Sheldon Benjamin

Neuropsychological correlates of domestic violence

Neuropsychological functioning was assessed in 39 males who had committed domestic violence (batterers) and compared to 63 nonviolent (both maritally discordant and satisfied) subjects recruited by advertisement. Subjects were subsequently divided into two groups (head injured, nonhead injured) and these groups were also contrasted as a function of batterer status. Tests were administered to assess for cognitive and behavioral functions, including executive dysfunction, hypothesized to be a factor contributing to propensity for violence. Questionnaires and structured clinical interviews were used to assess marital discord, emotional distress, and violent behaviors. Batterers differed from nonbatterers across several cognitive domains: executive, learning, memory, and verbal functioning. Batterers were reliably discriminated from nonbatterers based on three neuropsychological tasks: Digit Symbol, Recognition Memory Test- Words, Wisconsin Card Sorting Test. Neuropsychological performance was the strongest correlate of domestic violence of all clinical variables measured. However, the inclusion of two other variables, severity of emotional distress and history of head injury, together with the neuropsychological indices provided the strongest correlation with batterers status. Among batterers, neuropsychological performance did not vary as a function of head injury status, indicating that while prior head injury was correlated with batterer status, it was not the sole basis for their impairments. The findings suggest that current cognitive status, prior brain injury, childhood academic problems, as well as psychosocial influences, contribute along with coexisting emotional distress to a propensity for domestic violence.

A pilot study of nadolol for overt aggression in developmentally delayed individuals

OBJECTIVE The aim of this preliminary pilot study was to investigate the safety and efficacy of open-label nadolol as an adjunctive pharmacological treatment for aggression and/or inattention/overactivity in a developmentally delayed child, adolescent, and young adult population. METHOD Twelve subjects enrolled and completed (mean age 13.8 years, range 9 through 24) a 5-month, open, prospective protocol of nadolol (mean dose 109 mg, range 30 through 220 mg) with systematic baseline and outcome evaluations and weekly clinical assessment. RESULTS All subjects were developmentally delayed and most were cognitively delayed. Ten subjects (83%) showed clinical improvement while receiving nadolol. Significant improvements were noted on observer-rated overt categorical aggression, severity of illness, and global impressions of improvement. No significant effects were found for inattention/overactivity. Nadolol was well tolerated, with few side effects. CONCLUSIONS Overt categorical aggression presenting in developmentally delayed children, adolescents, and young adults may respond to nadolol treatment.

Case Study: Paradoxical Response to Naltrexone Treatment of Self-Injurious Behavior

Opioid receptor antagonists have been studied in the management of self-injurious behavior (SIB) in developmentally disabled individuals. The authors present a case of a severely retarded, autistic man whose SIB increased dramatically during a trial of naltrexone. A paradoxical increase in SIB, attributed to the extinction burst phenomenon during the initial period of nonreward, is known to occur during treatment with naloxone, a short-acting parenteral opioid antagonist. It has only once been reported during treatment with naltrexone, a long-acting orally administered agent. Opioid analgesic effects and learning theory can explain both increases and decreases in SIB after opioid blockade.

Professionalism and the Internet in Psychiatry: What to Teach and How to Teach It

The digital revolution has had a profound impact on medicine and patient care. Patients have a growing expectation that they can find medical information on the web and discuss it with their physician by e-mail (1). Physicians, including psychiatrists, are increasingly using blogs and Twitter to promote their practices (2, 3). The internet itself is used as a vehicle for therapeutic modalities, even psychotherapy (4). Social networking among patients, physicians, and other “friends” are blurring boundaries as never before (5, 6). The potential clinical, legal, ethical, and professionalism issues in using the internet and digital media in psychiatry have been outlined elsewhere, including explicit recommendations for resident education in this area (7). This article focuses on how to teach residents about appropriate use of the internet. The evidence of unprofessional online behavior among physicians and the complexity of the potential issues raised with internet use in psychiatry suggest that psychiatric residents, educators, and administrators need explicit teaching about potential clinical, ethical, and legal pitfalls of internet use. In 2010, the President of the American Association of Directors of Psychiatric Residency Training (AADPRT) established a Taskforce on Professionalism and the Internet, charged with reviewing the literature and creating a curriculum to teach psychiatric trainees about online professionalism. Participants in a Taskforce-run workshop on this subject were asked for examples from their own experience of online professionalism concerns (8), and an outpouring of vignettes ensued. TheTaskforce undertook to create a curriculum based on vignettes designed to promote similar discussion. The principles elicited in these vignettes might be seen as extensions of well-established principles of professionalism (9, 10). Trainees accustomed to continual use of interactive technologies, however, may overlook boundary and other professionalism issues if they are not made explicit in training. The curriculum strives to address principles, rather than specific technologies, since the latter are expected to continue to evolve rapidly. The vignettes in this curriculum (available online at aadprt.org (11)) are designed for either group discussion or individual study; they are accompanied by relevant references and a teacher’s guide. The vignettes are organized around nine issues that may be relevant to various teaching venues: liability, confidentiality, and privacy; psychotherapy and boundaries; safety issues; mandated reporting; libel; conflicts of interest; academic honesty; “netiquette;” and professionalism remediation. We discuss the first eight of these topics, using vignettes from the curriculum for illustration. Where vignettes are based on actual cases, all identifying details are disguised.

