bluuebunny/crossref_metadata_2025 huggingface dataset:
Obesity, Diabetes, and the Metabolic Syndrome: New Challenges in Antipsychotic Drug Therapy
Authors: Caballero Enrique
Published: August 2016

Obesity and diabetes continue to be national health epidemics. Greater than 50% of adults in the United States are overweight, and >17 million people have diabetes—one third of whom are not diagnosed. Diabetes ranks number 1 in direct health care costs of any disease category. Patients who suffer from schizophrenia may be at twice the risk of developing diabetes compared with the general population. Some new antipsychotic agents are among several types of medications that may potentially impair glucose metabolism. For example, studies have shown that people treated with clozapine and olanzapine have developed elevated fasting serum insulin levels, suggestive of insulin resistance. Insulin resistance may be a result of irregularities in the insulin action sequence and it may occur long before overt diabetes. The further study of the effects of medications on glucose metabolism and their mechanisms, therefore, is essential to developing better treatment regimens that minimize insulin resistance and avoid associated health risks such as obesity and diabetes.
Outcome Measures for Clinical Drug Trials in Autism
Authors: Aman Michael G. , Novotny Sherie , Samango-Sprouse Carole , Lecavalier Luc , Leonard Elizabeth , Gadow Kenneth D. , King Bryan H. , Pearson Deborah A. , Gernsbacher Morton Ann , Chez Michael
Published: August 2016

This paper identifies instruments and measures that may be appropriate for randomized clinical trials in participants with autism spectrum disorders (ASDs). The Clinical Global Impressions scale was recommended for all randomized clinical trials. At this point, however, there is no “perfect” choice of outcome measure for core features of autism, although we will discuss five measures of potential utility. Several communication instruments are recommended, based in part on suitability across the age range. In trials where the intention is to alter core features of ASDs, adaptive behavior scales are also worthy of consideration. Several “behavior complexes” common to ASDs are identified, and instruments are recommended for assessment of these. Given the prevalence of cognitive impairment in ASDs, it is important to assess any cognitive effects, although cognitive data from ASD randomized clinical trials, thus far, are minimal. Guidance from trials in related pharmacologic areas and behavioral pharmacology may be helpful. We recommend routine elicitation of side effects, height and weight, vital signs, and (in the case of antipsychotics) extrapyramidal side-effects assessment. It is often appropriate to include laboratory tests and assessments for continence and sleep pattern.
Treatment-resistant Depression in Late Life
Authors: Flint Alastair J.
Published: August 2016

Treatment resistance is reported in up to 40% of older patients with major depression. Before labeling an episode of depression as treatment resistant, it is important to ensure that the diagnosis is correct and that the patient has received and adhered to an adequate dose of treatment for an appropriate length of time. It is also important to assess the patient for comorbid physical and psychiatric conditions that can contribute to treatment resistance. In patients who do not experience remission of symptoms with an adequate trial of medication, the following options can be considered: augmenting the antidepressant with a drug that is not primarily an antidepressant, adding a second antidepressant to the first, switching to a different antidepressant medication, or switching to electroconvulsive therapy. This paper reviews the concept of treatment-resistant depression and discusses its assessment and management in the elderly. The author concludes that when a systematic stepped-care approach to treatment is followed, most older patients with major depression will experience remission of symptoms.
Brain-Imaging Studies of Posttraumatic Stress Disorder
Authors: Liberzon Israel , Phan K. Luan
Published: August 2016

Brain-imaging studies of posttraumatic stress disorder (PTSD) have rapidly increased in recent years. Structural studies have identified potential smaller volumes of the hippocampus of traumatized and/or PTSD subjects. Functional activation studies have implicated hyperactive or altered functioning of brain regions, such as the amygdala and the insula, and a failure to engage emotional regulatory structures, such as the medial prefrontal and anterior cingulate cortex. Recent neurochemical investigations have suggested that neuromodulatory systems (eg, γ-aminobutyric acid, μ-opioid) may underlie these aberrant brain activation patterns. This article reviews the literature on structural, functional, and neurochemical brain-imaging studies of PTSD.
Social Cognition and Its Neural Correlates in Schizophrenia and Autism
Authors: Abdi Zeinab , Sharma Tonmoy
Published: August 2016

The study of social cognition in psychiatric disorders has become increasingly popular in recent years. This is due to the its proposed link to social functioning and the inability of general neurocognitive skills to explain the spectrum of impairments observed in patients. This article reviews research into two of the processes thought to underlie social cognition (emotion perception and theory of mind) in schizophrenia and autism. This is followed by a look at neuroimaging studies and their efforts to localize the neural correlates of emotion perception and theory of mind in the two disorders. We concluded that while a specific impairment in emotion perception and theory of mind skills cannot be generalized to all individuals with autism and schizophrenia, there are subpopulations that have lingering deficits of social cognition tasks. Neuroimaging work consistently points to the involvement of the fusiform gyrus and amygdala in emotion processing, while the medial prefrontal and frontal cortex are implicated in tasks invoking theory of mind. We propose that deficits of social cognition may benefit from cognitive remediation therapy and pharmacological cognitive enhancers.
Ziprasidone as an Augmenting Agent in the Treatment of Anxiety-Spectrum Disorders
Authors: Crane Daniel L.
Published: August 2016

