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biIntroduction:/i/bTo examine the effects of coronavirus disease 2019 (COVID-19) on patients in an academic psychiatric ambulatory clinic, data from a measurement-based care (MBC) system were analyzed to evaluate impacts on psychiatric functioning in patients using telemedicine. Psychiatric functioning was evaluated for psychological distress (brief adjustment scale [BASE]-6), depression (patient health questionnaire [PHQ]-9), and anxiety (generalized anxiety disorder [GAD]-7), including initial alcohol (U.S. alcohol use disorders identification test) and substance use (drug abuse screening test-10) screening.biMethods:/i/bThis observational study included MBC data collected from November 2019 to March 2021. Patient-Reported Outcome Measures (PROMs) were examined to determine changes in symptomatology over the course of treatment, as well as symptom changes resulting from the pandemic. Patients were included in analyses if they completed at least one PROM in the MBC system.biResults:/i/bA total of 2,145 patients actively participated in the MBC system completing at least one PROM, with engagement ranging from 35.07% to 83.50% depending on demographic factors, where completion rates were significantly different for age, payor status, and diagnostic group. Average baseline scores for new patients varied for the GAD-7, PHQ-9, and BASE-6. Within-person improvements in mental health before and after the pandemic were statistically significant for anxiety, depression, and psychological adjustment.biDiscussion:/i/bMBC is a helpful tool in determining treatment progress for patients engaging in telemedicine. This study showed that patients who engaged in psychiatric services incorporating PROMs had improvements in mental health during the COVID-19 pandemic. Additional research is needed exploring whether PROMs might serve as a protective or facilitative factor for those with mental illness during a crisis when in-person visits are not possible.

Background Measurement-Based Care (MBC) is an evidence-based practice shown to enhance patient care. Despite being efficacious, MBC is not commonly used in practice. While barriers and facilitators of MBC implementation have been described in the literature, the type of clinicians and populations studied vary widely, even within the same practice setting. The current study aims to improve MBC implementation in adult ambulatory psychiatry by conducting focus group interviews while utilizing a novel virtual brainwriting premortem method. Methods Semi-structured focus group interviews were conducted with clinicians (n = 18) and staff (n = 7) to identify their current attitudes, facilitators, and barriers of MBC implementation in their healthcare setting. Virtual video-conferencing software was used to conduct focus groups, and based on transcribed verbatin, emergent barriers/facilitators and four themes were identified. Mixed methods approach was utilized for this study. Specifically, qualitative data was aggregated and re-coded separately by three doctoral-level coders. Quantitative analyses were conducted from a follow-up questionnaire surveying clinician attitudes and satisfaction with MBC. Results The clinician and staff focus groups resulted in 291 and 91 unique codes, respectively. While clinicians identified a similar number of barriers (40.9%) and facilitators (44.3%), staff identified more barriers (67%) than facilitators (24.7%) for MBC. Four themes emerged from the analysis; (1) a description of current status/neutral opinion on MBC; (2) positive themes that include benefits of MBC, facilitators, enablers, or reasons on why they conduct MBC in their practice, (3) negative themes that include barriers or issues that hinder them from incorporating MBC into their practice, and (4) requests and suggestions for future MBC implementation. Both participant groups raised more negative themes highlighting critical challenges to MBC implementation than positive themes. The follow-up questionnaire regarding MBC attitudes showed the areas that clinicians emphasized the most and the least in their clinical practice. Conclusion The virtual brainwriting premortem focus groups provided critical information on the shortcomings and strengths of MBC in adult ambulatory psychiatry. Our findings underscore implementation challenges in healthcare settings and provide insight for both research and clinical practice in mental health fields. The barriers and facilitators identified in this study can inform future training to increase sustainability and better integrate MBC with positive downstream outcomes in patient care.

Schizoaffective disorder is categorized by major mood episodes and symptoms of schizophrenia that include disorganized speech, delusions, paranoia, and hallucinations. It is associated with risk factors, including a history of abuse and cannabis use, and patients are typically diagnosed in adolescence and young adulthood. In this case report, we describe the unusual case of a 39-year-old male patient with undiagnosed schizoaffective disorder who self-eviscerated his intestines during an episode of psychosis. He received an emergent exploratory laparotomy with a partial colectomy. After medical stabilization and reorientation, the patient recalled a 10-year history of paranoia associated with significant cannabis use, despite otherwise functioning appropriately in society. During a two-week hospital course, his paranoia and hallucinations were remitted on olanzapine and valproic acid. In addition to discussing his presentation and recollection of the incident, we also discuss similar cases of self-mutilation in nonsuicidal patients and the relationship between cannabis use and schizophrenia spectrum disorders. Published version

