pot fii enumerate: refuzul direct de a lua
medicamentul, subdozarea, tratamentul intermitent, intreruperea prematura,
supradozarea, toate acestea ducand la ineficienta terapeutica sau riscuri importante.
Factorii implicati in obtinerea compliantei pot fii grupati in factori ce tin de pacient,
factori ce tin de medic, de caracteristicile bolii, de caracteristicile tratamentului, de
diversi factori contextuali. Buna tolerabilitate, ameliorarea rapida a simptomelor
deranjante, usurinta in utilizare a medicamentelor sunt factori importanti ce concura la
complianta pacientului.
In Grecia antica, Hipocrate a observat ca pacientii isi pot impiedica propria vindecare
prin sustragerea de la tratamentele prescrise si astfel atragea atentia asupra importantei
noncompliantei la tratament. Acelasi fenomen este observat si in zilele noastre, cand noua
din zece pacienti nu iau corect medicamentele prescrise sau nu le iau deloc.
Aderenta terapeutica a aparut de curand ca un termen ce tinde sa-l inlocuiasca pe cel de
complianta terapeutica. Termenul de aderenta il include pe pacient in procesul de luare a
deciziilor. Indicatia terapeutica nu mai este perceputa ca un ordin de indeplinit.

Lipsa unei definitii codificate a aderentei are drept consecinta confuzia in cazul oricarei
incercari de a compara ratele de aderenta in diferitele studii clinice. Gilmer si
colaboratorii(2004) au gasit rate diferentiate ale respitalizarilor psihiatrice pentru
pacienti care au fost aderenti , nonaderenti, partiali aderenti si excesiv de fillers, ceeace
sugereaza ca denumirea de aderenta poate avea implicatii importante in predictia
rezultatului tratamentului.
Unii cercetatori sugereaza ca predictorii aderentei ar fi diferiti de cei ai
nonaderentei.Loffler, Killan, Toumi si Angermeyer, 2003.- iarVelliga et al. recomanda ca
prima treapta in definirea aderentei este sa desemnezi distinctia dintre nonaderenta
intentionala si neintentionala, de exemplu uitarea.
Indiferent cum este definita sau masurata aderenta, aderenta scazuta pare sa contribuie in
mod substantial la rezultatul functional scazut pritre pacientii cu schizofrenie.
O trecere in revista a rezultatelor estimeaza rata respitalizarilor pacientilor cu complianta
la antipsihotice scazuta ca fiind 75% comparativ cu 35% la pacientii cu complianta
buna.-Theida et al 2003. dimensiunea economica a costurilor medicale determinate de
nonaderenta este uriasa.

KAPLAN & SADOCK MANUAL DE BUZUNAR DE PSIHIATRIE CLINICĂ

TABELUL 23-7
DECESUL ŞI MOARTEA (REACŢIILE PACIENŢILOR TERMINALI)

Elisabeth Kubler-Ross
Stadiul 1 Şoc şi negare. Reacţia iniţială a bolnavului este şocul, urmat de negarea
faptului că ceva ar fi în neregulă. Unii bolnavi nu trec de acest stadiu şi
pot să meargă de la un medic la altul, până când găsesc unul care le
sprijină poziţia.
Stadiul 2 Mânie. Pacienţii devin frustraţi, iritabili şi mânioşi pentru că sunt
bolnavi; întreabă “de ce eu?”. Managementul bolnavilor în acest stadiu
este dificil, pentru că mânia este deplasată asupra medicilor, personalului
spitalului şi familiei. Uneori mânia este direcţionată către ei înşişi, din
credinţa că boala a apărut ca pedeapsă pentru rele.
Stadiul 3 Negociere. Pacientul poate să încerce să negocieze cu medicii, prietenii
sau chiar cu Dumnezeu ca, în schimbul vindecării, să îndeplinească una
sau mai multe promisiuni (de ex., să doneze la organizaţii de caritate, să
meargă regulat la biserică).
Stadiul 4. Depresie. Pacientul manifestă semne clinice de depresie; retragere,
încetinire psihomotorie, tulburări de somn, lipsă de speranţe şi, posibil,
ideaţie de sinucidere. Depresia poate fi o reacţie la efectele bolii asupra
vieţii personale (de ex., pierderea serviciului, dificultăţi financiare,
izolarea de prieteni şi familie) sau poate să fie o anticipare a pierderii
reale a vieţii, care va avea loc în curând.
Stadiul 5 Acceptare. Persoana realizează că moartea este inevitabilă şi acceptă
universalitatea ei.
TABELUL 23-2
DOLIUL ŞI TRAVALIUL DE DOLIU
Stadiul John Bowlby
1 Amorţire sau protest. Se
cracterizează prin suferinţă, frică
şi mânie. Şocul poate să dureze
momente, zile sau luni.
2 Dorul şi căutarea după figura
pierdută. Lumea pare goală şi
lipsită de sens, dar stima de sine
rămâne intactă. Se caracterizează
prin preocupare cu persoana
pierdută, nelinişte fizică, plâns,
mânie. Poate să dureze câteva luni
sau chiar ani.
3 Dezorganizare şi disperare.
Nelinişte şi lipsă de scop.
Creşterea preocupărilor somatice,
retragere, introversie şi
iritabilitate. Retrăiri repetate ale
amintirilor.
4 Reorganizare. Odată cu formarea
unor noi paternuri, obiecte şi
scopuri, doliul cedează şi este
înlocuit de amintiri dragi. Se
produce identificarea sănătoasă cu
decedatul.
TABELUL 23-3
DOLIUL LA PĂRINŢI ŞI LA COPII
Pierderea unui părinte
Faza de protest. Copilul îşi doreşte cu
putere părintele pierdut.
Faza de disperare. Copilul resimte lipsă de
speranţe, retragere şi apatie.
Faza de detaşare. Copilul cedează
ataşamentul emoţional faţă de părintele
Stadiul C.M. Parkes
1 Alarmă. Stare stresantă
caracterizată prin modificări
fiziologice (de ex.,creşterea TA şi
a pulsului); asemănătoare cu
stadiul 1 al lui Bowlby.
2 Amorţire. Persoana pare doar
superficial afectată de pierdere,
dar în realitate se protejează pe
sine de suferinţa acută.
3 Nostalgie (căutare). Caută sau îşi
aminteşte persoana pierdută.
Stadiu asemănător cu stadiul 2 al
lui Bowlby.
4 Depresie. Persoana se simte
lipsită de speranţe asupra
viitorului, simte că nu poate
continua să trăiască şi se retrage
faţă de familie şi prieteni.
5 Recuperare şi reorganizare.
Persoana realizează că viaţa sa va
continua, cu noi ajustări şi scopuri
diferite.
Pierderea unui copil
Poate fi o trăire mai intensă decât pierderea
unui adult.
Sentimentele de vinovăţie şi neajutorare pot
fi copleşitoare.
Apar stadii de şoc, negare, mânie,
negociere [“târguială”] şi acceptare.
pierdut.
Copilul poate să-şi transfere nevoia de
părinte asupra unuia sau mai multor adulţi.
Manifestările de doliu pot să dureze toată
viaţa.
Până la 50% din căsătoriile în care un copil
a decedat se sfârşesc prin divorţ.

