Eleni Maneta

Psychiatric manifestations of anti-NMDA receptor encephalitis: neurobiological underpinnings and differential diagnostic implications.

OBJECTIVE Anti-N-methyl-d-aspartate receptor (NMDA-R) encephalitis is a recently discovered disorder with prominent psychiatric manifestations that is often misdiagnosed. The objective of this review is to raise awareness of the disorder among psychiatrists and to expand upon the diagnostic considerations that arise in the context of the neurobiology and symptomatology of this disorder. We also aim to examine the similarities in terms of symptoms and underlying neurobiology between anti-NMDA-R encephalitis and schizophrenia-spectrum illnesses. METHODS The information presented will reflect a review of the literature of the symptomatology and pathophysiology of anti-NMDA-R encephalitis and the role of the NMDA-R in both anti-NMDA-R encephalitis and schizophrenia-spectrum illnesses. RESULTS The studies reviewed highlight the role of the NMDA-R in both anti-NMDA-R encephalitis and schizophrenia in terms of symptom presentation and neurobiology. Studies have also begun to identify involvement of NMDA-R antibodies in patients diagnosed with schizophrenia. CONCLUSIONS There is an increasing need for psychiatrists to become aware of the disorder and consider it in their differential diagnosis, as they are often the first to be consulted on patients with anti-NMDA-R encephalitis. The similarities identified between anti-NMDA-R encephalitis and schizophrenia-spectrum illnesses also raise questions about a common underlying pathophysiology particularly in regard to the NMDA-R.

Links between childhood physical abuse and intimate partner aggression: the mediating role of anger expression

Research linking childhood physical abuse (CPA) and adult intimate partner aggression (IPA) has focused on individuals without sufficient attention to couple processes. In this study, 109 couples reported on histories of CPA, IPA, and anger expression. Actor–partner interdependence model (APIM) was used to examine links between CPA and revictimization and perpetration of IPA, with anger suppression as a potential mediator. Women’s CPA histories were associated with more physical aggression towards and more revictimization by partners. Men’s CPA histories were only associated at the trend level with their revictimization. Anger suppression fully mediated the link between women’s CPA and both revictimization and perpetration of IPA. Findings suggest that women with CPA histories are more prone to suppress anger, which leaves them at greater risk for revictimization and perpetration of IPA.

Two to tango: a dyadic analysis of links between borderline personality traits and intimate partner violence

Although research has shown links between borderline personality and intimate partner violence (IPV), few studies have examined how each partners personality traits may influence the others behavior (Hines, 2008). This study incorporated dimensional assessments of borderline personality organization (BPO) in both partners into a dyadic model that examined associations with IPV. In a community sample of 109 couples, an Actor-Partner Interdependence Model was used to examine links between BPO traits in each partner and victimization and perpetration of IPV. Mens level of BPO traits was associated with more IPV toward and more victimization by their partners. Womens level of BPO traits was associated with their victimization only. This study is unique in examining links between BPO and IPV in couples using analyses that account for the interdependence of these variables in dyads.

Epigenetic Treatment of Neuropsychiatric Disorders: Autism and Schizophrenia.

Preclinical Research

Teaching Child and Adolescent Psychiatry in the Twenty-First Century: A Reflection on the Role of Technology in Education

Technology has become an integral part of everyday life and is starting to shape the landscape of graduate medical education. This article reviews the use of technology in teaching child and adolescent psychiatry (CAP) fellows, and 3 main aspects are considered. The first aspect is use of technology to enhance active learning. The second aspect covers technology and administrative tasks, and the third aspect is the development of a technology curriculum for CAP trainees. The article concludes with a brief review of some of the challenges and pitfalls that have to be considered and recommendations for future research.

Lessons from the Launch: Program Directors Reflect on Implementing the Child and Adolescent Psychiatry Milestones

Beginning in July 2014, the Accreditation Council for Graduate Medical Education (ACGME) required all psychiatry residency programs in the USA to implement milestonebased assessments as a critical component of the Next Accreditation System (NAS). Milestones are competencybased developmental outcomes (i.e., knowledge, skills, attitudes, and performance) that a trainee is expected to progressively attain over the course of training [1]. The new milestone-based assessment was derived from the ACGME’s original six core competencies of patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills, which are assessed among all medical specialties. The ACGME Psychiatry Milestone Working Group developed 22 sub-competencies for assessment within general psychiatry. A year later, the Child and Adolescent Psychiatry (CAP) Milestone Working Group derived 21 CAP-specific sub-competencies from those established for general psychiatry.Within each sub-competency are five levels, each of which details specific milestones that are achieved before one progresses to the next level. This national approach to assessment was developed to ensure that residents and fellows in graduate medical education are capable of independently providing high-quality, safe patient care upon completion of training [2]. Prior to the formal July 2014 implementation, there were publications describing the purpose and intent of the Psychiatry Milestones Project, the development process, potential evaluation tools and techniques to assess milestone acquisition, and a resident perspective on the potential utility of milestones [3–5]. Since implementation of the milestones, some educators have raised concerns about whether the shift to milestone-based assessments was premature. One concern is that the milestones were based solely on consensus expert opinion in the absence of empirical evidence of their validity in assessing meaningful markers of psychiatric competence that actually translate to positive patient outcomes. Another

Mobile Technologies in Child and Adolescent Psychiatry: Pushing for Further Awareness and Research

Over the past four decades, mobile devices have evolved from the once bulky and expensive cellular phones of the past to the sleek, inexpensive, and omnipresent smartphones of today, which are used by adults and children alike. In the United States nearly 75% of teens either own or have access to a smartphone. Family income and place of residence do not appear to change teens’ access to smartphones drastically; 61% of teens in households with income less than

