Major depression is common in patients hospitalized with CHF and is independently associated with a poor prognosis.

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Ten subjects who exhibited feminine behavior and cross-dressing as young boys are described. At follow-up, 8 to 10 years later, 4 are heterosexual, 2 are homosexual, 1 is transsexual, and the outcome is uncertain in 3. Of the eight who met DSM III criteria when evaluated, three are heterosexual, two are homosexual, one is transsexual, and the outcome is uncertain for two. Gender dysphoria appears to be a necessary but not sufficient factor in a transsexual outcome. The strength, rigidity, and persistence of cross-gender behavior through latency may be a good predictor of transsexual outcome.

Summary: Psychogenic seizures and psychogenic syncope are common disorders but are difficult to identify. Head-upright tilt table testing has emerged as a promising means of evaluating vasovagally mediated syncope and convulsive syncope. Of a total of 42 patients evaluated by head-up tilt for recurrent syncope and 10 evaluated for recurrent idiopathic seizures, a total of 5 patients experienced syncope and 3 had tonicclonic seizure activity unaccompanied by any significant changes in blood pressure, heart rate, transcranial Doppler cerebral blood flow velocity, and electroencephalographic monitoring. Psychiatric evaluation revealed that seven patients suffered from conversion reactions and one from probable malingering. We conclude that patients who pass out or convulse during head-upright tilt without any change in physiologic parameters can be presumed psychogenic in origin and may be referred for psychiatric evaluation without further expensive diagnostic studies.tion. However, a number of these episodes are nonepileptic in ~t u r e and may result from various physiologic dysfunctions (such as vasovagal syncope and cardiac dysrhythh a ) , or may arise from psychologic factors (psychogenic syncope or psychogenic seizures). Recently, headupright tilt table testing has emerged as a useful means of identifying vasovagal episodes as a cause of recurrent idiopathic syncope and in differentiating convulsive syncope from epilepsy in individuals with recurrent seizure-like episodes.I4 The identification of individuals with psyche logic causes of recurrent syncope or seizures often has been much more difficult and time consuming. In addition to its ability to unmask a predisposition to vasovagal syncope in susceptible individuals, head-upright tilt table testing may be a powerful psychologic trigger that can provoke psychogenic syncope or seizures in individuals predisposed to these conditions. We report on eight patients in whom the diagnosis of either psychogenic seizures or syncope was established during head-upright tilt table testing.

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