Addressing Adherence
Seizures may result in physical, psychological, and social repercussions. One
might assume that people with epilepsy would adhere rigorously to their
medication regimens in order to prevent these deleterious outcomes.
However, epilepsy patients, like patients with other illnesses, do not always
take their medications as prescribed.[1]

Furthermore, an inverse relationship exists between the number of doses

prescribed per day and adherence: The more frequently medication must be
taken, the less likely it is the patient will consume all doses. Many patients fail
to achieve 100% adherence even with once-a-day dosing. [2] Although 100%
medication adherence does not guarantee seizure control, lack of adherence,
not surprisingly, may result in increased seizure frequency. [2]

More than 25 years ago, Cramer and colleagues[1] used a medication event

monitoring system to measure adherence in several groups of people with
epilepsy. The system records the time that the medication bottle is opened on
a computer chip contained within the cap. The results can then be printed and
analyzed when the patient returns for follow-up.

Even though patients had consented to the study and knew they were being
monitored, only 76% of doses were taken as prescribed. Adherence was 87%
for once-a-day medications, 81% for twice-daily medications, 77% for
medications taken three times daily, and only 39% for those taken four times
daily.

Other adherence studies have revealed similar results.[3] These findings provide a clear
rationale for clinicians to limit the number of daily medication doses for each patient in order to optimize
adherence.
Weighing Your Options With Extended Release Meds
Extended-release (ER) preparations offer a means to decrease dosing
frequency compared with immediate-release (IR) medications. In addition, ER
preparations offer more consistent serum drug levels with higher troughs,
which may protect against breakthrough seizures, and lower peaks, which
may mitigate dose-related side effects.

ER formulations, which include controlled-release, delayed-release, modified-

release, slow-release, and sustained-release preparations, aim to achieve
more consistent serum drug levels. (For simplification, the term "ER" is used
in this article to represent these different formulations.) ER preparations are
available for many antiepileptic drugs (AEDs), including carbamazepine,
lamotrigine, levetiracetam, oxcarbazepine, phenytoin, topiramate, and
valproate.[4]

More than one ER formulation may be available for a given AED. For
example, carbamazepine is available in two different ER formulations. Shire's
Carbatrol® relies on Microtrol® technology that uses combinations of three
different types of beads with different dissolution characteristics within a
single capsule, whereas Novartis' Tegretol® XR uses tablets with an osmotic-
release delivery system.

Although compliance may be enhanced by a once-a-day ER product,

clinicians may hesitate to prescribe such preparations because the
consequences of a missed dose may be more severe owing to the extended
interval before the next dose.[3] Pellock and Brittain[4] recently addressed this
issue in an industry-sponsored computer-modeling pharmacokinetics study.
Defining "forgiveness" (F) as the "margin of therapeutic effect following a
missed dose," the authors calculated F as the difference 

between duration of action (D) and dosing interval (I), or F = D – I.