Case study : neuroleptic withdrawal dyskinesia exacerbated by ongoing stimulant treatment

Risk factors for neuroleptic withdrawal dyskinesia in children have not been well studied. The authors present a case of a child who had been treated with a combination of neuroleptics and stimulants for nonpsychotic aggressive behavior. A severe withdrawal dyskinesia precipitated by neuroleptic tapering was ameliorated by discontinuation of the psycho-stimulant. Although stimulants have been reported to increase certain involuntary movement disorders, this is the first known report of psychostimulant exacerbation of withdrawal dyskinesia.

Educating psychiatry residents in neuropsychiatry and neuroscience

Abstract Neuropsychiatry and psychiatric neuroscience should be part of the general psychiatry curriculum so that graduate psychiatrists will be able to allow their patients the benefit of neuroscientifically informed diagnosis and treatment. Current neurology and neuroscience educational requirements for US psychiatry training are reviewed. The draft milestone requirements for clinical neuroscience training as part of the US Accreditation Council for Graduate Medical Educations Next Accreditation System are also provided. Suggestions for the neuropsychiatric and neuroscience content of psychiatry residency training are made, along with a description of pedagogic methods and resources. Survey data are reviewed indicating agreement by programme directors with the importance of neuroscience training and an increase in the amount of time devoted to this area. Faculty staff development in neuropsychiatry and neuroscience literacy will be needed to provide high quality training in these areas.

Psychiatric presentations of epilepsy.

&NA; The abnormal neuronal excitability underlying seizure disorders may alter behavior. Behavioral alterations associated with epilepsy can occur during the ictal period, especially in patients who suffer partial seizures of temporal or frontal lobe origin, or during the interictal period in the setting of chronic temporolimbic seizure discharges. We use case descriptions to illustrate behavioral presentations of epilepsy that resemble primary psychiatric illnesses, including schizophrenic psychoses, mood disorders, panic disorder, and dissociative disorders. The varied secondary psychiatric syndromes produced by epilepsy are elucidated by a consideration of normal functions of temporal and frontolimbic structures. The clinical pictures provide clues to the causes of primary psychiatric disorders.

Congenital and Acquired Disorders Presenting as Psychosis in Children and Young Adults

A review of the published literature found 60 congenital and acquired disorders with symptoms that include psychosis in youth. The prevalence, workup, genetics, and associated neuropsychiatric features of each disorder are described. Eighteen disorders (30%) have distinct phenotypes (doorway diagnoses); 18 disorders (30%) are associated with intellectual disability; and 43 disorders (72%) have prominent neurologic signs. Thirty-one disorders (52%) can present without such distinct characteristics, and are thus more easily overlooked. A systematic and cost-effective differential diagnostic approach based on estimated prevalence and most prominent associated signs is recommended.

Psychopharmacology curriculum field test

ObjectiveAs part of an effort to improve psychopharmacology training in psychiatric residency programs, a committee of residency training directors and associate directors adapted an introductory schizophrenia presentation from the American Society of Clinical Psychopharmacology’s Model Psychopharmacology Curriculum to develop a multimodal, interactive training module. This article describes the module, its development, and the results of a field trial to test its feasibility and usefulness.MethodsNineteen residency programs volunteered to use the module during the first half of the 2007–2008 academic year. Evaluation consisted of a structured phone interview with the training director or teaching faculty of participating programs during February and early March 2008, asking whether and how they used the curriculum, which components they found most useful, and how it was re]by faculty and residents.ResultsOf the 19 programs, 14 used the module and 13 participated in the evaluation. The most commonly used components were the pre- and postmodule questions, video-enhanced presentation, standard presentation, problem- or team-based teaching module, and other problem-based teaching modules. No two programs used the module in the same fashion, but it was well re]by instructors and residents regardless of use.ConclusionThe results of this field trial suggest that a dynamic, adult-centered curriculum that is exciting, innovative, and informative enough for a wide variety of programs can be developed; however, the development and programmatic barriers require considerable time and effort to overcome.

Neuropsychiatry and Neuroscience Milestones for General Psychiatry Trainees

For nearly 50 years, psychiatric thought leaders have suggested that advances in our understanding of the brain should lead psychiatry training to include more clinical neuroscience [1–13]. The importance to psychiatric training of a foundation in neurology has been acknowledged since at least 1939, when the predecessor of the Accreditation Council on Graduate Medical Education (ACGME), the American Medical Association (AMA) Council on Medical Education and Hospitals, established the requirement that “a program of graduate studies should run concurrently with clinical instruction, covering the fundamentals of neuroanatomy, neuropathology, neurophysiology, psychobiology, and psychopathology [14].” In 1987, the ACGME and American Board of Psychiatry and Neurology (ABPN) initiated the current two-month neurology experience requirement. The 2007 ACGME ProgramRequirements in Psychiatry included little guidance as to the content or goals of this experience beyond “supervised clinical experience in the diagnosis and treatment of patients with neurological disorders/conditions” and the competencies and didactic components listed in Table 1. A number of trends in recent years argue strongly for increased attention to clinical neuroscience in psychiatric training: