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INTRODUCTION: Spatial patterns of long-range seizure propagation in epileptic networks have not been well characterized. Here, we use ictal high gamma activity as a proxy of intense neuronal population firing to map the spatial evolution of seizure recruitment. METHODS: Ictal high gamma activity (80–150 Hz) was analyzed in 13 patients with 72 seizures recorded by stereotactic depth electrodes, using previously validated methods. Distinct spatial clusters of channels with the ictal high gamma signature were identified, and seizure hubs defined as stereotypically recruited non-overlapping clusters. Clusters were correlated with asynchronous seizure terminations to provide supportive evidence for independent seizure activity at these sites. The spatial overlap between seizure hubs and interictal ripples was compared. RESULTS: Ictal high gamma activity was detected in 71% of seizures and 10% of implanted contacts, enabling tracking of contiguous and noncontiguous seizure recruitment. Multiple seizure hubs were identified in 54% of cases, including 43% of patients thought preoperatively to have unifocal epilepsy. Noncontiguous recruitment was associated with asynchronous seizure termination (Odds ratio=19.7, p=0.029). Interictal ripples demonstrated greater spatial overlap with ictal high gamma activity in cases with single seizure hubs compared to those with multiple hubs (100% vs 66% per patient, p=0.03). CONCLUSIONS: Ictal high gamma activity may serve as a useful adjunctive biomarker to distinguish contiguous seizure spread from propagation to remote seizure sites. High gamma sites were found to cluster in stereotyped seizure hubs rather than being broadly distributed. Multiple hubs were common even in cases that were considered unifocal.

Objective Report on the first known successful use of ECT for treatment of catatonia in a patient with hypoxic-ischemic brain injury. Background Catatonia is a psychomotor disorder characterized by difficulty initiating or inhibiting volitional behavior. Catatonia is likely underdiagnosed in medically ill patients, whose features may be misinterpreted as delirium or static brain injury-related deficits. While catatonia itself is rarely described after hypoxic-ischemic brain injury, its features are commonly reported in the context of delayed post-hypoxic leukoencephalopathy. To date, there are no reports of successful use of ECT for catatonia in this population. Methods Case Report. 32-year-old man with opioid and cocaine use disorders suffered hypoxic-ischemic brain injury after heroin overdose. He recovered well though reported depressive symptoms. Seven months later, he developed progressive mutism, rigidity, stupor, catalepsy, and dysautonomia consistent with catatonia, unspecified. MRI at that time did not show leukoencephalopathy. Results Twenty-four months after initial injury, lorazepam trial for suspected catatonia produced dramatic improvement but he required increasing doses to maintain effect. Right unilateral ECT was initiated for benzodiazepine-resistant catatonia and the patient received 12 treatments during an inpatient admission with complete resolution of catatonia. He reported no adverse effects. Catatonic symptoms re-emerged after discharge, and he received 21 outpatient ECT treatments (9 right unilateral and 12 bilateral) with overall improvement in catatonia. Conclusions The following factors may underlie the successful use of ECT for treatment of catatonia in this patient with hypoxic-ischemic brain injury: mood symptoms prior to onset of catatonia; initial response to lorazepam; absence of neuroimaging evidence of leukoencephalopathy; and longer length of time between the hypoxic-ischemic brain injury and initiation of ECT. Despite literature suggesting ECT can be detrimental after hypoxic-ischemic brain injury, stringent case selection criteria may allow for safe and effective use of ECT for catatonia in these patients.

The coronavirus disease 2019 (COVID-19) pandemic is a global health crisis associated with significant psychosocial stressors. Core concepts from the trauma field are relevant to informing expected mental health sequelae and an evidence-guided mental health response. The most common response to trauma and other major stressors is resilience, but a minority of people will experience persistent or impairing mental health challenges. Those exposed to trauma may develop acute stress disorder and/or posttraumatic stress disorder. COVID-19–related traumas and stressors can also result in stress-related conditions including adjustment disorders, depression, and anxiety disorders. Mitigation of modifiable risk factors at the individual, organizational, or community level can support resilience. Interventions such as psychological first aid, screening and identification of those at risk, and providing phased mental health resources are relevant to this pandemic. For those experiencing acute or persistent traumatic distress, evidence-based trauma strategies that take the unique challenges of COVID1-19 into account should be used. [ Psychiatr Ann . 2020;50(7):295–300.]