Anxiety disorders are currently one of the most common health concerns in the United States. Overall, they are the single largest cost to the healthcare system. They are also underdiagnosed and undertreated. Selective serotonin reuptake inhibitors and benzodiazepines appear to be the most common pharmacologic treatment approaches. Unfortunately, not all patients respond to these treatments. Many augmentation strategies have been tried in the past with varying levels of success or safety. This article describes a safe and highly effective augmentation technique in patients suffering from some of the most serious and debilitating forms of anxiety disorders, namely obsessive-compulsive disorder and panic disorder.
Hypercoagulable States and Stroke: A Selective Review
Authors: Levine Steven R.
Published: August 2016

Blood disorders have been implicated in ~5% to 10% of ischemic stroke, with an increased frequency in younger patients. Most disorders are associated with an increased thrombotic tendency and, therefore, an increased risk of ischemic stroke. Less commonly, a bleeding diathesis may predispose a patient to intracranial hemorrhage. While many conditions predisposing to thrombosis have been associated with stroke, there are relatively few prospective, epidemiological studies addressing hypercoagulable states and arterial stroke compared with the number of studies on the genetic thrombophilias, which are predominantly associated with venous thrombosis. When ordering tests of coagulation in stroke patients, one should keep in mind whether the results will influence therapy and/or patient outcome. It is generally not advocated to screen all stroke patients for a “hypercoagulable workup”. Typically, patients to be screened for coagulation defects will have a prior history of one or more unexplained thromboembolic events. The yield for diagnosing a hypercoagulable state is typically greatest for young stroke patients or those with a family history of thrombosis and who have no other explanations for their stroke (cryptogenic stroke). The yield in typically low in unselected ischemic stroke patients and older patients. Treatment of a first stroke with a documented hypercoagulable state is typically long-term or indefinite duration warfarin, although there is a paucity of clinical trial data supporting this clinical approach.
Empathy: At the Heart of the Mind
Authors: Stein Dan J.
Published: August 2016

Evelyn is a 35-year-old woman who presented to a psychiatrist with complaints of marriage difficulties. As she described some of these difficulties, she leaned forward, and her psychiatrist responded by changing her body posture and unfolding her arms. Evelyn explained that she had been brought up to be stoic in the face of difficulties. When she described some of the family's early circumstances, her expression became sad and her psychiatrist responded by furrowing her brow. Evelyn's parents had encouraged the kids to be self-reliant and independent; problems were not complained about, they were simply dealt with. At present, however, her situation felt overwhelming. She felt embarrassed to have to talk with a stranger about her marriage. Her psychiatrist reflected back, saying that her early family had obviously given her many strengths, and that it must be difficult to have to ask for help. At that point in the conversation, Evelyn's eyes misted over with tears.
A Neuropsychiatrist's Perspective on Selected Dermatoses
Authors: Chemali Zeina N. , Touma Dany J.
Published: August 2016

Many neuropsychiatric diseases present with concomitant dermatologic manifestations. These manifestations may help the clinician formulate a correct diagnosis when it is otherwise unclear. In this article, we present six cases with clinical photographs of associated skin findings discussed from a neuropsychiatrist's perspective. Each case will be followed by a discussion and a brief review of the associated neuropsychiatric and dermatologic aspects of the disease.
Generalized Anxiety Disorder: Rethinking Diagnosis and Rating
Authors: Stein Dan J.
Published: August 2016

Faye is a 44-year-old woman who presented complaining of tension. She felt tense in her muscles, her whole body felt “on edge,” and she was unable to relax or to fall asleep easily. The tension was not only physical but also mental, she experienced anxiety on and off throughout the day, had multiple worries, and often felt irritable. Ever since she could remember, she had been somewhat highly strung, but in her thirties she took a more stressful job, and there were often times when the physical symptoms became more intense and even interfered with her work function. During these periods of increased anxiety, she resorted to using benzodiazepine tablets prescribed by her primary care physician for poor sleep.
Brain Stimulation Techniques in the Treatment of Obsessive-Compulsive Disorder: Current and Future Directions
Authors: Dell'Osso Bernardo , Altamura Alfredo Carlo , Allen Andrea , Hollander Eric
Published: August 2016

Recent studies on the epidemiology of obsessive-compulsive disorder (OCD) estimate 50 million patients suffer from OCD worldwide, thus making it a global problem. The treatment of OCD has changed substantially over the last 2 decades following the introduction of selective serotonin reuptake inhibitors, which provide symptom improvement in ~60% of patients. However, some patients remain resistant to the standard pharmacologic and behavioral treatments. Although some treatment-resistant patients respond to pharmacologic augmentations, others do not, and there is evidence that some of the most severe cases benefit from treatment with neurosurgical interventions. Besides pharmacologic, behavioral, and neurosurgical approaches, different brain stimulation methods—transcranial magnetic stimulation, deep brain stimulation, and electroconvulsive therapy—have been investigated in treatment-resistant patients with OCD. However, available data about the use of these techniques in OCD treatment are quite limited in terms of sample size and study design, given the difficulty in conducting standard blinded trials for these procedures. In addition, none of the mentioned treatments have received Food and Drug Administration approval for the treatment of OCD. Nevertheless, promising findings regarding efficacy, tolerability, and non-invasiveness and/or reversibility of these techniques have increased interest in investigating their use in treatment-resistant OCD.
Imitators of Epilepsy
Authors: Fisher Robert S.
Published: August 2016

