Mathew Nguyen

Family Engagement, Consumer Satisfaction and Treatment Outcome in the New Era of Child and Adolescent In-Patient Psychiatric Care

This study examined the association between family engagement and consumer satisfaction for the seriously emotionally disturbed children and adolescents admitted to an in-patient psychiatric unit in a large medical center. Participants were 45 male and female in-patients, aged 7–17, and their parents. At the time their child was discharged, parents completed a demographic questionnaire, the Achenbach Child Behavior Checklist, and the Inpatient Parental Satisfaction Index. At the same time, the child’s psychiatrist completed the Family Engagement Questionnaire. Results indicated that engagement is related to satisfaction, prior in-patient treatment is negatively related to engagement, and satisfaction with prior in-patient services is highly predictive of satisfaction with current services. At 9-month follow-up, 32% of the sample had been re-hospitalized. Rehospitalization was associated with poorer engagement in treatment and lower parent ratings of satisfaction with care. These results suggest the existence of a group of patients who undergo repeat hospitalizations with poor levels of engagement in their care.

A Review of the Use of Clonidine as a Sleep Aid in the Child and Adolescent Population

Clonidine is a presynaptic α 2 -agonist that is approved by the Food and Drug Administration (FDA) for the treatment of hypertension. There has also been growing evidence that α-agonists have been effective in the treatment of attention-deficit/hyperactivity disorder (ADHD), with the first trial of clonidine in children with ADHD taking place in 1985. Since then, immediate-release (IR) formulations of clonidine and guanfacine and an extended-release clonidine transdermal therapeutic system have been used off-label for the treatment of ADHD in children. More recently, long-acting formulations of clonidine and guanfacine have been approved by the FDA for the treatment of ADHD in children and adolescents. Clonidine in particular has also received notoriety for being prescribed as a sleep aid in children with or without ADHD. In this review, we examine the current practices of prescribing IR clonidine in the child and adolescent population as a sleep aid, the evidence-based medicine supporting its use, its safety and efficacy, and its current place in treatment.

Adult Baby Syndrome and Gender Identity Disorder

Adult Baby Syndrome (ABS) has been reported now by several authors. Pate and Gabbard (2003) associated it with paraphiliaand Croarkin,Nam,andWaldrep (2004)connected it to Obsessive–Compulsive Disorder (OCD). Evcimen and Gratz (2006) described a case that was associated with neither paraphilia nor OCD. We present a case of ABS in a patient in which there did not seem to be a connection to either paraphilia or OCD, but, interestingly, the case was further complicated by gender identity issues. Mr. B is a 38-year-old biological male who prefers to be identified as a female; therefore, Mr. B will further be referred to as Ms. B. She currently lives in a nursing home. She was first placed in a nursing home per her request after she was hospitalized with chest pain2yearsprior.Shewasreferredforpsychiatric treatmentbyher nursing home physician forevaluation of‘‘delusions.’’Ms.Bstated that she was born with both female and male reproductive organs, specifically,uterus,ovaries,andapenis,andclaimedshewasraised as a female. Her primary complaint during the evaluation was that the nursing home staff often addressed her as a male rather than a female. When this occurred, she becameveryupset and essentially hada temper tantrum,grabbingherchest,gasping forair, crying hysterically,yelling andcursing,anddemanding toseeasupervisor:‘‘It takes an army of nurses to calm me down.’’Ms. B also did not like male staff in her room because of a reported history of sexual abuse by an uncle at the age of 3. She also claimed physical abuse by a staff member in her previous nursing home who had allegedly hit, slapped, and punched her in the stomach. Ms. B’s other complaint was that she liked to be treated as a baby. The Certified Nurse Aide who accompanied her said she often regressed toan infant, particularly at night time. She used bottles, pacifiers, and baby-talk. She would rather have a crib than a bed. Ms. B had been engaging in these behaviors the last 2 years, but stated she had wanted to be a baby for the last 7years. Shesaid that the pacifiergaveher security. Sheworea briefdue to incontinence but insisted on calling it a diaper so she could be identifiedmore asa baby. Ms. B stated she would like to bea baby because it relieved her of all her adult responsibilities. She felt she would not have to worry about anything as babies are innocent. She did not‘‘want to grow up.’’Often when asked a question, she prefaced her answer with‘‘Well, as a baby’’and then proceeded to answer the question. The patient stated,‘‘For the record, I don’t consider myself an adult. I would like to be treated asa baby, be re-taught, and be re-trained.’’She was very clear, however, that she knew she was not a baby. Ms. B denied a history of depression. She reported as a teenagerbeingplacedonfluoxetine for 2 weeks but had not beenon antidepressants since. However, her medical record indicated that shewascurrentlyonescitalopram10 mgdaily.The patient denied taking any psychiatric medications and was very upset that this was on her medical record. She denied current depressive symptoms and suicidal ideation. Ms. B also did not endorse any current subjective anxiety symptoms. She reported a history of sexual molestation and physical abuse; however, her symptomatology did not meet the level of Posttraumatic Stress Disorder.Other than thisunusualdesire tobecomeababy, thepatient did not endorse nor did she display other psychotic symptoms, such as auditory or visual hallucinations, paranoia, ideas of reference, thought broadcasting, thought insertion or disorganized behavior or speech. The patient reported being placed in a psychiatric hospital 8 months prior because the nursing home did not wantheranymore. She endorsed seeing an outpatient psychiatrist in 1994 for evaluation for gender reassignment surgery and was reportedly approved for surgery, but had yet to have the surgery for unclear reason. The patient reported having Guillain–Barre K. Kise (&) M. Nguyen Division of Child and Adolescent Psychiatry, University of Florida College of Medicine, POB 100234, Gainesville, FL 32610, USA e-mail: kkise@ufl.edu