This review paper aims to update readers on the importance of screening for attention-deficit/hyperactivity disorder (ADHD) in adults and to provide a primer on how best to screen and diagnose this condition in an efficient and reliable manner. The ASRS Screening Scale was updated in 2017 to reflect the changes made to identify ADHD based on the DSM-5 criteria and to reflect our understanding that adult ADHD is characterized by executive functioning deficits that are not explicitly reflected in the DSM-5 criteria. The use of the ASRS Screening Scale improves the clinician’s ability to rapidly identify adult patients who require a comprehensive evaluation to diagnose ADHD and/or other comorbid psychiatric conditions. The scale has been validated for use in both the general population and in the ADHD specialty treatment population, which supports its use by both general clinicians and mental health clinicians. Identification of adult ADHD is critical due to the profound personal, familial, and societal costs associated with this condition.

ObjectiveCharacterization of progressive multi-site seizure recruitment using high frequency oscillations.MethodsIctal and interictal high frequency oscillations were identified in a series of 13 patients with 72 seizures recorded by stereotactic depth electrodes, using previously validated methods. Channels with ictal high frequency oscillations were assigned to distinct spatial clusters, and seizure hubs were identified by stereotypically recruited non-overlapping clusters. Clusters were correlated with asynchronous seizure terminations to provide supportive evidence for independent seizure activity at these sites. The spatial overlap of ictal and interictal high frequency oscillations were compared.ResultsIctal high frequency oscillations were detected in 71% of seizures and 10% of implanted contacts, enabling tracking of contiguous and noncontiguous seizure recruitment. Multiple seizure hubs were identified in 54% of cases, including 43% of patients thought preoperatively to have unifocal epilepsy. Noncontiguous recruitment was associated with asynchronous seizure termination (Odds Ratio=10, 95% CI 2.9-41, pSignificanceAnalysis of ictal high frequency oscillations can serve as a useful adjunctive technique to distinguish contiguous seizure spread from propagation to remote seizure sites. This study demonstrated that multiple seizure hubs were commonly identified by spatial clustering of ictal high frequency oscillations, including in cases that were considered unifocal. The distinction between initially activated and delayed seizure hubs was not evident based on interictal high frequency analysis, but may provide important prognostic information.Key Points-Spatial clustering and temporal activation sequences of ictal HFOs were analyzed in a cohort of surgical epilepsy patients.-Ictal HFOs revealed recruitment of multiple noncontiguous seizure hubs during seizure propagation, even in cases thought to be unifocal.-The presence of multiple seizure hubs was associated with asynchronous seizure terminations.-Interictal HFOs showed greater spatial overlap with ictal HFOs in cases with single compared to multiple seizure hubs.

Objective To test the hypothesis that posttraumatic stress and depressive symptoms, not cognitive or functional impairment, are associated with cardiac arrest survivors' negative recovery perceptions at hospital discharge. Methods Prospective observational cohort of cardiac arrest patients admitted between 9/2015–5/2017. Survival to discharge with sufficient mental status to complete a psychosocial interview was the main inclusion criterion. Perceived recovery was assessed through the question, “Do you feel that you have made a complete recovery from your arrest?” The following measures were examined as potential correlates of perceived recovery: Repeatable Battery for Assessment of Neuropsychological Status, Modified Lawton Physical Self-Maintenance Scale, Barthel Index, Modified Rankin Scale, Cerebral Performance Category, Center for Epidemiological Studies–Depression (CES-D), and PTSD Checklist–Specific (PCL-S). Logistic regression evaluated associations between perceived recovery and potential correlates of recovery. Results 64/354 patients (58% men, 48% white, mean age 52 ± 17) were included. 67% (n = 43) had a negative recovery perception. There were no differences among patients' cognitive and functional domains. In individual models, patients with higher PCL-S and CES-D scores were more likely to have a negative recovery perception after adjusting for age and gender (OR: 1.2, 95% CI [1.1, 1.4], p = 0.003) and (OR: 1.1, 95% CI [1.0, 1.1], p = 0.05). Conclusions Within one month after a cardiac arrest event, survivors' negative recovery perceptions are associated with psychological distress.