Epilepsy is common, but conditions that imitate epilepsy are even more common. In order to make a correct diagnosis of epilepsy, the clinician must carefully elicit a detailed history of the seizure episode. Realizing the overlap that exists between seizures that define epilepsy and those of other psychiatric conditions can also help in differentiating between epilepsy and an imitator of epilepsy. Deciphering the features of a seizure episode is also key to correct diagnosis.

In this article, the physiological and psychological imitators of epilepsy are described, as well as the features of a seizure episode that should be considered in making a diagnosis. Seizure presentations are also explained followed by a description of common diagnostic pitfalls to avoid.
Neuroimaging in Temporal Lobe Epilepsy
Authors: Muro Gerard J. , Karis John P.
Published: August 2016

Various neuroimaging modalities are available for evaluating patients with temporal lobe epilepsy (TLE). All patients considering surgery should undergo magnetic resonance imaging, which is valuable in the detection and characterization of lesions, particularly mesial temporal sclerosis, the most common abnormality in TLE. A localized seizure focus is predictive of successful surgical outcome. Complimentary neuroimaging studies include positron emission tomography, single-photon emission tomography, and proton magnetic resonance spectroscopy.
Augmentation of Antidepressant Pharmacotherapy: A Preclinical Approach Using the Mouse Forced Swimming Test
Authors: Redrobe John P. , Bourin Michel
Published: August 2016

Until recently, several weeks of treatment were required in order to obtain a clinically significant antidepressant response using pharmacotherapy. The present study, using the mouse forced swimming test, investigated possible antidepressant augmentation strategies, together with the probable mechanisms involved in such potentiations. It is clear from this and other similar studies that it is possible to enhance the activity of antidepressant drugs with the addition of other compounds (ie, clonidine, quinine, glyburide, pindolol, or buspirone). These data indicate that direct/indirect manipulation of serotonergic receptor systems potentiates the effect antidepressant drugs (ie, selective serotonergic reuptake inhibitors) in the mouse forced swimming test, and thus establish this model as a reliable preclinical tool for the investigation of possible antidepressant augmentation strategies. It also appears that this model can be used as a method for identifying the mechanisms involved in such treatment strategies.
Genetics of Bipolar Disorder
Authors: Pato Carlos N. , Kennedy James L. , Bauer Amy , Pato Michele T.
Published: August 2016

The growing number of reports on candidate genes an genomic regions of interest in bipolar disorder reveals a tremendously active field of study. As with other complex psychiatric syndromes, these early findings will require a great deal of effort to replicate and clarify. This review serves both as an update and an introduction to some of the issues confronting investigators. Potential strategies in study design, population selection, and molecular methods are explored as well.
Psychoanalytic Treatment of a Woman With Anxiety Attacks and Conversion
Authors: Goldstein David
Published: August 2016

This case study describes the psychoanalytic treatment of a young woman presenting with symptoms of overwhelming anxiety, panic, and conversion. The emphasis is on technique with detailed reporting on the psychoanalytic process. Attention is paid to transference-countertransference paradigms at critical junctures in the treatment. The role of clinical supervision in the unfolding of the process is described also. This patient developed an identifiable transference neurosis during the course of the treatment, which became the focus of the analysis. Follow-up observations on this patient are also presented, as she returned for a brief course of treatment 4 years following initial termination.
Neurobiology of Social Phobia
Authors: Bebchuk Joseph M. , Tancer Manuel E.
Published: August 2016

Social phobia is an anxiety disorder that is characterized by excessive fear and/or avoidance of situations in which an individual believes that he or she may be the subject of evaluation or scrutiny while interacting with other people or performing a specific task. This article reviews the available literature on the neurobiology underlying social phobia, including autonomic nervous system effects, neuroimaging findings, pharmacologic challenge studies, and neuroendocrine responsivity and function. Overall, such studies have found few consistently demonstrable differences in neurobiology between patients with social phobia and healthy controls, but further investigations are needed.
Theory-Driven Interventions in Psychoneuroimmunology and HIV-1 Infection
Authors: Tyll Mary D. , Goodkin Karl , Blaney Nancy T. , Baldewicz Teri T. , Hunt Jodi Dee , Asthana Deshratn
Published: August 2016

Psychoneuroimmunology (PNI) is a rapidly evolving multidisciplinary field founded on the premise that psychosocial factors, the central nervous system, and the immune system are intimately linked. Following publication of scientific evidence supporting this link, a number of animal and human studies have been published, both inside and outside the area of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome. These studies support the existence of bidirectional feedback mechanisms operating between the brain and the immune system. To date, however, there is no all-encompassing model that predicts individual differences in the relationship among psychosocial factors, immunologic measures, and clinical disease progression in HIV type 1 (HIV-1) infection. This variability in human response has been explained by a number of cofactors (host as well as environmental) that appear to accelerate the course of the disease.

