Yael Dvir

Childhood maltreatment, emotional dysregulation, and psychiatric comorbidities

AbstractAffect dysregulation, defined as the impaired ability to regulate or tolerate negative emotional states, has been associated with interpersonal trauma and posttraumatic stress. Affect-regulation difficulties play a role in many psychiatric conditions, including anxiety and mood disorders, and especially major depression in youth and bipolar disorder throughout the life span. Exposure to traumatic events and interpersonal trauma in childhood is associated with wide-ranging psychosocial, developmental, and medical impairments in children, adolescents, and adults, with emotional dysregulation being a core feature that may help to account for this heightened risk. In order to understand how the developmental effects of childhood maltreatment contribute to emotional dysregulation and psychiatric sequelae, we review emotional regulation and its developmental neurobiology, and examine the research evidence of associations between childhood trauma, emotional dysregulation, and psychiatric comorbidities in children, adolescents, and adults.

Serotonin syndrome: a complex but easily avoidable condition

Serotonin syndrome is a potentially life-threatening adverse drug reaction caused by excessive serotonergic agonism in central and peripheral nervous system serotonergic receptors (Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005;352:1112-1120). Symptoms are characterized by a triad of neuron-excitatory features, which include (a) neuromuscular hyperactivity -- tremor, clonus, myoclonus, hyperreflexia and, in advanced stages, pyramidal rigidity; (b) autonomic hyperactivity -- diaphoresis, fever, tachycardia and tachypnea; (c) altered mental status -- agitation, excitement and, in advanced stages, confusion (Gillman PK. Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. Br J Anaesth 2005;95:434-441). It arises when pharmacological agents increase serotonin neurotransmission at postsynaptic 5-hydroxytryptamine 1A and 5-hydroxytryptamine 2A receptors through increased serotonin synthesis, decreased serotonin metabolism, increased serotonin release, inhibition of serotonin reuptake or direct agonism of the serotonin receptors (Houlihan D. Serotonin syndrome resulting from coadministration of tramodol, venlafaxine, and mirtazapine. Ann Pharmacother 2004;38:411-413). The etiology is often the result of therapeutic drug use, intentional overdosing of serotonergic agents or complex interactions between drugs that directly or indirectly modulate the serotonin system (Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005;352:1112-1120). Due to the increasing availability of agents with serotonergic activity, physicians need to more aware of serotonin syndrome. The following case highlights the complex nature in which serotonin syndrome can arise, as well as the proper recognition and treatment of a potentially life-threatening yet easily avoidable condition.

Childhood trauma and psychosis

Childhood trauma is a common occurrence and has been associated with psychosis and suggested as a risk factor leading to psychosis and schizophrenia in adulthood. This article introduces the scope of the problem and discusses the evidence for causal relationships between childhood adversities and increased risk for psychosis. The relationship between specific types of trauma and their association with specific psychotic symptoms is described, as well as the manifestations of co-occurring trauma effects and psychosis in adolescents. Clinical presentations and the use of diagnostic instruments, diagnostic comorbidities, and evidence-based psychotherapeutic interventions to treat effects of trauma in youth with psychotic illnesses are discussed.

Child and adolescent schizophrenia: pharmacological approaches

Background: Childhood-onset schizophrenia is a serious, chronic and disabling illness that can significantly affect the quality of life of the affected individuals and their families. The affected children commonly show significant premorbid developmental impairment and social abnormalities that may provide an early clinical clue to pursue treatment. Until recent times, treatment approaches for childhood schizophrenia were derived from the adult population. However, given the unique developmental challenges in the pediatric population, this extrapolation may not hold true. Objective: This review encompasses and elaborates on the efficacy, safety and tolerability data available at present for both typical and atypical antipsychotics for treatment of childhood schizophrenia. Method: A literature search was conducted on PUBMED with special emphasis on double-blind placebo-controlled studies in childhood schizophrenia. Data from similar studies presented in recent meetings were also added to the review. Conclusions: Recent research in pediatric psychopharmacology has led to the Food and Drug Administrations approval of two atypical antipsychotics for the treatment of schizophrenia. Although data in this age group are still sparse, research in this unique population has grown over the years.

