MYSOUNE@(priDlidone)consider It first for controlof grand mal, psychomotorana focal seizuresInitial dose in patients eight years old and older:250 mg daily at bedtime

BRIEF SUMMARY(For full prescribing information. see package circular.)MYSOLINEe Brand of PRIMIDONE AnticonvulsantCONTRAINDICAnONS: Primidone is contraindicated in: 1) patients withporphyria and 2) patients who are hypersensitive to phenobarbital.WARNINGS: The abrupt withdrawal of antiepileptic medication mayprecipitate status epilepticus.The therapeutic efficacy of a dosage regimen takes several weeks beforeit can be assessed.Uuge In pnlgll8ACy: The effects of MYSOLINE in human pregnancy andnursing infants are unknown.

Recent repOrts suggest an association between the use of anticonvulsantdrugs by women with epilepsy and an elevated incidence of birth defectsin children born to these women. Data are more extensive with respect todiphenylhydantoin and phenobarbital. but these are also the mostcommonly prescribed anticonvulsants; less systematic or anecdotalreports suggest a possible similar association with the use of all knownanticonvulsant drugs.The reports suggesting an elevated incidence of birth defects in childrenof drug·treated epileptic women cannot be regarded as adequate to provea definite cause and effect relationship. There are intrinsic methodologicproblems in obtaining adequate data on drug teratogenicity in humans;the possibility also exists that other factors. e.g.. genetic factors or theepileptic condition itself. may be more important than drug therapy inleading to birth defects. The great majority of mothers on anticonvulsantmedication deliver normal infants. It is impOrtant to note that anticonvul·sant drugs should not be discontinued in patients in whom the drug isadministered to prevent major seizures because of the strong possibility ofprecipitating status epilepticus with aflendant hypoxia and threat to life. Inindividual cases where the severity and frequency of the seizure disorderare such that the removal of medication does not pose a serious threat tothe patient. discontinuation of the drug may be considered prior to andduring pregnancy. although it cannot be said with any confidence thateven minor seizures do not pose some hazard to the developing embryoor fetus.The prescribing physician will wish to weigh these considerations in treat­ing or counseling epileptic women of childbearing potential.Neonatal hemorrhage. with a coagulation defect resembling vitamin Kdeficiency. has been described in newborns whose mothers were takingprimidone and other anticonvulsants. Pregnant women under anti·convulsant therapy should receive prophylactic vitamin K, therapy for onemonth prior to. and during. delivery.PRECAUTIONS: The total daily dosage should not exceed 2 g. SinceMYSOLINE therapy generally extends over prolonged periods. a completeblood count and a sequential multiple analysis-12 (SMA-12) test should bemade every six months.In nUl'8lng mothers: There is evidence that in mothers treated withprimidone. the drug appears in the milk in substantial quantities. Sincetests for the presence of primidone in biological fluids are too complex tobe carried out in the average clinical laboratory. it is suggested that thepresence of undue somnolence and drowsiness in nursing newborns ofMYSOLINE-treated mothers be taken as an indication that nursing shouldbe discontinued.ADVERSE REACnONS: The most frequently occurring early side effectsare ataxia and vertigo. These tend to disappear with continued therapy. orwith reduction of initial dosage. Occasionally. the following have beenreported: nausea. anorexia. vomiting. fatigue. hyperirritability. emotionaldisturbances. sexual impotency. diplopia. nystagmus. drowsiness. andmorbilliform skin eruptions. Occasionally. persistent or severe side effectsmay necessitate withdrawal of the drug. Megaloblastic anemia may occuras a rare idiosyncrasy to MYSOLINE and to other anticonvulsants. Theanemia responds to folic acid without necessity of discontinuingmedication.

Reference: 1. Schoflelius. D.o.. and Fincham. R. w.: Climcal effectivenessof primidone as a single antiepileptic medication. Paper presented at theThirteenth Annual Meeting of the American Academy of Neurology. LosAngeles. California. Apr. 27-30. 1978.

IAVArs61 AYERST LABORATORIES7177/. .,- ~ New York NY 10017

ABSTRACTS

Child psychiatry-pediatricsconsultation-liaison servicesin the hospital settingRothenberg MB. Gen Hosp Psychiatry1:281-286. 1979.