Topiramate, zonisamide and weight loss in children and adolescents prescribed psychiatric medications: A medical record review.

Background Childhood obesity is a growing epidemic that is contributed to by the use of psychopharmacological agents, such as antipsychotics. This study represents a preliminary investigation into the effectiveness of two anticonvulsants that were hypothesized to reduce weight in a pediatric sample seeking treatment at a psychiatric clinic. Methods The electronic medical records of a university-based child and adolescent psychiatric clinic were reviewed for patients who were first prescribed either topiramate or zonisamide between 1 July 2011 and 30 June 2013. Based on inclusionary criteria, the review identified 47 children or adolescents. Results Multilevel modeling was utilized for study analyses. Including the full sample and controlling for confounders, anticonvulsant dosage was uniquely associated with an average reduction in body mass index of 1.3 (dosages above 200 mg) to 4.1 (dosages below 50 mg) every six months of treatment. Exlucing patients whose baseline body mass index was below 25.0 and controlling for confounders, anticonvulsant dosage was uniquely associated with an average reduction in body mass index of 3.2 (dosages above 200 mg) to 6.1 (dosages below 50 mg) every six months of treatment. Weight reduction was not statistically different between topiramate or zonisamide. Anticonvulsants were associated with an increase in body mass index, yet the benefits of the two anticonvulsants on weight loss remained despite the counteractive effects of antipsychotics. Conclusions Results provide preliminary evidence that topiramate and zonisamide may be utilized for weight loss in a pediatric psychopharmacological treatment seeking sample, even if antipsychotics are also prescribed. A randomized controlled trial investigating the impact of topiramate and zonisamide on weight reduction is warranted.

Treatment of refractory substance-induced psychosis in adolescent males with a genetic predisposition to mental illness.

Abstract This article presents two cases of adolescent males who were admitted to our inpatient psychiatric unit with a psychotic, disorganized presentation. Both males had a genetic vulnerability to mental illness and reported significant substance use. Their symptoms were refractory to treatment and required the use of clozapine. Both patients experienced significant side effects, which limited the maximum daily dose of clozapine. However, they responded to a dose that was much lower than that typically used in adults. There is significant evidence in the literature about cannabis use triggering psychotic breaks in vulnerable individuals. We speculate that substance use (including synthetic cannabinoids) triggers treatment-resistant psychosis that requires the use of clozapine. Further, lower doses of clozapine may be sufficient to treat the substance-induced psychotic symptoms than those typically used in adult schizophrenia.