Since psychosocial factors are highly amenable to behavioral interventions, several models for intervention research have been proposed to evaluate whether such interventions can enhance immune functioning, thereby curtailing disease progression. Examination of these interventions in the context of PNI and HIV-1 infection, however, is rather limited. Therefore, researchers and clinicians must not only consider conceptualizations and paradigms in this area of research, but also focus on empirically testable, theory-driven models that allow for the unique characteristics of individual patients.
Parkinson's Disease, Tourette Syndrome, and the Changing Nature of Depression: The Dog Days of Summer
Authors: Hollander Eric
Published: August 2016

Since the development of selective serotonin reuptake inhibitors there has been a widening of the definition of depression and a decrease in the placebo-drug difference in controlled studies. In the early 1960s, ~33% of depressed patients improved with placebo and 66% with active compounds and current controlled studies suggest that the situation has certainly not improved. The Sequenced Treatment Alternatives to Relieve Depression Study found that response rates to new compounds after the failure of the first antidepressant are low. The monoamine hypothesis of depression was formulated in the mid 1960s based on the antidepressant efficacy of the monoamine reuptake inhibitors, monoamine oxidase inhibitors and the depressogenic effects of reserpine as a monoamine depleter. However, no monoamine-related finding has been found that is diagnostic for depression. A second major hypothesis regarding depression has been the stress cortisol hypothesis. However, blood cortisol levels are not diagnostic of depression. Every psychiatric clinician is convinced that there are patients for whom antidepressants have made the difference between life and death. However, physicians may generalize unjustifiably based on single dramatic cases to a much larger diagnostic group. Perhaps there are many causes of different types of human sadness, and perhaps only some of these involve mechanisms related to monoamines. Thus, Robert H. Belmaker, MD, suggests that perhaps only some kinds of depression are responsive to monoamine affecting antidepressants.
Mixed Amphetamine Salts Extended Release for the Treatment of ADHD in Adolescents: Current Evidence
Authors: Spencer Thomas J.
Published: August 2016

Ongoing research on attention-deficit/hyperactivity disorder (ADHD) has yielded important new information that has impacted the clinical recognition and management of this disorder. ADHD has long been considered one of the most common psychiatric disorders initially diagnosed and treated in childhood. Contrary to the once widely held assumption that symptoms spontaneously resolved or abated, clinically significant symptoms for most patients persist into adolescence and adulthood. While hyperactivity appears to decrease with age, impaired attention and impulsivity persist into adolescence and are linked to clinically significant functional impairments in academic, social, and family settings.

Like their younger counterparts, adolescents with ADHD exhibit higher rates of comorbid psychiatric illness and concomitant mental health service use. Among the most common comorbid psychiatric disorders seen in adolescents with ADHD are major depression, anxiety disorders, conduct disorder, and oppositional defiant disorder (ODD). In young adults, a direct correlation has been revealed between ongoing ADHD symptom severity and lower levels of academic achievement, greater risk of illicit drug use, and drug-related crime. These findings highlight the potential importance of adequate ADHD symptom management in adolescence in predicting long-term outcomes; as a result, a lifespan approach toward ADHD is beginning to be adopted by many clinicians, and anti-ADHD medication (including psychostimulants) is being recommended for the management of ADHD in all age groups. However, most clinical research involving psychostimulants has been conducted in school-age children <12 years of age, and knowledge concerning the use of medications in adolescents with ADHD is limited. Questions about dosing, safety, level of efficacy to be expected, and optimal duration of treatment in adolescents with ADHD must be addressed. Clinical choice of therapy is also complicated by the fact that the anti-ADHD armamentarium continues to evolve, and now includes long-acting formulations of methylphenidate, mixed amphetamine salts, and nonstimulants.
Pharmacokinetics of Mixed Amphetamine Salts Extended Release in Adolescents With ADHD
Authors: Kramer William G. , Read Stephanie C. , Tran Bao-Van , Zhang Yuxin , Tulloch Simon J.
Published: August 2016

Objective

A randomized, open-label, single-dose, three-treatment, three-period, crossover, phase I study was conducted to assess the pharmacokinetics of mixed amphetamine salts extended release (MAS XR) in adolescents with attention-deficit/hyperactivity disorder (ADHD).

Methods

Two cohorts of healthy adolescents 13–17 years of age with ADHD were enrolled in the study. Seventeen subjects, weighing ≤75 kg (≤ 65 lbs), were randomized to one of three dosing sequence groups (a single oral dose of MAS XR 10, 20, or 40 mg, follwed by crossover to the alternate treatments, with a 7-day washout between treatments). Six additional subjects, weighing >75 kg (>165 lbs), were randomized simihrly but received larger doses of MAS XR (20, 40, and 60 mg). Blood samples were collected before and at hours 1–12 after drug administration, as well as before and at hours 14, 24,48, and 60.