Objective Selective laser amygdalohippocampotomy (SLAH) using magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is emerging as a treatment option for drug-resistant mesial temporal lobe epilepsy (MTLE). SLAH is less invasive than open resection, but there are limited series reporting its safety and efficacy, particularly in patients without clear evidence of mesial temporal sclerosis (MTS). Methods We report seizure outcomes and complications in our first 30 patients who underwent SLAH for drug-resistant MTLE between January 2013 and December 2016. We compare patients who required stereoelectroencephalography (SEEG) to confirm mesial temporal onset with those treated based on imaging evidence of MTS. Results Twelve patients with SEEG-confirmed, non-MTS MTLE and 18 patients with MRI-confirmed MTS underwent SLAH. MTS patients were older (median age 50 vs 30 years) and had longer standing epilepsy (median 40.5 vs 5.5 years) than non-MTS patients. Engel class I seizure freedom was achieved in 7 of 12 non-MTS patients (58%, 95% confidence interval [CI] 30%-86%) and 10 of 18 MTS patients (56%, 95% CI 33%-79%), with no significant difference between groups (odds ratio [OR] 1.12, 95% CI 0.26-4.91, P = .88). Length of stay was 1 day for most patients (range 0-3 days). Procedural complications were rare and without long-term sequelae. Significance We report similar rates of seizure freedom following SLAH in patients with MTS and SEEG-confirmed, non-MTS MTLE. Consistent with early literature, these rates are slightly lower than typically observed with surgical resection (60%-80%). However, SLAH is less invasive than open surgery, with shorter hospital stays and recovery, and severe procedural complications are rare. SLAH may be a reasonable first-line surgical option for patients with both MTS and SEEG confirmed, non-MTS MTLE.

Background There is a paucity of literature regarding the effect of antipsychotics on absolute neutrophil count (ANC) of patients with benign neutropenia (BN). We evaluated the change in ANC after atypical antipsychotic prescription (excluding clozapine) in a retrospective cohort of 22 patients with BN. Methods/procedures Records of all patients with BN who were prescribed antipsychotics and who had ANC measured before and during antipsychotic treatment were obtained from Bronx VA Medical Center between 2005 and 2015 (inclusive). Twenty-two patients met criteria for inclusion. Individual and group mean ANC were calculated before treatment and during treatment. A paired, two-tailed t test was performed on the group ANC means. Results The group mean pretreatment ANC was 1.24 ± 0.220 K/cmm, and the mean ANC during the time of antipsychotic prescription increased to 1.40 ± 0.230 K/cmm, with a P value of 0.0045, t value of 3.18, degrees of freedom equal to 21, and 95% confidence interval of 1.30 to 1.49 K/cmm. Conclusions There was a statistically significant increase in ANC among our cohort during the time of antipsychotic prescription. All BN patients who were prescribed antipsychotics maintained a stable neutrophil count, with none of the 22 patients with BN in this study developing agranulocytosis during treatment. Although this study is limited by a low patient count as well as other demographic factors, these findings provide initial evidence regarding the safety of prescribing atypical antipsychotics to BN patients. Further studies are needed to replicate these findings and assess for effects of individual medications.