• Reviewing the historical devel­opment of pediatrics as well aschild psychiatry offers some under­standing of the culture in which thepediatric consultation-liaison ser­vice must exist. Pediatrics initiallywas a specialty concerned withidentification and description ofchildhood diseases. Only with theadvent of antibiotics and immun­izations was there an active attemptto treat common childhood dis­eases. Therapeutic developmentsallowed a shift in the focus of hos­pital pediatrics to more complexand chronic illnesses. Child psychi­atry developed from a milieu ofpsychochometric investigation inmeasuring school children'sachievement. Recently, child psy­chiatry has again begun to mergewith pediatrics, with the develop­ment of behavioral pediatric pro­grams. Anders surveyed pediatrictraining centers in 1977 to inves­tigate psychosocial education. Thepredominant mode of this educa­tion was pediatric consultations onpediatric hospital units. Child psy­chiatrists generally provided directservice, with rare joint departmen­tal support. This report demon­strates a paradigm that may beadopted by pediatric hospital ser­vices to develop consultation-liai­son programs. An inpatient psy­chosocial research group (IPRG)was developed to provide consulta­tion-liaison services to a 18S-bedchildren's medical center. Thegroup staff included a child psychi-

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atrist, one full-time nurse, one half­time nurse, one half-time medicalsocial worker, and a full-time chap­lain; there was also support fromthe recreational therapy depart­ment. In addition, behavioral pe­diatric fellows and senior child psy­chiatry fellows augmented thegroup. The group's specific taskswere to fulfill direct consultations.Emergency consultations were per­formed by the child psychiatry fel­lows. The work load initiallyreached a level of 40 formal con­sultations, as well as multiple infor­mal liaison interactions, per month.This format provides a superbtraining arena for both behavioralpediatricians and child psychia­trists. It allows the two disciplines tobe integrated as opposed to havingseparate yet overla pping roles.Working together, the child psychi­atrists and behavioral pediatricianshave a common forum for mutualgrowth and exchange of informa­tion. Although the service has beensupported by the hospital's generaloperating budget, funding con­tinues to be a problem.

Thomas N. Wise, M. D.The Fairfax HospitalFalls Church, Va.

Neuroleptic drugs: How toreduce the risk of tardivedyskinesiaDeVeaugh-Geiss J. Geriatrics 34(7):59-66.1979.

• This paper reviews the symptomsof tardive dyskinesia for the pri­mary physician. It emphasizes earlyrecognition of the syndrome andalso warns that neuroleptic drugsshould not be used without careful

MAY 1980· VOL 21 • NO 5

thought, especially in institutionalsettings where disruptive behavioramong elderly patients may becontrolled with their use. The earli­est sign of tardive dyskinesia maybe vermicular movements andtremor of the tongue and, later,abnormal involuntary movementsof orofacial musculature and/ormuscles of trunk and extremities.There may be eye blinking andgrimacing. Movements are rhyth­mic and repetitive and may inter­fere with functioning. Drug-with­drawal dyskinesias may look verymuch like the irreversible tardivedyskinesias, but usually disappearin six to 12 weeks after drugs arestopped. Tardive dyskinesias mayappear only a few weeks afterneuroleptics are begun as well asmuch later in therapy. Differentialdiagnosis should also includechoreas, athetosis, torsion dys­tonias, Wilson's disease, and dys­kinesias from other drugs. Thecause of this syndrome is believedto be a post-synaptic hypersensiti­vity in the nigrostriatal neurons in­duced by prolonged blockade ofthe dopamine receptor sites byneuroleptic drugs. The low-dose,high-potency drugs that cause thegreatest degree of extrapyramidalside-effects are also most oftenthose related to tardive dyskinesia.The syndrome is more common inolder patients with longer durationof treatment, and with higherdoses. The prevalence in schizo­phrenic outpatients has been re­ported as high as 43.4%, and thepercentages increase with age to75% of hospitalized schizophrenicpatients over age 70. The authoremphasizes the need for preventionsince no treatment exists. He sug-

gests low dosage for the shortestpossible time, drug holidays for atleast six weeks annually, and pro­grams for in- and outpatients thatminimize the need for behavior­controlling drugs.

Miriam Rosenthal, M.D.University Hospitals ofCleveland

A behavioral approach topatient complianceSchmidt JP. Postgrad Med 65(5):219-224,1979.

