The relationship between prototype ratings of personality and self and interpersonal functioning with an adolescent inpatient sample.

Personality pathology is conceptualized, in part, as impairments in self and interpersonal functioning. Although most of the research has focused on adult samples, fewer have looked at this relationship in adolescent samples. This paper investigates the relationship between clinician-rated personality prototypes, the Shedler-Westen Assessment Procedure-Prototype Matching Adolescent Version (SWAP-A-P) derived from the SWAP-II-A, and a measure of self and interpersonal functioning, the Social Cognition and Object Relation Scale-Global Rating (SCORS-G). Clinicians rated 66 adolescents hospitalized at a safety net teaching hospital in the northeast. The patient's individual and group therapist rated the patients at discharge using the SWAP-A-P and the SCORS-G at discharge blind to each other's ratings. Results showed that more severe personality pathology was linked with more impairments in self and interpersonal functioning.

Survey of physician attitudes towards psychogenic nonepileptic seizures and driving.

BACKGROUND: Physicians from various disciplines encounter patients presenting with psychogenic nonepileptic seizures (PNES) as part of their routine clinical practice. Recommendations towards assessing fitness to drive and reporting are clearer for conditions such as neurocognitive disorders and epilepsy, but such guidelines do not exist for patients with PNES. Here, we assess physicians' attitudes towards driving for patients diagnosed with PNES. METHODS: Electronic questionnaires were sent to Neurology and Family Medicine physicians practicing at Creighton University Medical Center and Psychiatry physicians practicing at Creighton-Nebraska Psychiatry Residency Program to assess their opinion regarding driving risk when encountering PNES. RESULTS: The survey request was sent to 125 physicians, of which close to 60% completed the survey. Eighty-eight percent of participants encountered PNES in their clinical practice, and 69.1% agreed it was a difficult problem to assess, with only 8.3% endorsing a belief that these patients should drive without restrictions. Ninety-three percent felt having guidelines would help them assess the driving risk in this population. CONCLUSION: Psychogenic nonepileptic seizures are common across neurology, psychiatry, and primary care, and most physicians find assessing driving risk in such individuals highly warranted yet difficult. Developing such assessment guidelines and recommendations is of great need for clinicians.

Lost in Translation: Challenges in the Diagnosis and Treatment of Early-Onset Schizophrenia.

Early-onset schizophrenia (EOS) is a heterogeneous condition that has a serious, insidious clinical course and poor long-term mental health outcomes. The clinical presentations are highly complex due to the overlapping symptomatology with other illnesses, which contributes to a delay in the diagnosis. The objective of the review is to study if an earlier age of onset (AAO) of EOS has poor clinical outcomes, the diagnostic challenges of EOS, and effective treatment strategies. The review provides a comprehensive literature search of 5966 articles and summarizes 126 selected for empirical evidence to methodically consider challenges in diagnosing and treating EOS for practicing clinicians. The risk factors of EOS are unique but have been shared with many other neuropsychiatric illnesses. Most of the risk factors, including genetics and obstetric complications, are nonmodifiable. The role of early diagnosis in reducing the duration of untreated psychosis (DUP) remains critical to reducing overall morbidity. Many specific issues contribute to the risk and clinical outcomes. Therefore, issues around diagnostic ambiguity, treatment resistance, nonadherence, and rehospitalizations further extend the DUP. There is hesitancy to initiate clozapine early, even though the empirical evidence strongly supports its use. There is a growing body of research that suggests the use of long-acting injectables to address nonadherence, and these measures are largely underutilized in acute settings. The clinical presentations of EOS are complex. In addition to the presence of specific risk factors, patients with an early onset of illness are also at a higher risk for treatment resistance. While there is a need to develop tools for early diagnosis, established evidence-based measures to address nonadherence, psychoeducation, and resistance must be incorporated into the treatment planning.

Long COVID in Children and Adolescents.