Background Considerable evidence suggests that posttraumatic stress disorder (PTSD) is a heterogeneous construct despite often being treated as a homogeneous diagnostic entity. PTSD in response to cardiac arrest is common and may differ from PTSD following other medical traumas. Most patients are amnesic from the cardiac event, and it is unclear if and how certain PTSD symptoms may manifest. Methods We examined the latent structure of PTSD symptoms in 104 consecutive cardiac arrest survivors who were admitted to Columbia University Medical Center. PTSD symptoms were assessed via the PTSD Checklist-Specific at hospital discharge. We performed a confirmatory factor analysis (CFA) to compare 4-factor dysphoria, 4-factor numbing, and 5-factor dysphoric arousal models of PTSD with our data. Results The CFA showed that each of the models had good fit. We chose the 4-factor numbing model (χ2 (113) = 151.59, p Limitations Certain factors were defined by only two items. Additionally, PTSD was assessed at discharge (median = 21 days); those assessed before 30 days could be displaying symptoms of acute stress disorder. Conclusions Our findings suggest that PTSD symptoms after cardiac arrest are best represented by a 4-factor numbing model of PTSD. PTSD assessment and intervention efforts for cardiac arrest survivors should consider the underlying dimensions of PTSD.

Introduction: Despite improved survivability, cardiac arrest (CA) survivors face significant “extracardiac” (i.e. functional, cognitive and psychosocial) sequelae. More so, survivors and their caregivers are seemingly unaware that they will be confronted with these issues post-discharge. As a response, we have created a multidisciplinary, follow-up clinic to provide comprehensive and well-coordinated care to CA survivors. The team includes a neurointensivist, neuropsychologist, neuropsychiatrist and a chaplain. Hypothesis: CA survivors attending a follow-up clinic will have improved outcomes compared to historical controls. Methods: Fisher’s exact and Wilcoxon Rank-sum tests were used to assess differences in 1-year outcomes between survivors who had at least one follow-up visit in the NeuroCardiac clinic (2/2017-1/2018), with historical controls (9/2015 - 1/2017) who had no clinic visits. Results: Clinic patients (n= 34; median visit per patient=2), were slightly younger (49 vs 57 years, p=0.03) than historic controls (n=47), but otherwise there were no significant differences in demographic, psychosocial or functional status at hospital discharge. At 1-year, clinic patients, compared to historic controls, had significantly greater independence on the Lawton Physical Self-Maintenance Scale (mean score 7.6 vs 8.9, p=0.03) and Instrumental Activities of Daily Living scale (4.9 vs 8.8, p =.01). In clinic patients, there was a trend towards return to work (38.2% vs 23.4%), having a less negative impact on their marital status (5.9% vs 21.3%) and reduced complaints of sleep issues (29% vs 52%). Clinic patients had lower rates of depression symptoms on the Center for Epidemiological Studies-Depression scale (9.8 vs 13.4), were less fearful about the possibility of arrest recurrence (23.5% vs 31.9%), had more positive recovery perceptions (55.9% vs 38.3%), and had higher self-reported overall health ratings on a 100-point scale (84.7 vs 75.4) at one year. Conclusions: We have taken an important step in early detection of extracardiac symptoms in a systematic manner after CA. This paradigm shift could potentially be utilized to develop and implement novel interventions responsible for improving clinical outcomes and quality of life.

Aim To examine gender differences among cardiac arrest (CA) survivors’ cognitive, functional, and psychiatric outcomes at discharge. Methods This is a prospective, observational cohort of 187 CA patients admitted to Columbia University Medical Center, considered for Targeted Temperature Management (TTM), and survived to hospital discharge between September 2015 and July 2017. Patients with sufficient mental status at hospital discharge to engage in the Repeatable Battery for Neuropsychological Status (RBANS), Modified Lawton Physical Self-Maintenance Scale (M-PSMS), Cerebral Performance Category Scale (CPC), Center for Epidemiological Studies Depression Scale (CES-D), and Post-Traumatic Stress Disorder Checklist – Civilian Version (PCL-C) were included. Fisher’s exact, Wilcoxon Rank Sum, and regression analysis were utilized. Results 80 patients (38% women, 44% white, mean age 53 ± 17 years) were included. No significant gender differences were found for age, race, Charlson Comorbidity Index, premorbid CPC or psychiatric diagnoses, arrest related variables, discharge CPC, or PCL-C scores. Women had significantly worse RBANS (64.9 vs 74.8, p = .01), M-PSMS (13.6 vs 10.6, p = .02), and CES-D (22.8 vs 14.3, p = .02) scores. These significant differences were maintained in multivariate models after adjusting for age, initial rhythm, time to return of spontaneous circulation, and TTM. Conclusions Women have worse cognitive, functional, and psychiatric outcomes at hospital discharge after cardiac arrest than men. Identifying factors contributing to these differences is of great importance in cardiac arrest outcomes research.