Objective To systematically review the available literature on the pharmacological management of agitation and/or aggression in patients with traumatic brain injury (TBI), synthesize the available data, and provide guidelines. Design Systematic review of systematic reviews. Main measures A literature review of the following websites was performed looking for systematic reviews on the treatment of agitation and/or aggression among patients with TBI: PubMed, CINAHL, DynaMed, Health Business Elite, and EBSCO (Psychology and behavioral sciences collection). Two researchers independently assessed articles for meeting inclusion/exclusion criteria. Data were extracted on year of publication, reviewed databases, dates of coverage, search limitations, pharmacological agents of interest, and a list of all controlled studies included. The included controlled studies were then examined to determine potential reasons for any difference in recommendations. Results The literature review led to 187 citations and 67 unique publications after removing the duplicates. Following review of the title/abstracts and full texts, a total of 11 systematic reviews were included. The systematic reviews evaluated the evidence for safety and efficacy of the following medications: amantadine, amphetamines, methylphenidate, antiepileptics, atypical and typical antipsychotics, benzodiazepines, β-blockers, and sertraline. Conclusions On the basis of the results of this literature review, the authors recommend avoiding benzodiazepines and haloperidol for treating agitation and/or aggression in the context of TBI. Atypical antipsychotics (olanzapine in particular) can be considered as practical alternatives for the as-needed management of agitation and/or aggression in lieu of benzodiazepines and haloperidol. Amantadine, β-blockers (propranolol and pindolol), antiepileptics, and methylphenidate can be considered for scheduled treatment of agitation and/or aggression in patients with TBI.

Global studies show patient suicides among psychiatrists, including trainees, range from 33 to 80%. To our knowledge, there is no such data in the United States following a single study in 1988 regarding psychiatrists’ or resident trainees’ emotional response to patient suicide. The objective of our study was to assess the stress- and trauma-related symptoms following patient suicide in practicing psychiatrists and trainees. Data were collected by sending an online version of the survey to randomly selected psychiatrists and residency programs throughout the United States. Program directors were requested to share the questionnaires with their residents and fellows in training. Participants’ stress was assessed by the impact of event scale–revised version (IES-R). Our study shows 324 (63.6%) of the participants experienced patient suicide, which included 292 psychiatrists (76.1%) and 31 trainees (27.2%). Among the respondents, 3.8% of the psychiatrists and 9.7% of the trainees had clinically significant stress- and trauma-related disorders. The presence of higher levels of emotional exhaustion and depression than medical or surgical colleagues depicts the need for training programs, formal and informal support, workshops, or curricular changes to address this almost inevitable issue in a psychiatrist’s career.

The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, incentive cost has often been cited as a barrier to delivering this type of treatment. In the present randomized parallel groups trial, we systematically replicated a previous trial we conducted that employed remote alcohol monitoring and incentive delivery to promote abstinence from alcohol, but with the additional requirement for participants to partially self-fund their abstinence incentives. Treatment-seeking participants with alcohol use disorder (n = 92) who met inclusion criteria (n = 36) were randomized to either a Contingent or Noncontingent group (n = 18 each). Those not meeting inclusion criteria included 15 participants who agreed to the deposit requirement but failed to make the deposit payment. The Contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The Noncontingent group received matched incentives each day they successfully provided samples independent of alcohol content. Days abstinent in the Contingent group were 86%, which was significantly higher than the 44% recorded in the Noncontingent group, corresponding to an odds ratio of 8.2. Exploratory analyses revealed that the deposit requirement prevented participation in those with lower incomes and those with greater alcohol use. These results support the efficacy of this remotely deliverable alcohol abstinence reinforcement incentive intervention with a deposit requirement. However, the requirement to provide a monetary deposit to self-fund abstinence incentives may prevent those with greater alcohol use and/or those experiencing extreme poverty from participating in the intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background: Deep brain stimulation (DBS) is a well-established neurosurgical procedure commonly used in movement and psychiatric disorders. Its widespread clinical implementation, however, may not be commensurate with medical education. No current assessment of medical student’s understanding of DBS as a treatment option for indicated conditions is available, potentially threatening the availability of DBS to future patients. The aim of the present study is to explore the current knowledge and attitudes of medical students toward DBS as a treatment modality. Methods: A total of 65 medical students at Virginia Tech Carilion School of Medicine were surveyed regarding their knowledge of DBS. The survey consisted of a 25-item questionnaire including a demographic section and 3 separate inventories designed to assess bias, knowledge, and self-assessment of knowledge specific to DBS therapy. Students in pre-clinical and clinical years were analyzed separately to describe changes in knowledge or attitude associated with clinical exposure to DBS. Comparisons were analyzed using t tests, ANOVA, and Pearson correlations. Results: Of surveyed students, 36% were unsure of the FDA approval status of DBS treatment; 65% of students believed they had not been adequately educated about DBS and its utility; and 10.6% of students believed that DBS is likely associated with severe adverse effects and/or brain damage. The overall baseline attitudes of students toward DBS were positive. There was no observed difference between surveyed pre-clinical and clinical students, highlighting a lack of exposure throughout the clinical years of medical school education. Conclusion: Although DBS is an effective treatment modality for various conditions, current education is non-commensurate with its application, which can negatively impact awareness and understanding for its implications by medical professionals. In order to better serve patients who may benefit from DBS, medical curricula must change to educate future physicians on the benefit of this intervention.

