Michael Shapiro

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.

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.

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.

Prevalence and characteristics of punding and repetitive behaviors among Parkinson patients in North‐Central Florida

To date, there are limited data on the prevalence of repetitive behavior and complex stereotyped motor behaviors such as punding in Parkinson’s disease (PD). A form of repetitive behavior, punding is characterized by an intense fascination with repetitive manipulations of technical equipment, continual examining, handling, and sorting of common objects; grooming, hoarding, and writing (Evans et al., 2004; Friedman, 1994; Nguyen et al., 2007; Miyasaki et al., 2007; Voon et al., 2006). While punding, has been technically described as a ‘‘meaningless preoccupation,’’ reported punding behavior in PD has included excessive gardening, organizing and sorting objects as well as increased writing (Evans et al., 2004; Friedman, 1994; Nguyen et al., 2007; Miyasaki et al., 2007; Voon et al., 2006). Therefore, our study broadly includes other purposeful preoccupations under the umbrella term ‘‘repetitive behavior.’’ A purposive sampling by mail was first conducted on patients diagnosed with PD from the University of Florida Movements Disorders Center. The survey contained a demographic data questionnaire and a compulsive behaviors questionnaire (Evans et al., 2004; Nguyen et al., 2007). Patient survey responses were screened, then patients who met criteria for ‘‘possible’’ punding or other pathological repetitive behavior were interviewed for further classification as having: no, mild, moderate, or severe repetitive behavior. Punding or pathological repetitive behavior was defined as: a stereotyped behavior; (meaningless or constructive) that was not in response to an obsession, fear or anxiety and was excessive, disruptive, and interruptive. The total daily levodopa equivalent dose (LED) was also determined in milligram for each patient (Evans et al., 2004). For the data analysis on completed surveys, frequency distributions were compared using x test and majority of continuous variables were compared using Student t-test. One hundred twenty two of 464 mailed surveys were completed. Twenty nine out of 122 (23.77%) met our initial criteria for ‘‘possible’’ punding or pathological repetitive behavior. The prevalence of repetitive

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.

Zonisamide for Weight Loss in Adolescents

Obesity in children and adolescents is a growing epidemic in the United States, and physicians are increasingly looking for safe and effective treatments. In recent years, pharmacologic treatment has been considered for severe and refractory cases of adolescent obesity. We present a case of an obese adolescent who presented to an inpatient psychiatric unit with a body mass index (BMI) of 37.8 (>98th percentile for age). He was started on zonisamide for the purposes of weight loss, and a steady decrease in weight and BMI was noted through 4 months of outpatient follow-up. During this time, the patients weight decreased from 126.8 kg to 106.2 kg, a 20.6-kg loss, representing a 16.25% reduction in weight. His most recent BMI decreased to 31.7 (96th percentile for age). We discuss the potential use of zonisamide for weight loss in adolescents, considering the potential risks and benefits.

Zonisamide for Attenuation of Weight Gain in a Morbidly-Obese Adolescent on an Antipsychotic

Obesity is a growing problem in the child and adolescent population. Particularly concerning is the trend of overweight children being increasingly prescribed antipsychotic medications that can lead to further weight gain. We present a case of a morbidly obese adolescent male who had made strides in weight loss with psychopharmacologic aide who was started on an antipsychotic. Weight loss plateaued, and zonisamide was added to further help with weight loss. We discuss the possible risks and benefits of this medication in aiding in preventing weight gain associated with antipsychotic medication.

A case of severe adolescent obsessive-compulsive disorder treated with inpatient hospitalization, risperidone and sertraline.

BACKGROUND The initial treatment of obsessive-compulsive disorder (OCD) has generally been limited to serotonergic agents, cognitive-behavioral therapy (CBT), or a combination of the two. These findings were supported by the POTS study for OCD in children and adolescents. However, treatment with serotonergic agents or CBT can take several weeks before benefit is seen; severe cases of OCD may require more immediate treatment. CASE REPORT The authors present a case of severe OCD in an adolescent that required immediate treatment due to her critical medical condition. The patients symptoms included not eating or taking medications or fluids by mouth due to fears of contamination. A medical hospitalization was previously required due to dehydration. As treatment with an SSRI would not have quick enough onset and the patient was initially resistant to participating in CBT, the patient was psychiatrically hospitalized and first started on liquid risperidone. After several doses of risperidone, the patient was able to participate in CBT and start sertraline. DISCUSSION The authors discuss the differential diagnosis of such a patient, including the continuum of OCD symptoms and psychotic symptoms. The authors discuss the different treatment options, including the utilization of inpatient psychiatric hospitalization. The authors discuss the potential risks and benefits of using atypical antipsychotics in lieu of benzodiazepines for the initial treatment of severe adolescent OCD. The authors also discuss other current treatment recommendations and rationale for the treatment that was pursued. CONCLUSIONS This patient received benefit of her symptoms relatively quickly with psychiatric hospitalization and an atypical antipsychotic. The diagnosis of a psychotic disorder should be considered. These treatment options must be weighed against the risks of atypical antipsychotics, including extrapyramidal symptoms, weight gain, and metabolic syndrome; benzodiazepines also have their risks and benefits. Additionally, the cost of time and finances of inpatient hospitalization must be considered. More research is needed regarding the short- and long-term efficacy and safety of antipsychotics in the treatment of OCD in the child and adolescent population.

