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7 Myopathies Associated with Other Disorders
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Myopathy may occur in association with chronic hypokalemia, any endocrinopathy, and in patients taking corticosteroids, chloroquine, colchicine, clofibrate, emetine, aminocaproic acid, lovastatin, bretylium tosylate, or drugs causing potassium depletion Weakness is mainly proximal, and serum creatine kinase is typically normal, except in hypothyroidism and some of the toxic myopathies Treatment is of the underlying cause Myopathy also occurs with chronic alcoholism, whereas acute reversible muscle necrosis may occur shortly after acute alcohol intoxication Inflammatory myopathy may occur in patients taking penicillamine; myotonia may be induced by clofibrate, and preexisting myotonia may be exacerbated or unmasked by depolarizing muscle relaxants (eg, suxamethonium), -blockers (eg, propranolol), fenoterol, ritodrine and, possibly, certain diuretics
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PERIODIC PARALYSIS SYNDROMES
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Periodic paralysis may have a familial (dominant inheritance) basis The syndromes to be described are channelopathies that manifest as abnormal, often potassium-sensitive, musclemembrane excitability and lead clinically to episodes of flaccid weakness or paralysis, sometimes in association with abnormalities of the plasma potassium level Strength is normal
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COMMON PSYCHIATRIC DISORDERS STRESS & ADJUSTMENT DISORDERS (SITUATIONAL DISORDERS)
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ESSENTIALS OF DIAGNOSIS
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Anxiety or depression clearly secondary to an identifiable stress Subsequent symptoms of anxiety or depression commonly elicited by similar stress of lesser magnitude Alcohol and other drugs are commonly used in selftreatment
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General Considerations
Stress exists when the adaptive capacity of the individual is overwhelmed by events The event may be an insignificant one objectively considered, and even favorable changes (eg, promotion and transfer) requiring adaptive behavior can produce stress For each individual, stress is subjectively defined, and the response to stress is a function of each person s personality and physiologic endowment
Classification & Clinical Findings
Opinion differs about what events are most apt to produce stress reactions The causes of stress are different at different ages eg, in young adulthood, the sources of stress are found in the marriage or parent-child relationship, the employment relationship, and the struggle to achieve financial stability; in the middle years, the focus shifts to changing spousal relationships, problems with aging parents, and problems associated with having young adult offspring who themselves are encountering stressful situations; in old age, the principal concerns are apt to be retirement, loss of physical capacity, major personal losses, and thoughts of death An individual may react to stress by becoming anxious or depressed, by developing a physical symptom, by running away, having a drink, starting an affair, or in limitless other
ways Common subjective responses are fear (of repetition of the stress-inducing event), rage (at frustration), guilt (over aggressive impulses), and shame (over helplessness) Acute and reactivated stress may be manifested by restlessness, irritability, fatigue, increased startle reaction, and a feeling of tension Inability to concentrate, sleep disturbances (insomnia, bad dreams), and somatic preoccupations often lead to self-medication, most commonly with alcohol or other central nervous system depressants Maladaptive behavior in response to stress is called adjustment disorder, with the major symptom specified (eg, adjustment disorder with depressed mood ) Posttraumatic stress disorder (PTSD) included among the anxiety disorders in DSM-IV is a syndrome characterized by reexperiencing a traumatic event (eg, rape, severe burns, military combat) and decreased responsiveness and avoidance of current events associated with the trauma Patients with PTSD experience physiologic hyperarousal, including startle reactions, intrusive thoughts, illusions, overgeneralized associations, sleep problems, nightmares, dreams about the precipitating event, impulsivity, difficulties in concentration, and hyperalertness The symptoms may be precipitated or exacerbated by events that are a reminder of the original stress Symptoms frequently arise after a long latency period (eg, child abuse can result in later-onset posttraumatic stress syndrome) The sooner therapy is initiated after the trauma, the better the prognosis Therapy at that time should be brief and simple (once in a safe environment), expecting quick recovery and promoting a sense of mastery over the traumatic event Treatment initiated later, when symptoms have crystallized, includes programs for cessation of alcohol and other drug abuse, group and individual psychotherapy, and improved social support systems The therapeutic approach is to facilitate the normal recovery that was blocked at the time of the trauma
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