B ackground: The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, technological barriers to accurate, frequent biochemical verification of alcohol abstinence have limited the dissemination of this technique. Methods: In the present randomized parallel trial, we employed a breathalyzer that allows remote, user-verified collection of a breath alcohol sample, text messaging, and reloadable debit cards for remote delivery of incentives to evaluate a contingency management treatment for alcohol use disorder that can be delivered with no in-person contact. Treatment-seeking participants with alcohol use disorder (n = 40) were recruited from the community and randomized to either a contingent or a noncontingent group (n = 20 each). The contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The noncontingent group received matched monetary payments each day they successfully provided samples independent of alcohol content. Groups were not masked as awareness of group contingencies was an essential intervention component. Results: The primary outcome of the intent-to-treat analyses (analyzed n = 40) was percent days abstinent as measured by the remote breathalyzer samples. Abstinence rates in the contingent group were 85%, which was significantly higher than the 38% recorded in the noncontingent group, corresponding to an odds ratio of 9.4 (95% CI = 4.0 to 22.2). Breathalyzer collection adherence rates were over 95%, and participant ratings of acceptability were also high. Conclusions: These results support the efficacy, acceptability, and feasibility of this remotely deliverable abstinence reinforcement incentive intervention for the initiation and near-term maintenance of abstinence from alcohol in adults with alcohol use disorder. Due to low provider and participant burden, this procedure has the potential for broad dissemination. National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health [R21 AA022727] Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under award number R21 AA022727 to MNK. 100% of this research was supported by federal money with no financial or nonfinancial support from nongovernmental sources. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding source did not have a role in writing this manuscript or in the decision to submit it for publication. All authors had full access to the data in this study, and the corresponding author had final responsibility for the decision to submit these data for publication.

Obsessive-compulsive disorder (OCD), a relatively common psychiatric illness, is diagnosed using DSM-V criteria. Its severity is assessed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Symptoms are broken down into five categories of obsessive-compulsive (O-C) manifestations: contamination/cleaning, symmetry/ordering, taboo thoughts, doubt about harm/checking, and worry about throwing away items that could prove useful or valuable/hoarding. CBT in the form of exposure response therapy (ERP) and/or SSRI/clomipramine administration is the mainstay of treatment. We present a unique OCD case in the nature of obsessions and compulsions, cachexia presentation without anorexia, and history of multiple inpatient psychiatric admissions. Our patient’s obsessions focus on eating at specific times, prompting compulsive eating patterns that often result in starvation due to missing timeframes that the patient deems acceptable for eating. His resulting cachexia and eventual worsening of depression to the point of suicidality necessitated multiple inpatient stays and placement at a long-term mental health care facility.

This study presents a mixed-methods evaluation of the first 12 years of the Association for Academic Psychiatry (AAP) Master Educator (ME) program, developed in 2003 to help academic psychiatrists hone their skills as educators. Participants attend two 3-h workshops at the annual meeting, organized in 3-year cycles, for a total of 18 h. Core topics include assessment, curriculum design, and program evaluation. Overall session rating scores from 2003 to 2014 were analyzed using descriptive statistics. A 20-question survey was sent to 58 program graduates in October 2014, exploring participant perspectives on the impact of the ME program on their careers and on the educational programs they were affiliated with. Survey responses were analyzed quantitatively (for multiple choice questions) and qualitatively (for open-ended questions). The mean overall session scores ranged between 4.1 and 4.9 (on a Likert-type scale of 1–5) for each 3-year cycle. Twenty-nine graduates completed the survey (50 % response rate). Survey responses indicated a positive perception of the impact of the ME program on participants’ careers. Most respondents noted improvement in their teaching methods and curriculum development skills and being able to link educational theory with their individual practices. There was a significant increase in perceived confidence, leadership, and further contributions to their educational milieu. Fifteen (52 %) participants also reported generative behaviors that directly impacted others, such as developing new programs, enhancing existing programs at their institutions, or contributing to national educational efforts. The AAP ME program has demonstrated significant benefit over its 12 years of existence. This program represents one strategy to sustain and grow an international community of like-minded educators working to develop their own and future generations’ skills in providing high-quality education in psychiatry.

Catatonia is a psychomotor syndrome with poorly understood pathophysiology that frequently occurs concurrently with acute psychiatric and medical illnesses. Its prevalence among psychiatric inpatients has been reported to be as high as 38% and is primarily observed in those with mood disorders. Diagnosis requires the presence of at least three of the following signs: mutism, negativism, immobility, agitation, waxy flexibility, catalepsy, posturing, grimacing, stereotypies, mannerisms, echopraxia, and echolalia. Although the most commonly observed signs are immobility and mutism, the presentation of catatonia is often highly variable and shares significant overlap with other neurological conditions. Consequently, diagnosing this complex clinical syndrome remains a challenge. Here, we present a case of catatonia initially unrecognized in a patient with major depressive disorder with psychotic features. The patient's catatonia was perceived incidentally after administration of a one-time dose of a benzodiazepine while on the inpatient psychiatry ward. Subsequent daily treatment with a benzodiazepine resulted in a drastic improvement in the patient's functioning over the following week. This case underscores the importance of performing a detailed psychiatric examination to avoid missing the diagnosis of catatonia, especially for patients with affective and psychotic disorders as more subtle catatonic signs may be masked. Therefore, being proficient at recognizing all the features and patterns of catatonia is essential for early detection and treatment.