Objective: To review the empirical evidence regarding neuropsychiatric illness (long coronavirus disease [COVID]) in children and adolescents post-severe acute respiratory coronavirus disease 2 (SARS-CoV-2) infection.Data Sources: A search of PubMed, PsycINFO, Cochrane Library, and Google Scholar was conducted from the date of inception until February 2022 using the keywords corona*, COVID-19, SARS-CoV-2, mental health, depression, anxiety, neurological, psychiatric, long COVID, and post-COVID outcomes. Age filters were used to include children and adolescents aged ≤ 18 years.Study Selection: The search resulted in the identification of 526 articles; 48 articles met the inclusion criteria.Data Extraction: Results are presented using a narrative review format. Data regarding long COVID in children and adolescents post-SARS-CoV-2 infection were extracted to understand epidemiologic trends, preventive measures, and treatment options.Results: Studies during the initial phase of the pandemic reported a mixed range of symptoms from case reports or case series. However, multisystem inflammatory syndrome in children (MIS-C) was widely reported. During the subsequent phases, the emergence of new variants led to a surge of SARS-CoV-2 infections in pediatric populations. There were highly variable, mixed symptom clusters within 60 days post-infection, which resolved in many patients within 6 months. There were prolonged illnesses and impairments in some children and adolescents with long COVID, and many had similar symptoms even though they tested negative for COVID-19.Conclusions: Long COVID symptoms are both physical and mental in nature among children and adolescents. The impairments have the potential to affect long-term functioning and increase the overall burden on health care delivery. Despite current studies having methodological issues, there is a consensus to provide multidisciplinary and holistic care to those in need.

Refractory Methamphetamine-Induced Psychosis: An Emerging Crisis in Rural America and the Role of Amantadine in Therapeutics.

In the last decade, methamphetamine (MA) use has substantially increased in rural America. These changes in the epidemiological trends could be attributed to the restricted availability of opioids after measures against the opioid epidemic were enforced. The availability of cheaper alternatives, such as fake prescriptions mixed with fentanyl, is a few among the many recent developments in the ongoing mental health and substance abuse crisis in rural America. A serious clinical effect of MA use is psychosis, which inadvertently has stretched mental health services. In recent times, the atypical clinical presentations of these psychotic episodes with a refractory course have challenged clinicians. Hence, the knowledge of its unique pharmacodynamics, neurotoxicity, similarities with schizophrenia amid the evolving empirical evidence is critical to addressing this unique conundrum.

Aducanumab as a Novel Treatment for Alzheimer's Disease: A Decade of Hope, Controversies, and the Future.

Alzheimer's disease (AD) is the most common type of dementia and is among the leading cause of death in the United States. Its worldwide prevalence is around 50 million and is projected to double by 2050. Deposition of beta-amyloid (also known as amyloid-beta) peptides (beta 40 and 42) in the brain continues to be the most widely accepted disease mechanism. Until recently, only two Food and Drug Administration (FDA)-approved groups of medications, namely, cholinesterase inhibitors and N-methyl-D-aspartate receptor antagonists, were available for symptomatic treatment with limited efficacy. Disease-modifying therapeutics, keenly desired by clinicians and patients alike, have long been elusive until recently. The FDA's Accelerated Approval Program for the approval of a new agent, aducanumab, is being considered a step in this direction by some, but not without controversy. Aducanumab, marketed as Aduhelm by Biogen, has been shown to lower beta-amyloid plaques in the brain. Biogen believes this will lead to improvement in cognition and functioning in patients with AD. However, within a month of this approval, the FDA has called for investigations into interactions between representatives of Biogen and the FDA preceding the approval of Aduhelm. This report provides an overview of the controversy surrounding the FDA's Accelerated Approval Program as it pertains to the approval of Aduhelm, and the potential impact of these issues on researchers, clinicians, patients, and families in the ongoing battle against this devastating, debilitating, and ultimately fatal illness.

An Unlikely Case of Benztropine Misuse in an Elderly Schizophrenic.