• Methods to overcome patientnoncompliance with medicationtherapy have received little atten­tion. Patient education has hadsome success, but many patientsstill fail to comply. This paper re­ports a new strategy to increasecompliance using the behavioralmodel. In this model, behavioralsequences have three compo­nents-the antecedent, the behav­ior, and the consequence-and ma­nipulation of the three increases thelikelihood of compliance. The an­tecedent to compliance is the cue orsignal that reminds the patient ofthe time to take the medication.External cues can serve more reli­ably than memory. First, the physi­cian must identify regularly occur­ring events in the patient's dailylife. Then patient and physician es­tablish a link between the habit andthe medication. In the absence ofregular habits or ability to establishlinks, the patient and doctor needto create cues, e.g., setting an alarmclock to signal medication time.Educating patients about their ill­ness and its treatment remains es­sential to reinforcing the behaviorcomponent of compliance. By ask-

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ing and listening to the patientcarefully, the physician can elicitinaccurate ideas about taking med­icine. Discussing these ideas in aconversational, relaxed mannercan establish trust and willingnessto follow recommendations. Non­compliance is fomented by side-ef­fects and inconvenience. Establish­ing a self-reward system can over­come these obstacles; rewards mustbe immediate, realistic, and sus­tained. A written "contract" canreinforce the agreement. The pa­tient can always break the contract,but most will comply if they havemade a commitment to the physi­cian. Maintenance of the behav­ioral program will benefit fromroutine monitoring by the physi­cian. The physician and the patientcan consider monitoring as a meansfor understanding and correctingproblems with the program, ratherthan as evidence of distrust. A col­laborative relationship betweenphysician and patient will increasethe latter's self-control and interestin the program's success. In addi­tion to the physician, nurses, tech­nicians, and physician's assistantscan readily develop behavioral­compliance programs for patients.

Henry Herrera. M.D.University ofCalifornia. Davis

A retrospective assessmentof emergency departmentpatients with complaint ofheadacheDhopesh V. Anwar R, Herring C. Headache19:37-42, 1979.

• This is the report of an assess­ment of emergency room patientswith chief complaints of headache

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at The Medical College of Pennsyl­vania between January I and De­cember 31. 1976. Among 34,000patients, 872 (2.5%) complained ofheadaches. Diagnostic distributionwas as follows: systemic infection37.3%, tension headaches 19.3%,post-traumatic headaches 9.3%,hypertension 4.8%, migraine 4.5%,subarachnoid hemorrhage 0.9%,meningitis 0.6%, combinationheadache (migraine and tension)0.5%, miscellaneous 14.9%, and nodiagnosis 6%. Since only 1.2% hadserious physical conditions, the au­thors conclude that the vast major­ity of emergency headaches are be­nign in nature.

Fred O. Henker III, M.D.University ofArkansasfor Medical Sciences

A model for psychosocialphasing in cancerWeisman AD. Gen Hosp Psychiatry1(3): 187-195, 1979.

• In order to improve understand­ing of the emotional adaptation tocancer, a model for psychosocialphasing in cancer has been devel­oped. Four phases have been iden­tified to describe the psychologicalcourse of the person with neoplasticdisease and, concurrently, thecharacteristics of individuals vul­nerable to psychosocial distress aredescribed. Those with higher emo­tional distress are generally pessi­mistic about their outcome, haveprior histories of psychiatric diffi­culties, have marital problems andlower socioeconomic status, andmore frequently abuse alcohol. Incontradistinction, those with lessemotional distress often haveavailable psychosocial support,

have better impressions of theirphysicians, and are more confidentabout their present treatment. Thefour stages outlined are initiated bythe phase of existential plight.During this phase, fears of annihi­lation, the pain of alienation, andthe feeling of endangerment andhelplessness are potentiated bymisuse of denial such as superop­timism or a dissociated type of cop­ing. This phase occurs around thetime the patient is initially diag­nosed. Active coping includes ap­propriate cooperation with healthcare, and seeking and receiving ap­propriate psychosocial support.The next phase is that of accom­modation and mitigation, wherethe major aim is to survey one'soptions and hope that there will bea cure without recurrence. Prob­lems include side-effects from che­motherapy or surgery. Phase three,of recurrence and relapse, is stress­ful because the individual musthope for control of the disease, nOLtotal cure. With increased impair­ment, the quality of life is modifiedand there is the fear ofdeath. Goalsare a reprieve from the dreadedillness with a guarded attitude. Thefinal phase is that of deteriorationand decline, where the person mustdrastically revise his quality of lifeand look toward relief. The timeperspective is closed and the copingmodes are frequently passive. Rec­ognition and understanding ofthese phases and their specificproblems can lead to better inter­vention methods for those manag­ing treatment.

Thomas N. Wise. M.D.The Fairfax HospitalFalls Church. Va.

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