Most of the psychopharmaceuticals used in children and adolescents have not gone through the clinical trials process; only slightly more have had research studies accomplished in this age group, particularly in younger children. Given the pressure to treat mood and behavioral disorders early, many of the medication decisions we make are based on experiences with adults. Therefore, it is prudent to review the potential problems involved in pediatric clinical research particularly as it relates to psychiatry. In this article we will examine current FDA and IRB policies, discuss the ethical issues involved in recruiting children and adolescents for these studies, as well as discuss reluctance of parents and their children to participate in clinical trials. This will be based on a long history of academic clinical trial participation at LSUHSC in Shreveport, LA. Awareness of these issues will hopefully facilitate greater research in our younger patients, leading to improved treatment options for mental illnesses.

BACKGROUND Evidence suggests that fibromyalgia is related to both chronic sympathetic hyperactivity and decreased levels of serotonin. OBJECTIVE To examine the efficacy of pindolol, a mixed serotonin (5-HT)1A presynaptic autoreceptor/β-adrenergic receptor antagonist, in the treatment of fibromyalgia. METHODS An open trial was conducted using 20 female patients who met the American College of Rheumatology criteria for fibromyalgia. Treatment was initiated with pindolol 7.5 mg/day and titrated to a maximum dose of 15 mg/day for a total of 90 days. Primary outcome measures were tender point analysis and the Fibromyalgia Impact Questionnaire (FIQ). Anxiety and depression were measured with the Hamilton Depression and Anxiety Scales and Beck Depression Inventory. RESULTS There was significant improvement in primary outcome measures, including Tender Point Count (mean ± SD, 16.3 ± 2.2 vs 12.3 ± 5.0; F = 8.9; p < 0.001), Tender Point Score (24.4 ± 5.7 vs 17.5 ± 9.4; F = 7.8; p < 0.001), and FIQ (45.3 ± 10.8 vs 35.0 ± 15.0; F = 5.6; p < 0.005). The depression and anxiety scores did not change significantly among women who completed the study, while the impact on cardiovascular parameters was clinically insignificant. CONCLUSIONS While the current results are encouraging, further studies are needed to determine whether pindolol might be effective in the treatment of fibromyalgia. Limitations of this study include small group size and lack of placebo control.

RNA and protein gene expression technologies are revolutionizing our view and understanding of human diseases and enable us to analyze the concurrent expression patterns of large numbers of genes. These new technologies allow simultaneous study of thousands of genes and their changes in regulation and modulation patterns in relation to disease state, time, and tissue specificity. This review summarizes the application of this modern technology to four common neurological and psychiatric disorders: HIV-1-associated dementia, Alzheimer's disease, multiple sclerosis, and schizophrenia and is a first comparison of these diseases using this approach.

The authors surveyed members of the American Association of Directors of Psychiatric Residency Training (AADPRT) and chief residents of training programs in 1999. (The Residency Review Committee [RRC] requires research training in psychiatry.) The survey gathered information on faculty and resident participation in research, attitudes, presentations and/or publications. The total response rate was 49%. Faculty and residents showed no significant difference in their residency training in research offerings/requirements; however, current residents showed greater access to more programs offering research. Ninety-eight percent of respondents indicated that research training should be offered to residents, but only 32% thought that research should be a requirement. Psychiatry residencies continue to require strong leadership in clearly defining acceptable components of strong research programs.

Ninety-three patients, including 47 patients with Generalized Anxiety Disorder (GAD) and 46 patients with Major Depression (MD), were entered into recent clinical trials. Clinicians acknowledge that during the initial screening process, clear separation between depressed and anxious patients may be difficult. By using the DSM-IV criteria, the Hamilton Depression and Anxiety Scales, and a variety of other structured evaluations, patients were divided into the two diagnostic groups. The Millon Multiaxial Inventory (MCMI-III) was administered to all 93 patients as part of their initial assessment, but was not used in the diagnostic decision making process or in assignment to a particular clinical study. Upon completion of these studies, the Millon data were analyzed utilizing a cutoff score of 75, conforming to previous studies. Statistically significant differences in Millon personality patterns between MD and GAD patients included dependent, obsessive-compulsive, self-defeating, and borderline traits. Patients exhibiting dependent, self-defeating, and borderline patterns were statistically more likely to be included in clinical trials of MD rather than GAD. Also, patients with MD were more likely to disclose clinical information and exhibit self-critical behavior when compared to those with GAD. These results suggest that the MCMI-III may detect personality differences between anxious and depressed outpatients presenting for clinical trials.