Vitamin D3 Supplemental Treatment for Mania in Youth with Bipolar Spectrum Disorders

OBJECTIVE We aimed to determine the effect of an open-label 8 week Vitamin D3 supplementation on manic symptoms, anterior cingulate cortex (ACC) glutamate, and γ-aminobutyric acid (GABA) in youth exhibiting symptoms of mania; that is, patients with bipolar spectrum disorders (BSD). We hypothesized that an 8 week Vitamin D3 supplementation would improve symptoms of mania, decrease ACC glutamate, and increase ACC GABA in BSD patients. Single time point metabolite levels were also evaluated in typically developing children (TD). METHODS The BSD group included patients not only diagnosed with BD but also those exhibiting bipolar symptomology, including BD not otherwise specified (BD-NOS) and subthreshold mood ratings (Young Mania Rating Scale [YMRS] ≥8 and Clinical Global Impressions - Severity [CGI-S] ≥3). Inclusion criteria were: male or female participants, 6-17 years old. Sixteen youth with BSD exhibiting manic symptoms and 19 TD were included. BSD patients were asked to a take daily dose (2000 IU) of Vitamin D3 (for 8 weeks) as a supplement. Neuroimaging data were acquired in both groups at baseline, and also for the BSD group at the end of 8 week Vitamin D3 supplementation. RESULTS Baseline ACC GABA/creatine (Cr) was lower in BSD than in TD (F[1,31]=8.91, p=0.007). Following an 8 week Vitamin D3 supplementation, in BSD patients, there was a significant decrease in YMRS scores (t=-3.66, p=0.002, df=15) and Childrens Depression Rating Scale (CDRS) scores (t=-2.93, p=0.01, df=15); and a significant increase in ACC GABA (t=3.18, p=0.007, df=14). CONCLUSIONS Following an 8 week open label trial with Vitamin D3, BSD patients exhibited improvement in their mood symptoms in conjunction with their brain neurochemistry.

An assessment of satisfaction with ambulatory child psychiatry consultation services to primary care providers by parents of children with emotional and behavioral needs: the Massachusetts Child Psychiatry Access Project University of Massachusetts Parent Satisfaction Study

This study evaluated parents’ experience with University of Massachusetts (UMass) Child Psychiatry Access Project (MCPAP), a consultation service to primary care providers (PCP), aimed at improving access to child psychiatry. Parent satisfaction questionnaire was sent to families referred to UMass MCPAP by their PCP, asking about their concerns leading to the referral, the satisfaction from the service provided, adequacy of the follow up plan, and outcome. Seventy-nine percent of parents agreed or strongly agreed that the services provided were offered in a timely manner. Fifty percent agreed or strongly agreed that their child’s situation improved following their contact with the services. Sixty-nine percent agreed or strongly agreed that the service met their family’s need. The results suggest moderate to high parental satisfaction with MCPAP model, but highlight ongoing challenges in making successful referrals for children’s mental health services in the community, following MCPAP recommendations.

Survey of Threats and Assaults by Patients on Psychiatry Residents

ObjectivesThe authors sought to determine the prevalence of threats and assaults by patients on psychiatry residents, their consequences, and the perceived adequacy of supports and institutional responses.MethodsAuthors conducted an anonymous survey of 519 psychiatry residents in 13 psychiatry programs across the United States. The survey questionnaire inquired about residents’ experiences of threats and assaults by patients during their residency training.ResultsThe response rate for this survey was 39% (N=204). Residents were most commonly threatened (N=175; 86%), physically intimidated (N=145; 71%) or received unwanted advances (N=118; 58%). One-quarter (N=51; 25%) were physically assaulted. Most of the incidents occurred in inpatient settings (N=92; 45%).ConclusionThis study, like previous studies on this topic, calls attention to the high number of residents that are affected by violence during their training, and it underscores the need to protect the safety of psychiatry residents and to support those who have been victimized.