Visual anosognosia is the lack of awareness and denial of one's blindness. It is often referred to as Anton syndrome (AS), after one of the physicians who described the phenomenon of lacking insight into one's sensory deficit. There are limited numbers of case reports documenting the condition and many refer to the phenomenon in association with bilateral occipital infarcts. We describe a patient who developed visual anosognosia as a result of multiple sclerosis (MS).

ObjectivesNot all patients referred for evaluation of multiple sclerosis (MS) meet criteria required for MS or related entities. Identification of markers to exclude demyelinating disease may help detect patients whose presenting symptoms are inconsistent with MS. In this study, we evaluate whether patients who present a self-prepared list of symptoms during an initial visit are less likely to have demyelinating disease and whether this action, which we term the “list sign,” may help exclude demyelinating disease.MethodsUsing chart review, 300 consecutive new patients who presented for evaluation to a neurologist at a tertiary MS referral center were identified retrospectively. Patients were defined as having demyelinating disease if diagnosed with MS or a related demyelinating condition.ResultsOf the 233 enrolled subjects, 157 were diagnosed with demyelinating disease and 74 did not meet criteria for demyelinating disease. Fifteen (8.4%) subjects had a positive list sign, of which 1 patient had demyelinating disease. The 15 subjects described a mean of 12.07 symptoms, and 8 of these patients met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for somatic symptom disorder. The specificity and positive predictive value of the list sign for non-demyelinating disease were 0.99 (95% confidence interval (CI) 0.96–0.99) and 0.93 (95% CI 0.66–0.99), respectively.ConclusionA positive list sign may be useful to exclude demyelinating disease and to guide diagnostic evaluations for other conditions. Patients with a positive list sign also have a high incidence of somatic symptom disorder.

Objective Given recent reports about the off-label use of modafinil as an adjuvant for the treatment of antipsychotic-associated sedation in schizophrenia patients and the recent interest in its putative cognitive-enhancing effects in this population, we present a systematic review of available data on trials of modafinil as an adjuvant in the treatment of cognitive deficits, negative symptoms, and antipsychotic-induced fatigue, and its tolerability. Data sources PubMed was searched for trials published in English up to January 2008 evaluating modafinil's effects on fatigue, negative symptoms, and cognition in schizophrenia with combinations of the following terms: schizophrenia, modafinil, cognition, negative symptoms, and fatigue. Study selection Six trials were identified: 2 randomized, prospective, double-blind placebo-controlled trials; 3 randomized, prospective, double-blind placebo-controlled crossover trials; and 1 open-label pilot study. Case series and case reports were excluded in the data analysis, except to identify potential adverse reactions to modafinil. Data extraction Studies were examined for number of subjects, trial duration, design, dosing, and outcomes with respect to sedation, negative symptoms, cognitive function, and tolerability. Results One of 4 reviewed studies found a significant effect of modafinil as an alerting agent for antipsychotic-induced fatigue and sedation. Neither of 2 reviewed studies found modafinil to improve negative symptoms of schizophrenia. Three of 6 reviewed studies showed that modafinil may improve short-term memory, attention, and the ability to shift mental sets. Two neuroimaging studies identified functional correlates in areas associated with working memory functions. The main adverse effect was found to be a small risk of psychosis exacerbation, which was seen in 5 of 83 patients (6.0%) in the active treatment groups as compared to 2 of 70 patients (2.9%) in the placebo groups. Conclusions While the available data suggest that modafinil is generally well tolerated and may have some efficacy in the treatment of antipsychotic-induced sedation and cognitive domains, the small sample sizes, contradictory results, and methodological differences between trials, especially with respect to cognitive testing, make it difficult to draw firm conclusions about the overall effectiveness of modafinil as an adjunct in the treatment of schizophrenia. Well-powered, prospective, randomized placebo-controlled trials using the MATRICS battery concomitantly with functional outcome measures are necessary to elucidate modafinil's efficacy and effectiveness as an adjunctive treatment for sedation, negative symptoms, and cognitive deficits in schizophrenia. Hence, before prescribing modafinil to a schizophrenia patient, the possible risks and benefits of each particular case should be evaluated.