Ramelteon is the only FDA-approved melatonin agonist for treatment of insomnia. It acts on melatonin MT1 and MT2 receptors. We describe a case of a patient who was prescribed ramelteon for insomnia disorder. Shortly after initiation of ramelteon, he described vivid nightmares leading to discontinuation of ramelteon. The nightmares ameliorated with ramelteon discontinuation. Ramelteon is well tolerated with a favorable side-effect profile. No documented cases of nightmares secondary to ramelteon use were found in the literature. The effects of ramelteon on rapid eye movement sleep, the stage of sleep where dreams occur, need to be further explored.

The most commonly abused substances in southwest Virginia are prescription medications. One of the most significant trends in Virginia is the percent of the population aged 12 and older using pain relievers for nonmedical purposes. Although the rate for the state as a whole (4.42%) is less than the national rate (4.89%), the southwest Virginia regional rate of 5.51% exceeds the national rate.1 The American Academy of Addiction Psychiatry, the American Osteopathic Academy of Addiction Medicine, and the American Psychiatric Association have been awarded a 3-year grant by the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment to operate the Physicians' Clinical Support System for Buprenorphine (PCSS-B), effective July 1, 2011.2 This initiative provides training and clinical mentorship to practicing physicians and physicians-in-training who wish to include office-based treatment of opioid use disorders in their practices.2 The state of Virginia has 5 general psychiatry residency programs, of which Carilion Clinic–Virginia Tech Carilion Psychiatry Residency Program (CC-VTCSOM) may be the first to teach their general psychiatry residents about office-based treatment of opioid dependence by using this initiative. The program coordinates PCSS-B training for 17 of CC-VTCSOM's 32 psychiatry residents. The size of the training group was capped at 20, and 3 members of the faculty took the training as well. Residents and faculty completed a 3.75-hour training course, according to guidelines from PCSS-B, followed by a 4.25-hour face-to-face session by board- certified addiction psychiatrists, which included the program director for the addictions fellowship at CC-VTCSOM. This session included an interactive component with clinical case vignettes. Topics included an overview of office-based treatment of substance use disorders, review of opioids, introduction to buprenorphine/naloxone, special aspects of treatment of substance abuse disorders, and use of buprenorphine in special patient populations. This workshop was intended to prepare psychiatry residents to understand the complex demands of southwest Virginia's patient population, given the region's higher risk for opioid dependence.