Findings

Linear pharmacokinetics of dextroamphetamine (D-amphetamine) and loamphetamine (L-amphetamine) were observed with MAS XR in both cohorts. The pharmacokinetics of D-amphetamine and L-amphetamine did not differ between male and female adolescents. A significant decrease in maximum exposure (Cmax) and increase in half-life were seen for both isomers with increasing age, but overall exposure (AUC∞ was not affected. Cmax and AUC∞ for both isomers decreased as body weight increased.

Conclusion

Exposure to MAS XR was linear and directly proportional to the dose administered in 13–17-year-old adolescents with ADHD. The time course of drug absorption and elimination did not appear to be affected by dose at 10–40 mg in subjects weighing ≤75 kg, and at 20–60 mg in subjects weighing >75 kg. Gender did not affect the pharmacokinetics of MAS XR; age and body weight influenced the profile of certain pharmacokinetic variables.
Alzheimer's Disease Pathways to Practice: Assessing Diagnosis and Outcome Measures
Authors: Grossberg George T.
Published: August 2016

Alzheimer's disease is the most common form of dementing illness, affecting nearly 4.5 million Americans according to current estimates. The disease exhibits a strong association with old age, and is not commonly observed in individuals <65 years of age. Among individuals >65 years of age, the prevalence of Alzheimer's disease is ∼10%, and nearly half of all persons >85 years of age are affected by this condition. Given the apparent link between Alzheimer's risk and increasing age, as well as expected changes in the demographic structure of the United States population, it has been projected that the number of Americans with Alzheimer's disease will reach unprecedented levels in the coming years. In fact, it has been predicted that, barring the development of novel preventive therapies, the number of US residents with Alzheimer's will increase to 11–16 million by the year 2050.

The expected rise in the number of Alzheimer's disease cases represents a daunting challenge, due to the far-reaching negative impact of the disease. Alzheimer's disease is a condition that not only has profound effects on the affected patient but also takes a dramatic toll on the patient's primary caregiver, who is in many cases the spouse or an adult child of the patient. Patients with Alzheimer's experience cognitive and functional declines, often in association with behavioral disturbances, while caregivers frequently suffer reductions in quality of life attributable to the immense emotional, physical, and financial burdens associated with the task of providing care.
“Mirror, Mirror…” Whose Explanation is the Fairest? Evolving Notions of Somatization and Idiopathic Physical Symptoms
Authors: Engel Charles C.
Published: August 2016

Somatization disorder, multiple chemical sensitivities, chronic fatigue syndrome, fibromyalgia, Gulf War syndrome, neurasthenia, irritable bowel syndrome, conversion disorder…idiopathies one and all. These syndromes and the many others like them have perhaps one overriding commonality: enormous unexplained heterogeneity. Patients and clinicians gaze into the suffering and impact of these symptoms and see as many potential causes as there are symptom combinations.

Whose explanation is best? When I am speaking with psychiatrists, the notion of somatoform symptoms goes largely unchallenged. When I am with rheumatologists, however, fibromyalgia is anything but a psychiatric problem and certainly not a somatoform disorder. Among my toxicologist colleagues, it is readily accepted that low-tevel toxic exposures could account for many idiopathic “sensitivities.”

But what of the high rate of depression and anxiety disorders we see in these patients?” I sometimes unwisely retort.

“Well, it could be a co-factor or an interaction,” is a common response.

Unshaken, I step further into the abyss: “How, then, do you explain the high rate of adverse childhood experiences among people with idiopathic symptom syndromes?”

The response is swift. “You cannot rule out biased recall. We cannot expect people to remember these things accurately in such a negative state of mind.”

And so it goes. After several of these kinds of conversations, I have finally concluded there is no point in arguing.The debate is largely irreconcilable, a debate that strikingly parallels the conflicts many primary care physicians experience with symptomatic patients. “How is your personal life?” the doctor may ask a symptomatic patient, suspecting a psychosocial explanation.
Application of The APA Practice Guidelines on Suicide to Clinical Practice
Authors: Jacobs Douglas G. , Brewer Margaret L.
Published: August 2016

This article presents charts from The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, part of the Practice Guidelines for the Treatment of Psychiatric Disorders Compendium, and a summary of the assessment information in a format that can be used in routine clinical practice. Four steps in the assessment process are presented: the use of a thorough psychiatric examination to obtain information about the patient's current presentation, history, diagnosis, and to recognize suicide risk factors therein; the necessity of asking very specific questions about suicidal ideation, intent, plans, and attempts; the process of making an estimation of the patient's level of suicide risk is explained; and the use of modifiable risk and protective factors as the basis for treatment planning is demonstrated. Case reports are used to clarify use of each step in this process.
Healthcare Resource Utilization in Bipolar Depression Compared with Unipolar Depression: Results of a United States Population-Based Study
Authors: Frye Mark A. , Calabrese Joseph R. , Reed Michael L. , Hirschfeld Robert M.A.
Published: August 2016

Introduction:

This study examined healthcare utilization in the past year by subjects who screened positive for bipolar versus unipolar depression.

