The 2001 Institute of Medicine Report “Crossing the Quality Chasm,” summarized the current care of chronic illness in the United States by emphasizing “Between the health care we have and the health care we could have lies not just a gap, but a chasm.” Across multiple chronic illnesses within primary and specialty care systems, this summary statement illustrates that clinicians and other health professionals are not adequately providing patients guideline levels of treatment–levels that can lower the risk for complications of those illnesses.

Introduction: The diagnosis of borderline personality disorder is complex as is its pharmacologic treatment. Lamotrigine may offer promise in the treatment of this condition.

Objective: To assess the use of lamotrigine to treat symptoms of affective instability in patients with borderline personality disorder.

Methods: Charts of patients treated with lamotrigine in a private practice during the period of 2003–2004 were reviewed. Patients were included in the analysis if they had been given a clinical diagnosis of borderline personality disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision, had continued to display affective instability while taking their previous medications before being treated with lamotrigine; had received a Clinical Global Impression-Severity score before and after lamotrigine therapy; had been treated with lamotrigine, as monotherapy or adjunctive therapy, at a dose ranging from 50–200 mg/day; and continued to take lamotrigine for at least 3 months.

Results: The charts of 13 patients were reviewed and included in the analysis. All patients were female, 19–43 years of age, and had reported continuing symptoms of affective instability despite treatment with two to seven psychotropic drugs, including, but not limited to, fluoxetine, paroxetine, escitalopram, buproprion, and clonazepan. The duration of lamotrigine treatment, before the end of the period covered by the chart review was 3–15 months. The patients had initial Clinical Global Impression-Severity scores of 5 or 6 and a final scores of 1 or 2, except for one patient with an initial score of 3 and a final score of 1 and one patient with an initial score of 6 and a final score of 7.

Conclusion: Lamotrigine seems to be a safe and effective option for the treatment of patients with symptoms of affective instability associated with borderline personality disorder.

In this review, the history of the concept of the body image in neuropsychiatry is presented. Links between the parietal cortex and the body image are discussed and the possible role of the parietal lobe in psychiatric disorders noted. The link between parietal lobe function and some neurophilosophical concepts are introduced.

Alzheimer's disease (AD) is a progressive disorder in which neurodegeneration begins decades before clinical symptoms appear. Detecting AD during this preclinical phase presents both the enormous challenge of identifying at-risk patients prior to symptom onset and the potential reward of treating patients early enough to prevent or slow disease progression. Given that a 5-year delay in the onset of the clinical manifestations of AD could result in almost a 50% reduction in disease prevalence, early detection of AD is a major focus of clinical research. Several objective, measurable indicators of preclinical and clinical characteristics of AD are currently available or in development. These biomarkers are promising because they promote identification of individuals at risk for AD onset and disease progression; diagnostic accuracy and treatment during the early stages of AD; and the development of disease-modifying therapies that may potentially slow or prevent disease progression during the preclinical phase of AD.

The comorbidity of schizophrenia and obsessive-compulsive disorder (OCD) might be approached from two different directions. One is the OCD with psychotic features, and the other is the schizophrenic patient with OCD.

Deficits in cholinergic and glutamatergic neurotransmission have been linked to the symptomatology of Alzheimer's disease, and current therapies for Alzheimer's, including cholinesterase inhibitors (ChEIs) and the N-methyl-D-aspartate receptor antagonist memantine, have been developed to compensate for these deficits. This article reviews the results of clinical trials involving agents approved by the United States Food and Drug Administration for use in the treatment of Alzheimer's disease (namely, ChEIs for mild to moderate Alzheimer's and memantine for moderate to severe Alzheimer's). In particular, the efficacy of current monotherapy strategies in the treatment of cognitive and functional symptoms of Alzheimer's disease will be addressed. In addition, data from a clinical trial examining the use of a ChEI in combination with memantine will also be discussed, as it has been hypothesized that ChEIs and memantine may offer synergistic benefits due to their distinct mechanisms of action.