Raise Concerns Without Fear and Protect Confidentiality: Why the Two Orders?

“Why the two orders?” was a question asked in a tense scene in the courtroom drama A Few Good Men, right before the famous “You can’t handle the truth!” speech. The question was in regards to a military general giving two orders whose premises were in contradiction with each other, and *spoiler alert* to anybody who has not yet seen the film. The movie concerns the military trial for twomarines accused in the death of a private. The two marines claim they were ordered by superiors to give the private a “code red,” an illegal and harsh form of discipline, and the private died during the “code red.” The arrogant colonel tries to refute this claim and testifies that he specifically ordered the rest of the marines not to harm the private, and his orders are never disobeyed. The colonel also testifies that he ordered to have the private transferred off the military base because he believed the private was in danger. The lawyer, however, asks the colonel that if his orders are always obeyed, and he ordered the marines not to harm the private, then why would the private be in danger? Why would it be necessary to order the private transferred off the base, if he already ordered the marines not to harm the private? Why the two orders? This contradiction forces the colonel to admit the two orders were lies: there was no transfer order, and the colonel really did order the code red. The colonel thought he could lie and cover his bases by making it look like he was doing everything he could to protect the private. In attempting to cover up his lie, the colonel described two orders that each alone would have protected the private, but both orders together are a contradiction. I was reminded of this scene during our most recent Annual Program Evaluation for our Child & Adolescent Psychiatry Fellowship. Yet again, we have to address the dilemma of the trainees’ fear of retaliation in reporting concerns or incidents of harassment and discrimination. This is apparently not an uncommon problem [1], as I found out at the annual meeting of the Association of Academic Psychiatry this year. At the reception dinner, I found myself chatting with a program director who was still battling the “fear of retaliation” on the resident surveys. Even after instituting a resident retreat, a process group, increased transparency of rotations, and confidential methods to report concerns, our institutions’ surveys continue to report high levels of fear. It was difficult to think of what else could logically be done to diminish this fear. The Accreditation Council for Graduate Medical Education (ACGME) Resident Survey Content Areas note that under “Evaluation,” residents are asked if they are “satisfied that evaluations of program are confidential” and “satisfied that evaluations of faculty members are confidential” [2]. Under “Resources,” they are asked if “residents/fellows can raise problems or concerns without fear of intimidation or retaliation” and are they “satisfied with your program’s process to deal confidentially with problems or concerns residents/fellowsmight have” [3]. The survey has not changed since 2011 to allow for historical tracking and reporting [4]. However, a previous version of the survey from 2007 to 2008 was evaluated and published [5]. In this earlier version, item #17 was written as, “Are mechanisms within the institution available to you so that you may raise and resolve issues without fear of intimidation or retaliation?” with 31.9% of responses indicating noncompliance. In the same year, item #7 asked whether trainees “have the opportunity to confidentially evaluate your faculty” and #8 asked the same about confidentially evaluating the program as a whole. These items were only rated as noncompliant in 3.8 and 8.2% of respondents, respectively. As a caveat, the use of surveys to accurately and truthfully assess residency programs is controversial [6]. Having said that, we might expect that high rates of confidentiality would be associated with lower rates of fear of retaliation or intimidation. However, despite the vast majority of programs being rated as compliant with issues of * Michael Shapiro mshapiro@ufl.edu

Recurrence of conversion disorder symptoms in a successfully treated 16-year-old female

We present a case of a 16-year-old Caucasian female with a history of major depressive disorder and post-traumatic stress disorder who was admitted to an inpatient adolescent psychiatric unit with symptoms of conversion disorder, including non-epileptic seizures, an inability to speak or walk, and not eating on her own. She has a history of multiple previous medical and psychiatric hospitalizations without any significant resolution of symptoms, and extensive medical workups have all been negative. Treatment ultimately involved reassuring the patient and family that there was no underlying medical condition and emphasizing the conversion disorder diagnosis. The patient participated daily in physical therapy to improve mobility, deconditioning, and functioning. Hospital staff was instructed on the nature of the non-epileptic seizures, which continued to occur during the hospitalization. After one month, the patient was discharged home fully functional: walking, speaking, and eating on her own. One week after discharge, the patient presented with the same symptoms and was readmitted to the psychiatric facility. She subsequently never regained her previous level of functioning, and she was ultimately transferred to a residential treatment facility. We will discuss factors that led to the initial improvement and the factors that led to recurrence and persistence of symptoms.