We discuss the case of a patient with Progressive Multifocal Leukoencephalopathy (PML), developed after treatment with Natalizumab for 42 months for relapsing remitting multiple sclerosis (RRMS). Imaging was consistent with wide-spread PML with features that portended a high risk of development of Immune Reconstitution Inflammatory Syndrome (IRIS). After completion of plasmapheresis, she was started on oral maraviroc, chemokine receptor 5 antagonists. Our patient did not develop radiological signs or symptoms of clinical IRIS and tolerated maraviroc without adverse side-effects. We propose that maraviroc merits further examination as an agent that may prevent IRIS in patients with natalizumab-associated PML.

We discuss the case of a patient with a known history of relapsing–remitting multiple sclerosis (MS) who presented with the isolated complaint of altered visual perception in the absence of abnormalities on ophthalmological examination. To the best of the authors’ knowledge, this is the first documented case of both facial metamorphopsia and palinopsia occurring as the symptoms of demyelinating brain lesions consistent with an acute MS exacerbation. These symptoms appear to be related to active demyelination that either involved the optic radiations in the visual pathway or the visual association area in the temporo-occipital region of the left hemisphere.

The authors surveyed Psychiatry Residency Training Directors' (RTDs') attitudes about the role and feasibility of international rotations during residency training.A 21-question survey was electronically distributed that explored RTDs' beliefs about the value, use, and availability of international clinical and research experiences during residency.Of 171 RTDs, 59 (34.5%) completed the survey; 83% of respondents rated the importance of global mental health education as 3-or-above on a scale of 1 (least important) to 5 (most important), but only 42% indicated that such opportunities were made available. The value of such opportunities was thought to lie primarily in professional development and cultural exposure, less so for enhancing core knowledge competencies. Obstacles to such opportunities included lack of accreditation, financial resources, and faculty/administrative support and supervision.RTD respondents endorsed the value of international experiences during residency, but their availability and educational impact are not fully supported.

Not enough research has been carried out on depression up to now in Latin America. The knowledge that has resulted from research activities in the USA or Europe offers limited generalizability to other regions of the world, including Latin America. In the Andean highlands of Ecuador, we found very high rates of moderate and severe depressive symptoms, a finding that must be interpreted within its cultural context. Somatic manifestations of depression predominated over cognitive manifestations, and higher education level was protective against depression. These findings call for an appreciation of culturally specific manifestations of depression and the social factors that influence them. These factors must be further studied in order to give them the deserved priority, allocate resources appropriately, and formulate innovative psychosocial interventions.

Not enough research efforts on depression have been carried out up to now in Latin America. The knowledge that has resulted from research activities in the United States or Europe offers limited generalizability to other regions of the world, including Latin America. In the Andean highlands of Ecuador, we found very high rates of moderate and severe depressive symptoms, a finding that must be interpreted within its cultural context. Somatic manifestations of depression predominated over cognitive manifestations, and higher education level was protective against depression. These findings call for an appreciation of culturally-specific manifestations of depression and the social factors that influence them. These factors must be further studied in order to give them the deserved priority, allocate resources appropriately, and formulate innovative psychosocial interventions.

We discuss the case of a 35-year-old woman who presented with thought impoverishment, disorganized behavior, and echolalia. The patient's condition progressed to treatment-refractory catatonia. She was started on oral Coenzyme Q10 after magnetic resonance imaging of the brain showed findings consistent with drug-induced leukoencephalopathy (DIL). Following improvement, she acknowledged cocaine use that suggested a diagnosis of cocaine-induced leukoencephalopathy (CIL). This case report seeks to elucidate radiological and clinical features of DIL.