Epidemiologic studies have shown a significantly greater likelihood of substance misuse in persons with psychiatric disorders. One of the largest studies showed that 60.7% of people with bipolar I disorder had a lifetime diagnosis of a substance use disorder (SUD). Moreover, 32% of individuals with any mood disorder, including depression, were found to suffer from substance abuse or dependence. In general population surveys, it has been found that the presence of a mood disorder at least doubles the odds of having SUD.

Bipolar disorder is a chronic, frequently relapsing illness with a prevalence of 1.2% to 3.4% in the general population. It is associated with high disability, higher comorbidity due to medical illnesses, and significant social and economical consequences for patients, their families, and society. The episodic nature of this disease warrants rational use of medications and proper monitoring for adverse events. Various drug classes, such as mood stabilizers, antipsychotics, benzodiazepines, and antidepressants, are used for the acute and maintenance treatment of bipolar disorder. Each group of drugs is associated with wide array of adverse events and drug interactions, which are the main hurdles in treatment outcome and compliance. Common side effects seen with several agents, particularly antipsychotics, are somnolence, weight gain, extrapyramidal symptoms, dyslipidemia, type-2 diabetes, and hyperprolactinemia. Major drug interactions are seen with drugs such as carbamazepine, due to hepatic enzyme induction. Adverse effects such as somnolence are tolerability concerns and can be managed easily; others, such as diabetes mellitus, are safety concerns. It is prudent to have precise knowledge of the individual drug's side-effect profile, pharmacokinetics, and pharmacodynamics, to plan a treatment regimen. More research is needed to understand potential rish of various drugs and to devise and incorporate monitoring protocols in the treatment regimen.

Panic disorder occurs frequently with different forms of cardiovascular disease and hypertension. The 13 panic symptoms described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) often overlap with manifestations of cardiovascular disorders, raising problems in the differential diagnosis. In order to explore in greater detail the phenomenology of panic symptoms in cardiovascular patients, the Structured Clinical Interview for Panic-Agoraphobic Spectrum (SCI-PAS) was administered to 111 patients with hypertension and 29 patients with a recent myocardial infarction.

With regard to the frequency of endorsement of many of the symptoms assessed on the SCI-PAS, more than 40% of the cardiovascular patients who failed to meet the DSM-IV criteria for panic disorder did not significantly differ from the 10% of cardiovascular patients who did fulfill the criteria for panic disorder. A third distinct subgroup comprising 48.6% of the cardiovascular patients reported a significantly smaller number of SCI-PAS symptoms than the other two groups.

These preliminary findings suggest the existence of a relatively large proportion of cardiovascular patients who present with physical and psychological symptoms that are potentially related to panic disorder and that may provoke considerable subjective distress. Further studies are needed to clarify the nature of these symptoms and their potential interference with treatment and symptomatology of cardiovascular disease.

Body dysmorphic disorder (BDD) is characterized by excessive preoccupation with an imagined or greatly exaggerated defect in appearance, and often by related rituals or pursuit of medical or surgical treatments. The frequent comorbidity of BDD with obsessive-compulsive disorder (OCD) and the phenomenological similarities between these two disorders suggest that they may be related. BDD reportedly responds to oral clomipramine (CMI).

We present here two case studies of patients meeting DSM-IV criteria for BDD with comorbid delusional disorder, somatic type, to whom we administered pulse-loaded intravenous (IV) CMI (150 mg on day 1, 200 mg on day 2). After a 4.5-day drug holiday, both patients continued on oral CMI. As reflected in modified Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores, both patients' BDD improved by about one third within 4.5 days of the second IV dose. Improvement continued over 2 months on oral CMI, and comorbid major depression present in one patient remitted. By the end of 8 weeks of oral CMI, the patients' modified Y-BOCS scores had decreased about 55%, and their social functioning had markedly improved.

As in OCD, pulse-loaded, IV CMI may produce a much faster response than oral CMI or selective serotonin reuptake treatment and can be well tolerated. This treatment approach to BDD deserves further study in a prospective, randomized controlled trial.