A case of priapism with risperidone.

Priapism is a urologic emergency defined as a prolonged, possibly painful, penile erection. There are several known causes of priapism including psychotropic medications. One of the mechanisms by which antipsychotics are believed to induce priapism is through alpha-1 antagonism. This is case of a 50-year-old male with a history of schizophrenia with previous priapism related to trazodone, who presents with new onset priapism associated with risperidone. In this case, the treatment of priapism includes discontinuation of the offending agent and drainage of the corpus cavernosum twice along with intracavernosal phenylephrine injections. It is important to educate patients on priapism as a possible side effect of medications. It is also important to consider previous episodes of medication-induced priapism when prescribing psychotropic medications as this may increase the patients future risk of priapism.

Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) in an Adolescent Treated With Lamotrigine

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a hypersensitivity syndrome most commonly associated with antiepileptic agents, allopurinol, and sulfonamides. It is a severe adverse reaction associated with fever, rash, eosinophilia, lymphadenopathy, and internal organ involvement. We present the case of a 17-year-old Caucasian female with bipolar disorder type II and posttraumatic stress disorder treated with lamotrigine for a non-Food and Drug Administration-approved indication that developed DRESS syndrome at an initial dose higher than that recommended. Her symptoms were atypical in that she developed a rash with influenza-like symptoms that resolved after discontinuation of lamotrigine and returned 8 days later. She was hospitalized because of elevated liver enzymes and treated with corticosteroids. In patients presenting with rash and systemic symptoms, DRESS syndrome should be considered and treated appropriately to reduce mortality, which can be as high as 10%. Treatment includes withdrawal of the offending agent and corticosteroids.

When Non-Epileptic Seizures Fool the Experts

Even when non-epileptic seizures are correctly diagnosed, appropriate treatment recommendations may not be fully or correctly implemented. We present a case of a 17-year-old girl with frequent non-epileptic seizures who presented for frequent trips to the emergency room (ER) and was admitted to an inpatient Child and Adolescent Psychiatric Facility. Despite being informed that episodes were non-epileptic seizures, various staff and healthcare providers at the psychiatric hospital continued to send the patient to the ER to treat suspected epileptic seizures. We discuss possible reasons why this may have occurred, including psychosocial and emotional reactions of staff members to the episodes. This discussion may also help to explain the persistence of the patients episodes. We also present options for minimizing the potential for future mismanagement of non-epileptic seizures.

A Case Study of Anorexia Nervosa Driven by Religious Sacrifice

Anorexia nervosa (AN) is considered a relatively “modern” disorder; however, a number of scholarly works have cited examples of voluntary self-starvation dating back to several centuries. In particular, there are many examples of female starvation for religious reasons during the medieval period, with many being elevated to sainthood. We present a case of an elderly woman with AN who began restricting her diet when she was 13-years old while studying to be a nun at a Catholic convent. She reports that, during the development of her disease, she had no mirrors and, rather than restricting her diet to be thin or attractive, she restricted her diet to be closer to God in hopes of becoming a Saint. This unique case presents an opportunity to deepen our understanding of AN and the cultural context that affects its development.

Severe Anorexia Nervosa in a 20-Year-Old Male with Pericardial Effusion and Cortical Atrophy

This case report describes a 20-year-old man with a severe presentation of anorexia nervosa. His case is unique in that he presented at 49% of his ideal body weight and had a body mass index (BMI) of 11.59. In addition, he had cognitive slowing on exam and had cortical atrophy on a head CT. Other medical complications included pericardial tamponade that was treated with an open window pericardiocentesis, hepatitis, and anemia. He was treated nutritionally, first with a Dobb-Hoff tube and then with oral feedings, as well as had group, individual, and family therapies. He responded well to treatment, his labs normalized and he was discharged at 75% of his ideal body weight after a weight increase of 40 pounds and after 106 days of hospitalization at our facility. In addition, a head CT was repeated and the cortical atrophy had resolved.