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BACKGROUND: Social dysfunction is reported in several psychiatric diseases and its evaluation is becoming an important measure of treatment outcome. The aim of this study was to obtain normative data, to test the validity and the ability of the Portuguese version of the Self-Report Social Adjustment Scale (SAS-SR) to detect different clinical conditions. METHODS: The Portuguese version of the SAS-SR was applied to a carefully selected non-psychiatric sample, and to depressed, panic, bulimic and cocaine-dependent patients. Depressed and panic patients were evaluated in two different clinical conditions: acutely symptomatic and in remission. RESULTS: SAS overall and sub-scale scores of the normal sample were consistently lower than all patient groups, indicating better social adjustment in all areas. Panic patients were impaired to a lower level than depressed and cocaine-dependent patients in overall adjustment. Depressed patients in remission, although in better condition, were still impaired in relation to normal subjects in overall social functioning, leisure time and marital areas. In panic patients in remission, normalization was not achieved in overall functioning, work and marital areas. LIMITATIONS: Sample size was small in some groups and the evaluation was cross-sectional. CONCLUSIONS: The Portuguese version of SAS-SR is a useful instrument for detecting differences between psychiatric patients and normal subjects and for the evaluation of different clinical conditions, recommending its use in outcome studies.

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The acute effects of flumazenil, a benzodiazepine (BZD) receptor antagonist in long-term BZD users were used as a possible test to detect physiological dependence. Thirty-four subjects (20 females, 14 males) aged 26-48 years (mean + SD, 42.4+/-8.5 years), all chronic users of low doses of diazepam (5-20 mg/day, 14.2+/-4.8 mg/day) for 5 to 28 years (10.5+/-6 years), received a single 1-mg i.v. flumazenil dose or saline, infused slowly under double-blind conditions. Physiological dependence was suggested as all patients receiving flumazenil developed an anxiety reaction while the placebo group did not. Flumazenil triggered a qualitatively different reaction amounting to a panic attack during infusion in nine out of 15 patients. These patients had a diagnosis of panic disorder or a history of panic attacks. Caution should be exercised when giving flumazenil to panic patients who are taking BZDs as maintenance treatment.

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The long-term effects of benzodiazepines (BDZ) on psychomotor and cognitive functions were assessed in 28 out patients, users of low therapeutic doses of diazepam (13.6 ± 4.9 mg/day, range: 5-20 mg/day) for 5-20 years (10.1 ± 5.0 years). These patients' performance was compared with two control groups: 53 BDZ-free anxious out patients and 56 healthy volunteers. The three groups were similar in sex, age and education. BDZ chronic users were tested before and after short-term (3 weeks) and long-term discontinuation (at an average of 10 months). Performance of chronic users of BDZ was consistently worse than those of the control groups, suggesting an impairment in these patients on both psychomotor and cognitive functions. These were not related to either dose or cumulative exposure to BDZ, and were also independent of diagnosis and levels of anxiety and depression. Moreover, these deficits were persistent as their performance failed to improve after drug discontinuation.

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The aim of this study is to determine whether long-term use (5-20 years) of therapeutic doses of diazepam (5-20 mg/day) in anxious patients (n = 28) is associated with tolerance to its psychomotor and cognitive effects. Patients were tested at baseline, before and after a 10 mg oral dose of diazepam during chronic use, and at 3 weeks and 10 months after benzodiazepine (BZ) discontinuation. The effects of a single i.v. dose of flumazenil (1 mg administered 5 days before baseline) on reversing tolerance were also assessed. No acute effect of diazepam was observed on the psychomotor performance of patients both under BZ treatment and after short- and long-term discontinuation, suggesting persistence of tolerance. In contrast, acute effects of diazepam were observed in memory measures at all times. Given subjects' very prolonged BZ use, it is possible to predict that tolerance to the memory effects never fully develops. Flumazenil administration did not reverse tolerance. This suggests that neuroadaptative mechanisms, other than benzodiazepine receptor set-point shift, occur after long-term use.

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PURPOSE: To determine the incidence of mitral valve prolapse (MVP), using echocardiographic and auscultatory criteria, in cases of panic disorder (complicated or not with agoraphobia). PATIENTS AND METHODS: Sixty-five patients (37 women) with panic disorder and without known cardiac disease, mean age 39.8 years (range 19-67) were studied. MVP was diagnosed when there was a typical auscultatory click or when the echocardiographic study (echo) registered one mitral lacinea 2 mm behind the C-D line at the "M" study or a systolic billowing of mitral leaflets in two views to the two-dimensional study. RESULTS: MVP was found in 29 (44.6%) of the patients, 12 (42.7) men and 17 (49.5%) women. A click was found in 19 (24%) of the cases and the Echo was positive in 24 (39.6%) of the patients. Click and a positive Echo finding were identified in 14 patients. CONCLUSION: MVP was found in panic cases, in incidence greater than in the general population.

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A prototype benzodiazepine (BDZ) antagonist, flumazenil (1 mg, i.v.) or placebo was administered to eight chronic users (5-15 years) of therapeutic doses of diazepam (10-25 mg/d), in a double-blind, placebo-controlled design in order to evaluate the presence of physiological dependence. The three patients receiving flumazenil developed anxiety reactions, with significant increases in bodily and psychological symptoms, as measured by rating scales. In two these amounted to a panic attack. Subjects on placebo tended to show decreases in measures of anxiety. The severity of precipitated reactions was not related to the total cumulative exposure to diazepam, but to a history of panic attacks. Previous panic may increase the vulnerability to severe reactions to flumazenil.

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The authors review recent studies on benzodiazepine, the most largely used drug for insomnia and anxiety. In this paper are summarized: the development, patterns of use and abuse, mechanism of action, development of differential tolerance to its many effects, and the phenomena of withdrawal and dependence on the benzodiazepines.

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This is a case report of benzodiazepine abuse and dependence with tolerance to some (psychomotor sedative) but not all (memory) of the BDZ effects. A withdrawal syndrome which included intensification of paranoid personality traits, was observed.

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