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Elective mutism: a case study

International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 49 ± 51 Elective mutism: A case study
We report a case of persistent elective mutism in a young single woman.
To our knowledge there has been no published study or case report
of persistent elective mutism starting at the age of acquisition of language
and persisting until she was 22.
(Int J Psych Clin Pract 2002; 6: 49 ± 51)
The Caludon Centre, Walsgrave, Coventry,UK Correspondence Address
Dr. Ashok Kumar Jainer, Specialist
Registrar, General Adult Psychiatry, The
Caludon Centre, Clifford Bridge Road,
Walsgrave, Coventry CV2 2TE, UK

Keywords
elective mutism

pathological shyness
Received 22 January 2001; revised 24 April social anxiety
aphasia voluntaria
grades, failing only in German language and music, due tothe oral component of these exams. Following on from T he German physician Kussmaul was the first to school she applied for college courses but was refused describe elective mutism. In 1877, he reported three admission, as she was not able to speak at interview.
clinical cases and termed the condition ``aphasia voluntar- However she enrolled on, and successfull y completed, a 6- ia’’.1 The first person to use the term ``elective mutism’’ was month computer course. Later on she managed to get a Moritz Tramer, a Swiss child psychiatrist , in 1934.1 Elective place at technical college. Her current situation is that she mutism is defined in ICD102 as ``marked emotionally is attending college, has friends, and no longer refuses to determined lack of speech in certain situations in a child with normal, or near normal, speech/language ability’’.
She has not got along with her middle sister since childhood; however she got on reasonably well with heryoungest sister for a time when they were younger, and used to play and communicat e with her, until 6 years ago,when her father died of a heart attack, after which she Miss X is a 24-year old, single, unemployed woman, living became more dependent on her mother and talked to her with her mother and two younger sisters. Starting from around the time she commenced school, it was noticed that She presents as a quiet, inhibited, well-groome d lady she had great difficult y in communicati ng with anyone who makes no eye contact. She exhibited features of social outside the home, and for many years she conversed only anxiety and some obsessiona l features. She spends much with her mother, and this continued until she was 22 years time in the bathroom getting ready and is very selective old. When she was three her mother noticed that she was a about the clothes she wears. She described herself as being shy, inhibited child and showed a degree of emotional a perfectionist , and is preoccupied with details. The criteria coldness to her newborn sister. Because of her problems at for obsessive compulsive disorder are not fulfilled : she this time, she was sent to play school, which it was hoped denied a feeling of subjective compulsion, or unpleasant would improve her social and communication skills. But irrational repetitive irresistibl e ideas, thoughts or images she failed to speak to anyone while she was there, although that she regards as alien. Nor did she meet the criterion of she was able to interact and make friends.
social phobia, as she denied irrational fear of, and When she was at primary school, her teachers asked her compelling desire to avoid, social situations. Though she mother to obtain tape recordings of her conversation s at felt anxious, nervous, uncomfortable around strangers, she home, as they were concerned that she did not talk at all.
denied any experience of blushing, trembling or vomiting The tapes obtained indicated that her verbal language skills in social situations. The impairment in social, academic or were normal for her age. She was allowed to remain in family functioning was attributable directly to her refusal to mainstream school and took her GCSE exams at the speak, and one concludes that she has marked social normal age of 16 years, achieving five subjects at D and E She was diagnosed as suffering from elective mutism (ICD-10). Her first contact with psychiatric services waswith the Child Clinical Psychology Services when she was Transient elective mutism is not uncommon, but persistent in primary school. At this time she was treated with a elective mutism is a rare disorder.10 Until recently most of gradual behaviour-sh aping programme, initially including the literature on elective mutism has been single case home visits from her teacher. She showed some response to reports or a series of case reports. There have been only a it. In her early primary school years she did speak a little few epidemiologi cal studies. In a survey conducted in all but apparently stopped again when she moved to the junior primary schools in Birmingham, the prevalence was school, and thereafter refused any psychologica l or other reported as 7.2 per 1000 after 8 weeks of school, but after 12 months this figure had fallen to between 0.3 and 0.6 per At the age of 18 (when following the death of her father, she would communicat e only with her mother) she was In another study carried out in Newcastle,12 a lon- again referred to psychiatric services.
gitudinal investigation of speech-retard ed children, the Results of clinical investigation s, including EEG, are prevalence of the condition was reported as 0.8 per 1000.
within normal limits. Psychologi cal tests included the Another study found only four cases among more than Millon Clinical Multiaxial Inventory3,4 in its newest 2000 children referred to the Department of Psychiatry at version; it is a well-researc hed self-repor t measure which has been updated explicitly to correspond to DSM-IV The social contexts in which children do not speak are criteria for Axis 1 symptomatology and Axis II personalit y mostly situations in which they are expected to speak to difficulties.5 The inventory has 24 scales: 11 Clinical strangers , e.g. at school. Miss X had such problems at Personalit y Patterns, three Severe Personalit y Pathology, school and later at college. In keeping with reports of seven Clinical Syndrome and three Severe Syndrome Scales; certain patterns of behaviour in other studies (where verbal plus four Modifying Indices: Disclosure , Desirability , communicati on with one or other family member was non- Debasement , and Validity, to ascertain test-taking attitude existent), Miss X did not speak to her younger sister, although it has been most often reported that fathers are Miss X’s profile on this measure was valid. The predominant feature identifie d on the Clinical Syndrome Association s between elective mutism and social anxiety Scale (correspondi ng to Axis I symptomatology) was have been reported.14,15 It has been suggested that elective anxiety. The most prominent features on the Clinical mutism might be a symptom of social anxiety, rather than a Personalit y Pattern Scales (correspondi ng to Axis II distinct diagnostic syndrome.6 The severity of anxiety and symptomatology) were Avoidant, Dependent, and Schizoid.