Method:

A self-administered survey was completed in 2002 by a United States population-based sample. Respondents were categorized into one of three subgroups: bipolar depressed screen positive (BP DEP+, n=394); unipolar depressed screen positive (UP DEP+, n=794); and control subjects (n=1,612).

Results:

For depressive symptoms in the past year, BP DEP+ respondents were significantly more likely than UP DEP+ respondents to report a healthcare visit to a number of diverse care providers. In analyses controlled for demographics and depression severity, the differences in psychiatric hospitalization, psychologist/counselor outpatient visit, substance abuse/social services visit, and number of emergency room visits remained significant between BP DEP+ and UP DEP+ respondents.

Conclusion:

Subjects with self-reported bipolar depression sought care more often from a number of diverse healthcare resources than subjects with self-reported unipolar depression. These findings underscore the morbidity associated with bipolar depression.
Potential Markers for Problematic Internet Use: A Telephone Survey of 2,513 Adults
Authors: Aboujaoude Elias , Koran Lorrin M. , Gamel Nona , Large Michael D. , Serpe Richard T.
Published: August 2016

Objective:

The Internet has positively altered many aspects of life. However, for a subset of users, the medium may have become a consuming problem that exhibits features of impulse control disorders recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Method:

This is the first large-scale epidemiological study of problematic Internet use through a random-digit-dial telephone survey of 2,513 adults in the United States. Given the lack of validated criteria, survey questions were extrapolated from established diagnostic criteria for impulse control disorders, obsessivecompulsive disorder, and substance abuse. Four possible diagnostic criteria sets were generated.The least restrictive set required the respondent to report an unsuccessful effort to reduce Internet use or a history of remaining online longer than intended, Internet use interfering with relationships, and a preoccupation with Internet use when offline.

Results:

The response rate was 56.3%. Interviews averaged 11.3 minutes in duration. From 3.7% to 13% of respondents endorsed ≥1 markers consistent with problematic Internet use. The least restrictive proposed diagnostic criteria set yielded a prevalence of problematic Internet use of 0.7%.

Conclusion:

Potential markers of problematic Internet use seem present in a sizeable proportion of adults. Future studies should delineate whether problematic Internet use constitutes a pathological behavior that meets criteria for an independent disorder, or represents a symptom of other psychopathologies.
Impulsive-Compulsive Sexual Behavior
Authors: Mick Thomas M. , Hollander Eric
Published: August 2016

Impulsive-compulsive sexual behavior is a little studied clinical phenomenon which affects ~5% to 6% of the population. In theDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision, it is classified as an impulse control disorder not otherwise specified or a sexual disorder not otherwise specified. It may be placed in a possible new category in theDiagnostic and Statistical Manual of Mental Disorders, Fifth Editioncalled substance and behavioral addictions.This clinical entity is reviewed and the merit of classifying it as an addiction is assessed. Information is presented regarding its diagnostic criteria, epidemiology, types of behavior it can involve, relationship to hypersexuality, comorbidities, treatment, and etiology. The data regarding this disorder and its overlap with chemical addiction is limited. If the two disorders are to be grouped together, further data are needed.
Long-Term Treatment of Patients with Recurrent Unipolar Major Depression: Evidence to Clinical Practice
Authors: Keller Martin B.
Published: August 2016

Major depressive disorder (MDD) is almost exclusively recurrent. The vast majority of patients who experience one episode of MDD will eventually experience at least one more episode during their lifetime. The recurrent nature of MDD increases the burden to both the individual and society. Hence, it is imperative that treatment strategies focus on achieving remission acutely, as well as maintaining of remission and preventing recurrence. The articles in this supplement are based on presentations and a dialogue among a group of experts who convened for a roundtable discussion on improving long-term outcomes with antidepressant therapy.

Improving long-term treatment of MDD begins with understanding the clinical course of recurrent depression and the ability to recognize those patients who are at greatest risk for recurrence. James H. Kocsis, MD, reviews the course of recurrent depression, emphasizing the tendency for it to progressively worsen. He also discusses patient characteristics and other risk factors for recurrence as well as current recommendations for long-term management of recurrent depression.

Although long-term antidepressant maintenance treatment studies are somewhat limited in number, they provide the evidence base that shapes existing guidelines for long-term management of recurrent depression. Michael E. Thase, MD, examines this evidence for the different classes of antidepressants. In addition, Thase reviews evidence for the efficacy of psychotherapy and discusses its potentially important role in long-term depression management.
Aripiprazole in Juvenile Bipolar Disorder Comorbid with Attention-Deficit/Hyperactivity Disorder:An Open Clinical Trial
Authors: Tramontina Silzá , Zeni Cristian Patrick , Pheula Gabriel Ferreira , de Souza Carla Ketzer , Rohde Luis Augusto
Published: August 2016

Introduction

Juvenile bipolar disorder (JBD) is a highly impairing chronic mental health condition that affects children and adolescents' overall functioning. Comorbidity with attention-deficit/hyperactivity disorder (ADHD) is extremely prevalent and may determine worse response to treatment. Few investigations have addressed the use of recent atypical antipsychotics in JBD, although several guidelines suggest their use.