Misdiagnosis and a suicide attempt: the importance of accurate evaluation and treatment

30k have access to smartphones, as do 68% of those living in rural areas. This increasing accessibility to smartphones raises important questions about their potential use as a vehicle to deliver improved mental health interventions, particularly in view of the continuing shortage of child and adolescent psychiatrists. A better understanding among clinicians of how smartphones can affect treatment is also important because children and adolescents are already using various forms of self-help applications (apps). The purpose of this column is to identify advantages and disadvantages of using mobile technology in the psychiatric treatment of children and adolescents, and also to identify the questions that remain to be answered in this ever growing aspect of child mental health. While the present article is not a comprehensive review of the literature available to date, we draw extensively on that literature to address the above issues concerningmental health treatment usingmobile technologies. A basic function of cell phone technology—texting—has already infiltrated into Child and Adolescent Psychiatry practice. DeJong and Gorrindo reviewed the use of texting in patient care and some of the advantages that it offers, which include speed and directness of interaction, accessibility, and portability. Preliminary evidence shows that adolescents are

Linkages between childhood emotional abuse and marital satisfaction: The mediating role of empathic accuracy for hostile emotions

. is a 16-year-old boy with a history of depression andnewly-diagnosed attention deficit hyperactivity disorder(ADHD) who was admitted to an adolescent inpatient psychiatricunit after an impulsive suicide attempt by overdose on 945mg ofOROS methylphenidate.History of Present IllnessB. had been described by his mother in general as ‘‘perpetuallyself-critical,’’shy,andintroverted.TheonsetofB.’sdepressedmoodoccurredapproximatelyoneyearpriortopresentation,andhesoughtmental health treatment at that time. His depressed mood was ac-companied by hopelessness, helplessness, anxiety, and low self-esteem. He was referred initially for cognitive behavioral treatmentin his community and was subsequently started on fluoxetine 10mgdailybyhispediatrician.Afterfluoxetineinitiation,B.demonstratedsome improvement in mood, and the dose was increased to 20mgdaily. Soon after the dose increase, he began to experience rest-lessness, and mother noted him to be more ‘‘fidgety,’’ constantlytapping his foot against the floor and wringing his hands.Within a few days of the fluoxetine dose increase, B. attemptedsuicide for the first time by ingesting an overdose of the remainingfluoxetinetablets;bothpatientandmotherwereunsureofquantity.He reported that he had been thinking about suicide for a day or sopriortotheattempt.Heconsumedthetabletsandwaitedacoupleofhoursforaneffect,butreportedlycontinuedto‘‘feelfine.’’Hethenplaced his bed sheets around his neck and fashioned them into anoosebutdidnotpullonthemortiethemtoanotherobject.Instead,B.becameconcernedanddisclosedhisattempttohismother.Theypresented to the emergency department of a local hospital, and B.was subsequently admitted to its inpatient psychiatric unit. Hissuicide attempt was attributed to activation by fluoxetine, whichwas discontinued; B. was started on lamotrigine 12.5mg twicedaily (BID) for mood stabilization and was discharged one weeklater to the care of his cognitive behavior therapist and a psycho-pharmacologist.B.continuedonlamotrigine12.5mgorallyBIDuntilonemonthprior to his current presentation when he started complaining ofmultiple, concurrent, and constantly running thoughts that dis-tracted him and slowed him in completing his schoolwork. He alsoreported that these ‘‘trains of thoughts’’ affected his concentrationwhen at home and when out with friends. He reported that histhoughts had always been this way, although he’d never struggledacademically and there was never anyconcern raisedby the schoolor his mother. At that time, B. was diagnosed with ADHD by hisoutpatient team, and OROS methylphenidate 27mg daily was ad-ded to his lamotrigine. OROS methylphenidate was increased to54mgdailyapproximately1weekpriortohiscurrentpresentation.After the dose increase B. reported that he initially felt his con-centration was improved; however, 4 days prior to presentation hehad an unusual episode during which he experienced suddenparanoia—he felt his peers were talking negatively about him andmocking him. He stated that he could hear their voices sayingderogatory comments, and he felt everyone was staring at him.He also reported anxiety, chest tightness, and a ‘‘panicky’’ feeling.B. was taken to the nurse’s office after disclosing this to a teacherand within a couple of hours began to calm down and feel better.This episode had reportedly been precipitated by limited food in-take and very little sleep the night before.Over the next few days, B. did not take his methylphenidate andstarted noticing increasing anxiety and shame around the inci-dent that had occurred at school. On the night of presentation, at 2am, B. had impulsively ingested all of his remaining OROSmethylphenidatetablets,whichtotaled35(approximately945mg).He denied any suicidal ideation prior to overdose and, in fact,denied any memory of the overdose—he stated that the first thinghe remembered was the sensation of pills in his throat, and this ishow he realized he had overdosed. B. alerted his mother immedi-atelyandtheypresentedtotheemergencydepartment.Uponinitialpresentation he was noted to be tachycardic and hypertensive, andwas treated with intravenous (IV) lorazepam. After medical sta-bilization, he was admitted to the inpatient psychiatric unit forfurther evaluation and treatment.Past Psychiatric HistoryB. had one prior suicide attempt and one prior psychiatric hos-pitalization approximately 5 months prior to his current presen-tation, as noted above. There was no other history of self-injuriousbehavior.Developmental HistoryB. was conceived via in-vitro fertilization and the product of anuneventful, full-term pregnancy. B. was reported to be develop-mentally on target, and all milestones were met on time.