social anxiety correlate with the severity of mutism. Our However, her scores on these scales were not high enough patient has shown features of social anxiety throughout her to warrant diagnosi s of a personalit y disorder. Her intellectual ability was not formally assessed, as her level In personalit y profiles , shyness and internalizin g of scholasti c attainment, in spite of her elective mutism, behaviour have been reported as the most prominent clearly indicated that she was of at least average ability.
personality features.1 Shyness was reported as a prominent She was initially treated in day hospital and was advised personality feature in 85% of children with elective to take part in music therapy, but this had to be mutism.1 Miss X was a shy girl from the very beginning , discontinued , as she did not involve herself in the activities.
even before the features of mutism appeared, and this may In addition to this, on the basis of case reports,6 open and double blind controlled trial,7,8 it was decided to try various The most striking feature of this case is the protracted medications in her management . We tried phenelzine , as course of her illness, which has lasted for about 20 years well as serotonin re-uptake inhibitors. She could not without any periods of full remission . One study found the tolerate phenelzine or fluoxetine. She was started on 20 mg illness to be persistent in only 54% of subjects, whereas it paroxetine a day, and her social anxiety reduced within a decreased with time in 35%, and another 8% showed a few weeks and she was able to answer the telephone at more fluctuating course of the symptoms.1 Black and home; the improvement was more marked after 8 weeks.
Uhde14 reported that the course of the illness could be She obtained a place at technical college within 3 months persistent in a minority of children. One possible and started speaking outside the home within a year. There explanation might be pathological shyness,4 which in our were no adverse effects reported with paroxetine. She was case seems to have been complicated by schizoid and also able to do voluntary work, has established relation- ships, and was discharge d from the outpatient clinic.
The mainstay of treatment until recently has been Although the role of non specific factors cannot be ruled psychotherap eutic intervention, using various methods out, all these improvement s correlated with the introduc- ranging from traditional psychoanaly sis to behaviour tion of paroxetine. Our finding is supported by recent modificatio n techniques. An association has been reported research reporting that paroxetine is effective in social between elective mutism and social anxiety,1,15 and this has opened the channels for pharmacother apy. Phenelzine was the first agent found effective, in a 7-year-old girl with a 2-year history of elective mutism.6 The first double-blin d placebo-contr olled study reported the efficacy of fluoxetinein such cases.7 Other studies have also shown the efficacy . Elective mutism may simply represent the most of fluoxetine in diminishin g anxiety and increasing speech severe end of the spectrum of childhood speech in a public setting.8 Miss X has shown improvement on paroxetine (20 mg), which she was given because she . Transient mutism is not uncommon but persistent could not tolerate fluoxetine: her communication at home, as well as in social situations outside the home, has . It can affect academic, social, or family functioning improved and her social anxiety has decreased. The efficacy of paroxetine in social anxiety and social phobia has also . Evidence suggests that SSRI drugs can be effective been reported in a randomized, double-blind , placebo- controlled study.9 She improved sufficientl y to be dis-charged from the outpatient clinic.
1. Steinhausen HC, Juzi C (1996) Elective mutism: An analysis of 9. Baldwin DS, Bobes J, Stein DJ et al (1999) Paroxetine in social 100 cases. J Am Acad Child Adolesc Psychiatry 35: 606 ± 14.
phobia/social anxiety disorder. Br J Psychiatry 175: 120 ± 6.
2. WHO (1992) Classification of Mental and Behaviour Disorder: 10. Morris JV (1995) Cases of elective mutism. Am J Mental Clinical Description and Diagnostic Guidelines (ICD-10). Geneva: Defiency 57: 661 ± 718.
11. Brown BJ, Lloyd H (1995) A controlled study of children not 3. Millon T (1994) Millon Clinical Multiaxial Inventory. Minnea- speaking at school. J Assoc Workers Maladjusted Children 3:
polis, MN: National Computer System.
4. Millon T (1997) The Millon Inventories: Clinical and personality 12. Fundis T, Kolvin I, Garside R (1979) Speech Retarded and Deaf assessment. New York: Guilford Press.
Children: Their psychological development. London: Academic 5. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn.). (DSM-IV) 13. Reed GF (1963) Elective mutism in children: A re-appraisal. J Child Psychol Psychiatry 4: 99 ± 107.
6. Goldwin DH, Weinstock RC (1990) Phenelzine treatment of 14. Black B, Uhde TW (1995). Psychiatric characteristic of children mutism. J Clin Psychiatry 57: 384 ± 5.
with selective mutism. A pilot study. J Am Acad Child Adolesc 7. Dummit ES (1996) Fluoxetine treatment of children with Psychiatry 34: 847 ± 56.
selective mutism: An open trial. J Am Acad Child Adolesc 15. Black B, Uhde TW (1992) Elective mutism is a variant of social Psychiatry 33: 615 ± 20.
phobia. J Am Acad Child Adolesc Psychiatry 31: 1090 ± 4.
8. Black B, Uhde TW (1994) Treatment of elective mutism with fluoxetine. A double-blind placebo-controlled study. J Am Acad
Child Adolesc Psychiatry
33: 1000 ± 6.

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