Methods

We conducted a 6-week open trial with aripiprazole in 10 children and adolescents with JBD comorbid with ADHD to assess impact on mania and ADHD symptoms, respectively, by means of the Young Mania Rating Scale and the Swanson, Nolan and Pelham Scale, as well as on global functioning (Clinical Global Impressions–Severity), and adverse events.

Results

Significant improvement in global functioning scores (F=3.17,P=.01, effect size=0.55), manic symptoms (F=5.63,P<.01; ES=0.93), and ADHD symptoms (t=3.42,P<.01; ES=1.05) were detected. Although an overall positive tolerability was reported, significant weight gain (F=3.07,P=.05) was observed.

Conclusion

Aripiprazole was effective in improving mania and ADHD symptoms, but neither JBD nor ADHD symptom remission was observed in most of the cases. Randomized placebo-controlled trials for JBD and ADHD are needed.
Quetiapine for Mania Due to Traumatic Brain Injury
Authors: Oster Timothy J. , Anderson C. Alan , Filley Christopher M. , Wortzel Hal S. , Arciniegas David B.
Published: August 2016

Secondary mania develops in as many as 9% of persons with traumatic brain injuries.The treatment of posttraumatic mania is not well defined, and agents traditionally used for the treatment of idiopathic manic episodes may not be well suited for use among individuals with traumatic brain injuries. Atypical antipsychotics are indicated for the treatment of idiopathic bipolar disorder, and have been used for other purposes among individuals with posttraumatic neuropsychiatric disturbances. This article offers the first description of the treatment of posttraumatic mania using the atypical antipsychotic quetiapine. Beneficial effects of this agent on posttraumatic mania, cognitive impairments, and functional disability in the subacute post-injury period are described. Possible mechanisms of action are discussed and the need for additional investigation of quetiapine for posttraumatic mania is highlighted.
Social Anxiety Disorder: Psychobiological and Evolutionary Underpinnings
Authors: Stein Dan J. , Vythilingum Bavanisha
Published: August 2016

Social anxiety disorder (SAD) also know as social phobia is increasingly recognized as a highly prevalent and disabling psychiatric disorder. SAD patients demonstrate cognitive-affective distortions in relation to social situations and abnormal activation patterns in limbic structures during functional imaging. Behavioral inhibition is an endophenotype that may be useful in understanding vulnerability to SAD, and that has specific imaging and genetic correlates. From an evolutionary perspective, it has been speculated that SAD represents a false appeasement alarm. It is notable that SAD responds to selective serotonin reuptake inhibitors and monoamine oxidase inhibitors, but not to most tricyclic antidepressants; this finding is consistent with the importance of serotonin and dopamine in mediating this disorder.
The Ventral Striatum as an Interface Between the Limbic and Motor Systems
Authors: Groenewegen Henk J. , Trimble Michael
Published: August 2016

Over the next 2 years,CNS Spectrumswill be publishing a series of articles on neuroanatomy. The purpose of these articles is to broaden knowledge and interest in neuroanatomy, with a special reference to some key brain structures that are important for neuropsychiatry. Interest in nuclear structures and hodology, in connectivity and circuitry between brain regions, and in neurochemical associations has increased in the last 3 decades due to new neuroanatomical staining methods, brain imaging, and new treatments, such as deep brain stimulation.These columns will enliven an understanding of the clinical neuroscience interface but also provide a solid framework of contemporary neuroanatomy for psychiatrists and neurologists.

The first in the series reviews the ventral striatum. Henk J. Groenewegen, MD, PhD, in a column dedicated to the late Lennart Heimer, MD, reveals the importance of this structure and its connectivity for a contemporary understanding of brain-behavior relationships. In earlier conceptions, the basal ganglia were solely related to motor function, uninvolved with emotion or cognition. This conception arose from a misunderstanding of basic neuroanatomy, which has been unravelled by careful neuroanatomical studies in the last 30 years with new tissue staining and tracing techniques.The basal ganglia are the main target structures of the limbic system, hence the motion in emotion.
Case Studies in Bipolar Depression: Best Practices for the Outpatient
Authors: Keck Paul E. , McIntyre Roger S. , Shelton Richard C.
Published: August 2016

Clinicians are fairly comfortable with the management of acute mania because of the abundance of research studies available. However, there are several important aspects of bipolar disorder that the field has been far less successful with, including management of acute and preventive treatment of bipolar depression, comorbid illnesses, and break-through depression in the context of long-term treatment. There is tremendous complexity in the various symptoms and behavioral dimensions associated with bipolar depression. To facilitate understanding of bipolar depression, this article focuses on treating and managing the bipolar outpatient at risk for a depressive relapse. The discussion poses several challenges associated with bipolar depression and addresses the morbidity of depressive states as well as acute and long-term management of this disorder. The best practices for the varying clinical states of bipolar depressive disorder will be demonstrated through two case examples of patients struggling with disturbances common in bipolar patients.
Acute and Long-Term Adverse Effects of Antipsychotics
Authors: Correll Christoph U.
Published: August 2016