Concentration/time curves were calculated for IR and ER formulations (called

"XR" in their study). For both formulations, duration of action increased with
larger doses. The duration of action was longer post-dose for ER than IR
products, which tended to mitigate the drop in level from a missed dose.
The authors observed, "Compared with TID [three times daily] dosing of the
IR formulation, the forgiveness interval was the same (XR ) or even longer
BID

(XR ) with the XR AEDs." They attributed this effect to the slower release rate
qd

and prolonged time of absorption of the ER product.

BIBLIOGRAFIE:

Medscape Neurology > Epilepsy Notes

COMMENTARY
Pros and Cons of Extended-Release Antiepileptic Drugs
Andrew N. Wilner, MD
Medscape Internal Medicine > George Lundberg: At Large at Medscape
COMMENTARY
CDC Guidelines for Opioid Use
George D. Lundberg, MD
 
Disclosures | February 19, 2016

On December 14, 2015, the CDC posted the draft guidelines. The number of
invited public comments through January 15, 2016, totaled more than 4000.

The process has been elaborate, based on exhaustively referenced literature

review and involving all of the major professional stakeholders. This draft is a
really big deal, and if you have the time, you could plow through all of it. But
here is the "skinny"—read it, apply it. It may be boring but it really matters to
your daily practice. The recommendations[4] are grouped into three areas for
consideration. (The evidence base and GRADE framework designations are
included in the full draft document.)

The Recommendations
But before we get started, understand that I, as a physician, deplore the use
of the word "provider" in all 12 recommendations. Please do not let that turn
you off to the whole schmear. Pretend it says "physician" each time and read
on.

Determining When to Initiate or Continue Opioids for Chronic Pain

1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are
preferred for chronic pain. Providers should only consider adding opioid
therapy if expected benefits for both pain and function are anticipated to
outweigh risks to the patient.

2. Before starting opioid therapy for chronic pain, providers should establish
treatment goals with all patients, including realistic goals for pain and function.
Providers should not initiate opioid therapy without consideration of how
therapy will be discontinued if unsuccessful. Providers should continue opioid
therapy only if there is clinically meaningful improvement in pain and function
that outweighs risks to patient safety.

3. Before starting and periodically during opioid therapy, providers should

discuss with patients known risks and realistic benefits of opioid therapy and
patient and provider responsibilities for managing therapy.

Opioid Selection, Dosage, Duration, Follow-up, and Discontinuation

4. When starting opioid therapy for chronic pain, providers should prescribe
immediate-release opioids instead of extended-release/long-acting (ER/LA)
opioids.

5. When opioids are started, providers should prescribe the lowest effective
dosage. Providers should use caution when prescribing opioids at any
dosage, should implement additional precautions when increasing dosage to
50 morphine milligram equivalents (MME)/day or more, and should generally
avoid increasing dosage to 90 MME/day or more.

6. Long-term opioid use often begins with treatment of acute pain. When
opioids are used for acute pain, providers should prescribe the lowest
effective dose of immediate-release opioids and should prescribe no greater
quantity than needed for the expected duration of pain severe enough to
require opioids. Three or fewer days usually will be sufficient for
most nontraumatic pain not related to major surgery.

7. Providers should evaluate benefits and harms with patients within 1 to 4

weeks of starting opioid therapy for chronic pain or of dose escalation.
Providers should evaluate benefits and harms of continued therapy with
patients every 3 months or more frequently. If benefits do not outweigh harms
of continued opioid therapy, providers should work with patients to reduce
opioid dosage and to discontinue opioids.

Assessing Risk and Addressing Harms of Opioid Use

8. Before starting and periodically during continuation of opioid therapy,

providers should evaluate risk factors for opioid-related harms. Providers
should incorporate into the management plan strategies to mitigate risk,
including considering offering naloxone when factors that increase risk for
opioid overdose, such as history of overdose, history of substance use
disorder, or higher opioid dosages (≥ 50 MME), are present.

9. Providers should review the patient's history of controlled substance

prescriptions using state prescription drug monitoring program (PDMP) data
to determine whether the patient is receiving high opioid dosages or
dangerous combinations that put him or her at high risk for overdose.
Providers should review PDMP data when starting opioid therapy for chronic
pain and periodically during opioid 

therapy for chronic pain, ranging from every prescription to every 3 months.

10. When prescribing opioids for chronic pain, providers should use urine
drug testing before starting opioid therapy and consider urine drug testing at
least annually to assess for prescribed medications as well as other controlled
prescription drugs and illicit drugs.*

11. Whenever possible, providers should avoid prescribing opioid pain

medication for patients receiving benzodiazepines.

12. Providers should offer or arrange evidence-based treatment (usually

medication-assisted treatment with buprenorphine or methadone in
combination with behavioral therapies) for patients with opioid use disorder.

Did you get all of that? If you want more detail, the full draft
document includes the large evidence base supporting these
recommendations and a whole lot more.
Pretty much every relevant professional US organization that matters has
bought into this effort. But it is all not worth a hill of beans unless you, the
physician in practice, implement these recommendations for daily use.

Do it now!

That's my opinion. I am Dr George Lundberg, at large at Medscape.