Parenting and Mental Illness: A Group for Mothers

Parenting and Mental illness Popular conceptions of motherhood tend to exclude considerations of mental illness; nevertheless, women with mental illness do become pregnant and care for their children, a finding consistent across major diagnostic groups. Sixty-seven percent of women meeting criteria for severe and persistent mental illness over a 12-month period are mothers (Hinden et al., 2005). Most mothers living with mental illness and caring for their children describe motherhood as rewarding and central to their lives, but also report it as a difficult subject to discuss with their mental health providers (Diaz-Caneja and Johnson, 2004). Families in which a mother has mental illness are families that may face multiple challenges. Mothers are at risk of psychiatric hospitalizations and child welfare involvement that may create separations and disruptions. Mothers living with mental illness are also more likely to be raising a child without a partner (Mowbray et al., 2001). Children with a mother with a mental illness have higher rates of psychiatric diagnosis and other psychosocial problems than children with mothers without mental illness (Hinden et al., 2005). Existing services aimed at addressing parenting are primarily deficit-based, and most often available only in crisis (Hinden et al., 2005). Preventive interventions are rare and often withdrawn when the immediate crisis has resolved (Diaz-Caneja and Johnson, 2004).

Early Onset Schizophrenia

Early onset schizophrenia (EOS) describes onset of the first episode of psychosis before age 18 years. Such an earlier onset of symptoms is often associated with a severe and chronic course of the illness, a poorer prognosis and a potentially significant negative impact on recovery and rehabilitation. A recent emphasis on early intervention by utilizing the advances in neurobiological and psychosocial domains along with psychopharmacological effectiveness research in managing this chronic psychotic disorder is paving the way for a more rigorous study of this chronic disabling disorder. This chapter reviews recent literature on diagnostic assessment and management of schizophrenia when it strikes during formative years, and provides future directions for further research in the area.

Autistic Spectrum Disorders and Schizophrenia

Autism spectrum disorders are a group of complex neurodevelopmental disorders that primarily present with deficits in social interactions, communication, and repetitive behaviors. With a progressive evolution in understanding this unique group of disorders, a variety of phenotypes have been postulated, with variability in both biological features and response to treatment. Etiologically, autism is believed to involve a genetic predisposition that may be triggered by environmental factors. While there is no known cure for autism, many treatment approaches are available that potentially improve certain core and associated symptoms. In the past decade, research in the etiology and treatment of these disorders has grown tremendously, as evident by the increasing number of publications in this area. This chapter will review some of the recent advances in the current understanding of these disorders. In addition, a historical background regarding the clinical diagnosis of autism spectrum disorders, including the development of diagnostic concepts and definitions, will be reviewed. Clinical features of autism, its course, prognosis, interventions, including psychosocial and educational interventions, and pharmacological treatments, will also be highlighted. This will be followed by an outline of standard clinical assessment of individuals with a suspected diagnosis of autism. Furthermore, epidemiological data along with recent advances in the understanding of autism’s etiology and pathogenesis, including genetic influences, neuropsychological research, and neurobiological mechanisms, will also be briefly discussed. Finally, although autism can be separated from early onset psychosis and recent data suggest that individuals with autism are probably not at higher risk for developing schizophrenia, it is striking that children with childhood onset schizophrenia show high rates of early social, language and motor developmental abnormalities, with premorbid social impairment being the most common feature. Beginning with Kanner’s use of the term autism that suggested a similarity to schizophrenia, the question of comorbid association or phenotypic variations between autism and schizophrenia has been frequently asked. This chapter will also aim to clarify the similarities and differences in presentation between autism and childhood onset schizophrenia.