Antipsychotics have become the cornerstone of management for many severe mental disorders. Primarily developed for the treatment of schizophrenia, several antipsychotics have been indicated for bipolar mania, bipolar depression, and irritability associated with autistic disorder. Antipsychotics are also used off label for psychotic or refractory depression; refractory anxiety disorders; and conditions associated with agitated or aggressive behaviors. Due to the severity and chronicity of severe mental disorders, the broad range of potential treatment targets, and the relative ease of use of second-generation antipsychotics (SGAs), which are associated with a lower risk of extrapyramidal symptoms (EPS) and tardive dyskinesia (TD), prescribing rates have increased considerably over the last decade. With increased utilization of these medications comes a greater responsibility to appropriately recognize, monitor, and manage side-effect clusters that can adversely affect physical and mental outcomes.
An Open-Label Trial of Venlafaxine in Body Dysmorphic Disorder
Authors: Allen Andrea , Hadley Sallie Jo , Kaplan Alicia , Simeon Daphne , Friedberg Jennifer , Priday Lauren , Baker Bryann R. , Greenberg Jennifer L. , Hollander Eric
Published: August 2016

Objective:

Body dysmorphic disorder (BDD), a preoccupation with imagined ugliness, is a disabling condition that seems to respond preferentially to selective serotonin reuptake inhibitors. This open-label trial examines venlafaxine's efficacy in BDD and is the first known study of this serotonin-norepinephrine reuptake inhibitor in BDD.

Methods:

A total of 17 BDD patients 16–65 years of age entered and 11 completed a 12–16 week open-label trial of venlafaxine. Participants were treated with venlafaxine until a therapeutic dose (minimum of 150 mg/day) was reached and then maintained at that dose for 8 weeks. Key outcome measures were the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder and Clinical Global Impressions-Improvement scale.

Results:

Venlafaxine was found to be effective in lessening the specific symptoms and global severity of BDD. Paired t-tests were used to compare baseline and final ratings on the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder total, obsessions, and compulsions scores; by this measure venlafaxine significantly reduced BDD symptoms overall (P=.012), as well as obsessions (P=.034) and compulsions specifically (P=.021). A single sample t-test, comparing final Clinical Global Impressions-Improvement scale ratings to “no change” (score: 4) found significant improvement following treatment.

Conclusion:

Venlafaxine may be an effective treatment for BDD, including both obsessive and compulsive symptoms. Controlled research on venlafaxine in BDD is recommended.
The Lateral Habenula:No Longer Neglected
Authors: Geisler Stefanie , Trimble Michael
Published: August 2016

In this contribution to theCNS Spectrumsneuroanatomy series, Stefanie Geisler, MD, discusses the lateral habenula (LHb). This nuclear complex is one of the areas of the brain that forms part of the cross-talk between limbic fore-brain and some important ascending modulatory pathways. Situated at the caudal end of the dorsal diencephalon and classically regarded as projecting largely to the brainstem, including the serotoninergic raphe nuclei, the LHb receives afferents from widespread forebrain areas. Therefore, the LHb is able to influence serotonin tone in the brain, and has long interested neuroanatomists as a potential limbic-motor interface. Nonetheless, the LHb was not much discussed outside neuroanatomical circles until recently, when it was discovered that its impact on the mesotelencephalic dopamine system is probably much greater than had been assumed. The LHb has become a hot topic. This article-addresses these developments and emphasizes the clinical relevance of this interesting brain structure.
Aripiprazole as Augmentation Treatment of Refractory Generalized Anxiety Disorder and Panic Disorder
Authors: Hoge Elizabeth A. , Worthington John J. , Kaufman Rebecca E. , Delong Hannah R. , Pollack Mark H. , Simon Naomi M.
Published: August 2016

Introduction:

Individuals with anxiety disorders often remain symptomatic despite treatment with a first-line pharmacologic agent. More research examining pharmacotherapy augmentation strategies to improve outcomes is needed.

Methods:

In an 8-week, open-label, prospective augmentation study, we examined the efficacy and tolerability of the novel antipsychotic agent aripiprazole for adult outpatients with generalized anxiety disorder (n=13) or panic disorder (n=10) who remained symptomatic despite treatment for at least 8 weeks with an adequate (or maximally tolerated) dose of typical pharmacotherapy.

Results:

Aripiprazole augmentation was associated with a significant reduction in Clinical Global Impressions-Severity scores (paired t=4.41, df=22, P<.001) in the intent-to-treat sample of 23 individuals. Three subjects (13%) discontinued due to sedation, chest discomfort, and restlessness, respectively.

Conclusion:

These data provide preliminary evidence that aripiprazole may be a useful augmentation strategy for individuals with generalized anxiety disorder or panic disorder who show a limited response to initial pharmacotherapy.
A Psychodynamic Understanding of Conversion Nonepileptic Seizures in a Young Woman with Acquired Blindness
Authors: Soffer Jocelyn , Alper Kenneth R. , Basch Samuel
Published: August 2016

Ms. G is a 19-year-old African-American female with acquired blindness and a seizure disorder following a ruptured cerebral arteriovenous malformation (AVM) in 2001. She currently lives with her mother, brother, and dog, and attends 10th grade in special education at a public high school.