To the Editor: Paraphilias are a complex and heterogeneous group of disorders in which sexual deviance is regarded as a medical phenomenon.1 We present a case of paraphilia disorder with depressive symptoms and suicidal ideations that was ameliorated with risperidone treatment. Case report. Mr A, a 42-year-old white man, sought help for depression and suicidal ideations. On a detailed interview, the patient revealed his involvement in sexual acts that make him guilty. He reported that he participates in sadomasochistic activity with his partner, that has been involved in sadistic and masochistic activities for the last 2 years, and that he was not involved in those acts prior to that. Mr A presented with 182 scars on his arms and chest that were very deep and in different stages of healing. He reported that he and his girlfriend of the last 2 years had been involved in cutting and drawing blood from each other’s body while engaging in sexual activity. The two also drank each other’s blood while involved in these sexual activities, and Mr A reported that cutting and drinking the other partner’s blood was the only way for them to reach orgasm. At the time of admission, he reported remorse and depression related to such acts. He was involved in recurrent, intense sexually arousing fantasies and behaviors. There was physical and psychological suffering of self and partner, and these urges and behaviors had been present for the last 2 years. The fantasies and urges were causing impairment in his social, occupational, and other areas of function. On physical examination, nothing significant was noted except for the aforementioned deep-seated scars in different stages of healing over the chest and arms. No scars were noted on the legs or back. His chest was clear to auscultation bilaterally, and no rhonchi, rales, or wheezing was appreciated. S1 and S2 were heard, and no murmurs were appreciated. On chest x-ray, no infiltrates were observed. A head computed tomography scan showed no acute hemorrhages or masses. His urine drug screen was negative; blood alcohol level was less than 0.03 g/dL. Most of the laboratory results were within normal range. His complete blood cell count and liver function tests revealed no abnormalities, as did urinalysis. Prothrombin time/international normalized ratio was within normal limits. Blood cultures and urine cultures were negative. Risperidone 2 mg/d was initiated for his major depressive disorder, moderate without psychotic features (DSM-IV criteria). The patient reported that he felt better in the next couple of weeks. He reported fewer urges, and the behavior abated; at follow-up after 4 weeks and 8 weeks, Mr A reported abatement of paraphilic tendencies and amelioration of his depressive symptoms. He was also offered psychotherapy, which he declined because of financial problems. His partner refused both pharmacotherapy and psychotherapy. Paraphilias may present with traits of addictive, impulsive, or obsessive-compulsive disorders or, in general, hypersexuality.1,2 The terms sadism and masochism were introduced by the German psychiatrist Richard von Krafft-Ebing in his book Neue Forschungen auf dem Gebiet der Psychopathia sexualis (“New Research in the Area of Psychopathology of Sex”), originally published in 1886.3 Practitioners of sadism and masochism derive sexual pleasure by inflicting and receiving pain, respectively. Sigmund Freud, a contemporary of Krafft-Ebing, in his Drei Abhandlungen zur Sexualtheorie (“Three Essays on Sexual Theory,” 1905), identified that these 2 entities could be present in the same individual, which led to the development of the term sadomasochism.4–6 Owing to their practice in privacy, sadomasochism and other paraphilias remain largely underreported.7 The pathophysiology of sadomasochism and other paraphilic behaviors remains poorly understood and underresearched.1 It has been implicated that endocrine and temporal lobe dysfunction could underlie sadomasochistic behavior.8 Moreover, sadomasochism has also been proposed as a potential reliever of physiologic stress as ascertained via salivary cortisol measurements.9 In addition to endocrine explanations, it has recently been proposed that sadomasochism could be the outcome of aberrant pain pathways, in which the patient acts out to self-medicate by using synesthesia to activate mirror pathways.10 Currently, 3 main categories of pharmacotherapeutic options exist for the treatment of paraphilias: (1) antidepressants, (2) steroid antiandrogens, and (3) gonadotropin-releasing hormone analogs.1 The side-effect profiles of the aforementioned treatment strategies and the endeavor to find a monotherapeutic option for the comorbidities associated with paraphilias require us to find additional putative therapeutic options. The role of monoamines serotonin and dopamine is well identified in sexual behavior.11,12 In preclinical models, serotonin impairs male sexual interest and behavior.13 In subsequent clinical studies, selective serotonin reuptake inhibitors have demonstrated an impairment in ejaculatory and orgasmic function and sexual interest in a dose-dependent manner.1,14–17 Moreover, serotonin is also implicated in comorbidities associated with paraphilias such as depression and anxiety disorders.1 Further support to the serotonin hypothesis in paraphilias is drawn by the similarities between paraphilias and obsessive-compulsive disorder.18 In addition to serotonin, dopamine is also implicated in sexual disorders.11,12 The association of dopamine with the reward system of the brain, reinforcement to perform certain activities,19 and aggressive behavior20 render dopamine a putative target for paraphilic behavior disorders. Risperidone, an atypical antipsychotic, in addition to blocking dopamine receptors (D2), binds with high affinity to serotonin receptors (5-HT2A), which contributes to the lower incidence of adverse effects of dopamine antagonism associated with typical antipsychotics, such as extrapyramidal symptoms (EPS) and elevated plasma prolactin.21 Undergirded with a possible neurobiological explanation of paraphilias and mechanism of action of risperidone,22 we gave this patient a trial of low-dose (2 mg) risperidone. As noted, he reported abatement of paraphilic tendencies and amelioration of his depressive symptoms at follow-up after 4 and 8 weeks. We found no report in the medical literature citing the use of atypical antipsychotics in the treatment of paraphilia. Hence, we hereby report, for the first time, a potential application of atypical antipsychotics, such as risperidone, in the treatment of paraphilia disorder presenting with depressive symptoms and suicidal ideation. Future placebo-controlled investigations are warranted to support plausible use of atypical antipsychotics in the treatment of paraphilia.

A growing number of patients present in clinics with complaints of insomnia. Over the past century, great advances have been made in our knowledge of mechanisms of sleep and wakefulness. Understanding sleep neurochemistry has led to better management of different types of insomnias with a variety of non-pharmacological and pharmacological treatments. Unfortunately, the increasing development and availability of second generation antipsychotics (SGA) have prompted their frequent use exclusively for insomnia. However, to date, no large randomized-controlled or placebo-controlled studies have shown the utility of SGAs in the realm of treating insomnia. Many clinicians use SGAs as "off-label" for sleep induction and maintenance, but this practice needs to be readdressed given their potential risks and the current lack of evidence base. This review will highlight the neurochemistry related to sleep, the mechanisms of action by which SGA may have some benefit in treating insomnia, and the risks associated with their utilization.

Although cocaine dependence affects an estimated 1.6 million people in the USA, there are currently no medications approved for the treatment of this disorder. Experiments performed in animal models have demonstrated that inhibitors of the stress response effectively reduce intravenous cocaine self-administration. This exploratory, double-blind, placebo-controlled study was designed to assess the safety and efficacy of combinations of the cortisol synthesis inhibitor metyrapone, and the benzodiazepine oxazepam, in 45 cocaine-dependent individuals. The subjects were randomized to a total daily dose of 500 mg metyrapone/20 mg oxazepam (low dose), a total daily dose of 1500 mg metyrapone/20 mg oxazepam (high dose), or placebo for 6 weeks of treatment. The outcome measures were a reduction in cocaine craving and associated cocaine use as determined by quantitative measurements of the cocaine metabolite benzoylecgonine (BE) in urine at all visits. Of the randomized subjects, 49% completed the study. The combination of metyrapone and oxazepam was well tolerated and tended to reduce cocaine craving and cocaine use, with significant reductions at several time points when controlling for baseline scores. These data suggest that further assessments of the ability of the metyrapone and oxazepam combination to support cocaine abstinence in cocaine-dependent subjects are warranted.