Cutaneous rashes and eruptions can be caused by many medications, including carbamazepine. The presentation can be varied depending on severity. Cutaneous eruptions occur in 3% of individuals administered carbamazepine. Angioedema, a rare side effect of carbamazepine, involves vascular leakage in dermis and subcutis mediated by immunoglobulin E and/or bradykinins. Angioedema is more common in females and in the third decade of life. We report the case of a 27-year-old Indian woman who developed maculopapular rash and angioedema secondary to carbamazepine administration. The patient responded successfully to withdrawal of the drug and treatment with antihistamines. Due to the potentially life-threatening complications of this condition and the increasing use of anticonvulsants in the treatment of mood disorders, psychiatrists must be aware of the diagnosis and treatment of this condition.

Chronic musculoskeletal pain is highly prevalent in the United States and includes inflammatory and non-inflammatory syndromes, such as low back pain (reported by 59 million Americans in the past 3 months), neck pain (reported by 30.1 million Americans in the past 3 months), clinical osteoarthritis (reported by 27 million Americans in the past 3 months), and fibromyalgia (FM). FM affects between 2% to 4% of the US population or 12 million people. Inflammatory pain conditions commonly reported by patients include rheumatoid arthritis (2.5 million) and gout (3 million), among others. This article will focus primarily on FM, which is a chronic pain condition that predominately affects women.

The current diagnostic criteria for FM include chronic widespread pain for at least 3 months and the presence of widespread mechanical tenderness. A patient with suspected FM must report pain in all four body quadrants and have at least 11 of 18 tender points for a positive diagnosis to be made. Tender points are areas of the body where pressure is applied until pain threshold is achieved. In addition to pain and tenderness, FM patients very frequently describe widespread stiffness and fatigue, disrupted or poor sleep, dyscognition, and mild soft tissue swelling. Patients often also report symptoms of anxiety and depression.

We describe a 17-year-old girl with hypersexuality resulting from virilization, the latter a consequence of polycystic ovary syndrome, and we review the literature pertinent to hypersexuality in children and adults. Inappropriate sexual behavior (a common cause of disruption among children who are hospitalized for psychiatric disorders) may be caused either by hypersexuality or by simply ill-regulated behavior: a definition of hypersexuality is proposed that can be applied at the bedside (namely, sexual behaviors or fantasies that have abruptly increased in frequency by comparison with a previous baseline, are of sufficient excessiveness to disrupt expected or usual social, academic, or occupational functioning, or constitute a source of distress), so that this distinction can be made promptly, and we present a differential diagnosis for hypersexuality to direct its evaluation. Virilization does not seem to be a common cause of hypersexuality in children and adolescents, but it should not be overlooked when it does exist.The differential diagnosis of hypersexuality in adults, which we present for comparison, is much larger than it is in children.

There is evidence that the serotonin norepinephrine reuptake inhibitors (SNRIs) venlafaxine, milnacipran, and duloxetine, have probable superior antidepressant activity to most selective serotonin reuptake inhibitors (SSRIs), especially in more severe depression. Some patients, however, respond better than others to SNRIs. Several factors influencing response to milnacipran have been recently studied. The presence of certain polymorphisms related to noradrenergic neurotransmission has been shown to be related to different degrees or rapidity of response to milnacipran. In addition, patients with low pretreatment levels of plasma 3-methoxy-4-hydroxyphenylglycol have a better response to milnacipran. These recent genomic and neurochemical data confirm that milnacipran, in contrast to SSRIs and venlafaxine, has an impact on the noradrenergic system. Differences in metabolism determined by genetic variables in cytochrome P450 (CYP) 2D6 activity are a major determinant of venlafaxine levels to such an extent that genetically determined decreases in CYP 2D6 activity have been associated increased adverse effects. Milnacipran, which is not metabolized by the enzymes of the CYP system is not influenced by polymorphism of these enzymes. These preliminary data suggest that a patient's biochemical and pharmacogenetic characteristics may be useful in the future to help clinicians chose the most  effective antidepressant medication.