To the Editor: Serotonin syndrome is defined as a clinical triad of autonomic hyperactivity, mental status changes, and neuromuscular changes, though the presentation could be very varied.1,2 We present the case of a man receiving sertraline for depression who developed serotonin syndrome after taking the over-the-counter medication NyQuil for treatment of cold symptoms. Case report. Mr A, a 46-year-old thinly built man, had received sertraline 100 mg/d for depression for 2 years. His medical history was significant for diabetes mellitus, for which he was being treated with metformin 500 mg twice daily; hypothyroidism, for which he was receiving levothyroxine 100 μg; and chronic low back pain, for which he was not taking medication. After he developed cough, congestion, and insomnia, he called his primary care physician for an appointment. The physician’s office recommended his taking over-the-counter (OTC) medications for congestion until he was to be seen the following day. Thus, he started taking OTC NyQuil containing dextromethorphan; in 1 night, he drank 240 mL of the liquid. The next day, Mr A presented to the emergency department with confusion, shivering, agitation, fever, diaphoresis, stupor, hyperreflexia, and diarrhea. Examination found tachycardia with pulse of 110 bpm, blood pressure of 155/89 mm Hg, tachypnea (24 breaths/min), and hyperthermia (39.0°C). Mydriasis and hyperactive bowel sounds were appreciated. Neurologic examination was positive for hyperreflexia (which was greater in the lower than in the upper extremities), tremor, and rigidity. S1 and S2 heart sounds showed no abnormalities, and breath sounds were clear on auscultation bilaterally. His laboratory test results were mostly within normal limits except for findings of metabolic acidosis and increased blood urea nitrogen/creatinine levels. White blood cell (WBC) count was 9,000/μL . Urine drug screen was negative for any illicit substances. No alcohol was detected in blood. Head computed tomographic scan and a chest x-ray revealed no abnormalities. A diagnosis of serotonin syndrome was suspected on the basis of the clinical picture. The patient met Sternbach criteria for serotonin syndrome3; Sternbach criteria were used as there was addition of a serotonergic agent the night before. He was admitted to the intensive care unit, at which time his sertraline was discontinued. The psychiatry department was consulted, and pertinent history regarding the use of dextromethorphan was elicited. Mr A improved with administration of diazepam 1 mg every 4 hours as needed and intravenous fluids. Symptoms resolved within 2 days, and the patient was later discharged. His sertraline was discontinued and was replaced with mirtazapine. In patients with serotonin syndrome, autonomic symptoms may range from fever, hyperthermia, and diaphoresis to tachycardia, tachypnea, flushing, diarrhea, hypertension, and dyspnea. Mental status changes may include confusion and coma when serotonin syndrome is severe and anxiety, agitation, restlessness, and insomnia when it is less severe. Neuromuscular symptoms may include clonus, hypertonia, tremor, shivering, and hyperreflexia.1,2 Medications that could be associated with serotonin syndrome include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors; analgesics such as fentanyl, methadone, and tramadol; antiemetics such as ondansetron and metoclopramide; triptans; herbal supplements such as St. John’s wort and ginseng; illicit drugs such as cocaine, ecstasy, and LSD; and over-the-counter medications such as dextromethorphan.1,2 Differentiation should also be made from other syndromes such as the neuroleptic malignant syndrome (NMS), anticholinergic poisoning, and malignant hyperthermia. Neuroleptic malignant syndrome, which is caused by excess of dopamine, starts with muscular rigidity followed by hyperthermia. Bradykinesia is prominent in NMS, whereas serotonin syndrome consists of hyperkinesias. In NMS, symptoms develop over days, whereas in serotonin syndrome, the onset and resolution of symptoms occur within hours.1 Diagnosis can be made by Sternbach criteria3 or Hunter criteria.4 Sternbach criteria consist of the following: recent addition of a serotonergic agent; no addition of a neuroleptic agent; absence of other etiologies (infection, substance abuse, withdrawal); and 3 or more symptoms including autonomic symptoms, mental status changes, and neuromuscular symptoms.3 Hunter criteria comprise the presence of a serotonergic agent and any one symptom including spontaneous clonus, inducible clonus with agitation and diaphoresis, ocular clonus and agitation or diaphoresis, ocular clonus or inducible clonus, tremor and hyperreflexia, and hyperthermia and hypertonia and ocular/inducible clonus.4 Dextromethorphan is a moderate serotonin reuptake inhibitor.5–7 Dextromethorphan also promotes serotonin release.7 In addition, N-methyl-d-aspartate receptor antagonism by dextromethorphan is associated with postsynaptic 5-HT2A stimulation.7 Dextromethorphan is metabolized by the cytochrome P450 (CYP) 2D6 pathway.8 Sertraline, an SSRI, is a moderate inhibitor of the CYP2D6 pathway.9 Hence, sertraline can increase levels of dextromethorphan and cause increased serotonin when the 2 agents are used concomitantly. Patients taking SSRIs should be warned about the increased chances of serotonin syndrome when also taking over-the-counter medications containing dextromethorphan. Once recognized, serotonin syndrome should be aggressively treated and offending agents should be removed.

Multiple sclerosis (MS) is one of the most frequently seen neurological causes of progressive disability in early to middle adulthood. The disease is variable in its presentation and course, affects roughly 100-300 per 100,000 persons within the United States alone, and is slightly more common among females than males. MS places substantial burdens on patients, families, and caregivers. It negatively affects cognitive abilities and psychiatric functioning, and can add a notably deleterious effect on a patient's quality of life. This chapter reviews the recent literature on the behavioral manifestations of MS. Cognitive domains discussed include executive functioning, processing speed, attention, learning and memory, language functioning, and visual spatial processing. Some attention will also be paid to differential diagnosis and the cognitive effects of treatment. Psychiatric manifestations are also discussed, including symptoms of depression, bipolar disorder, euphoria, pathological laughter and crying, and psychosis, as well as maladaptive personality traits. Finally, the chapter concludes with a discussion of the effects of MS on quality of life including such areas as fatigue, sexual dysfunction, pain, employment, and cognitive functioning.

Recognizing cognitive deficits and psychiatric disorders in patients with autosomal dominant ataxias is relatively new. At this time, the percentage of patients with these disorders who experience changes in cognition or psychiatric symptoms is unknown. Cognitive impairment, when seen, is often found on tests of executive function, probably reflecting disruption of afferent and efferent pathways of the prefrontal cortex and subcortical structures, including the cerebellum. Widespread global dysfunction does occur in some cases, especially later in the disease course. Psychiatric symptoms including depression, aggression, irritability, and psychosis have all been reported. As these behavioral changes receive further study, one hopes that guidelines for treating these symptoms will emerge. Clinicians should be mindful of the psychosocial effects that genetic testing for the hereditary ataxias may have, especially in cases of predictive testing for those who are asymptomatic but at risk because of family history. Guidelines established for genetic testing in HD may be helpful when approaching these cases.

Objective: Approximately 30% of women experience some type of anxiety disorder during their lifetime. In addition, some evidence exists that anxiety disorders can affect pregnancy outcomes. This article reviews the literature on the course of generalized anxiety disorder (GAD) and panic disorder during pregnancy and the postpartum period and presents guidelines for management. Data Sources and Study Selection: An English language electronic search of relevant studies using PubMed (January 1, 1985–January 2004) was performed using the search terms anxiety and pregnancy, maternal mental illness, panic and pregnancy, psychotropic medications in pregnancy, and treatment options in pregnancy. Review articles and primary pharmacologic treatment articles were selected for discussion. Data Extraction and Synthesis: Despite the extensive use of psychotropic drugs such as antidepressants during pregnancy, there is a scarcity of information regarding the effect of such exposure on the developing fetus. Review articles and primary pharmacologic treatment trials were analyzed and incorporated into the review based on adequate methodology, completeness of data, and information on pregnancy outcome. Conclusion: It is important that physicians understand the course of these disorders during pregnancy and available treatments so they appropriately counsel women who are or intend to become pregnant. The goal of treatment during pregnancy and lactation is sufficient treatment for syndrome remission. To minimize the potential for neonatal withdrawal and maternal toxicity after delivery, vigilant monitoring of side effects is indicated. Also, if possible, nonpharmacologic treatment, such as cognitive-behavioral therapy, should be first-line treatment in pregnant women with GAD or panic disorder.

Early recognition and intervention in psychosis is the focus of more intensive research. In this paper, we critically review the ideas that have emerged in this field. We also propose a model or hypothesis for testing in the prodromal phase of schizophrenia. Attention to practical and ethical issues, particularly with the use of atypical antipsychotics in one arm of the protocol, is addressed. Studies by Yung and Falloon describe prodromal intervention with psychosocial strategies and time-limited low potency neuroleptics, respectively, that suggest benefits of such a model. Although we have respect for the DSM system, this paper is written more from a Bleulerian than Kraepelinian perspective in that we emphasize affective, cognitive, and negative symptoms in addition to positive symptoms. The paper recognizes the strong conceptual disagreements implicit in this area stemming not only from Kraepelin and Bleuler but work from the 1930s by Cameron. The clinical research advocated is timely in that the atypicals are more congruent to the Bleulerian conception with a neurodevelopmental hypothesis of schizophrenia. We also have exciting new imaging and genetic technologies to refine our concepts of schizophrenia and its prodromal and premorbid phases.