Although data on the prevalence of anticholinergic misuse is scarce, it has been reported among psychiatric patients. Anticholinergic drugs can act as potent indirect dopamine agonists in the limbic system, a mechanism that has been hypothesized to explain their misuse potential among patients. In psychiatric practice settings, the use of typical antipsychotics in conjunction with anticholinergics is common, with the latter mainly used to manage extrapyramidal side effects of the former. Haloperidol is a first-generation (typical) antipsychotic with weak anticholinergic properties that may sometimes be potentiated when it is used in combination with other anticholinergic medications. This combination can induce significant gastrointestinal hypomotility, constipation, and rarely even paralytic ileus. We present the case of a 67-year-old African American male with a history of schizophrenia, benign prostatic hyperplasia, and essential hypertension, who abruptly started misusing benztropine, without any prior history of a substance use disorder. This case highlights the importance of obtaining a detailed history when previously stable psychiatric patients develop acute physical symptoms. It also illustrates the importance of care coordination among care providers and the central role of the psychiatrist in the care of patients with medical comorbidities.

Levetiracetam and Suicidality: A Case Report and Literature Review.

OBJECTIVE: To identify clinical characteristics common among epileptic patients prescribed levetiracetam who report suicidal ideation or who exhibit suicidal behavior. A case is also provided that highlights the need for increased vigilance for neuropsychiatric sequelae in fragile epileptic patients prescribed levetiracetam, especially post dosage adjustment. DATA SOURCES: PubMed was queried with no time limitation to December 2018 using a combination of controlled terms. Using the Boolean operators "AND" and "OR," the authors searched PubMed for case reports and case series on levetiracetam-related suicidal behavior. The search terms used were [levetiracetam] OR [Keppra] AND in combination with suicidal, suicide, suicidal ideation, suicide attempt, and suicidality. STUDY SELECTION: Relevant English-language human studies on levetiracetam and its effect on suicidal behavior were included. The search terms generated 78 results from the databases. After excluding all duplicates and applying the inclusion and exclusion criteria, a total of 14 clinical studies were retained for review. DATA EXTRACTION: Two reviewers independently extracted relevant data and assessed the methodological quality of each study. RESULTS: The included studies reveal a number of risk factors for suicide ideation, suicide-related behavior, and suicide attempt among individuals taking levetiracetam. These risk factors include a prior psychiatric disorder, a history of traumatic brain injury, a history of substance use disorder, and a structural brain abnormality. Patients with these risk factors constitute a specific subgroup of patients with epilepsy who have an increased vulnerability to suicidal ideation or behavior if prescribed levetiracetam. These patients should, therefore, be monitored closely. CONCLUSIONS: Suicidal behavior in epileptic patients appears to be multifactorial in etiology. Psychiatric disorders are more prevalent in epileptic patients than in the general population and contribute to this risk. In spite of the high risk of suicidal behavior with the use of antiepileptic drugs, studies have shown that the benefits of anticonvulsant therapy often outweigh the risks. Nevertheless, timely consultation with a psychiatrist is invaluable in the care of these patients, particularly those with multiple risk factors, as in the index case. The risk of suicidality should be balanced with the risk of uncontrolled seizures. Specifically, in the case of levetiracetam, it is important to be aware of the subgroup of individuals with prior severe psychiatric illness, a history of traumatic brain injury, or a history of substance use disorder who might be at an increased risk of developing suicide-related behavior and suicidal ideations once levetiracetam is started.

A Case of Kratom-induced Seizures.

Kratom or Mitragna speciosa is a tropical tree that is indigenous to Southeast Asia, where it has been used for various medicinal reasons. In the West, it is used in the self-treatment of opioid withdrawal, pain, and a variety of mood and anxiety states. Two active ingredients in kratom are mitragynine and 7-hydroxymitragynine, which have affinity at the mu-opioid receptor among others. Kratom is easily available over the Internet and its use is increasing in the United States. It is currently listed by the Drug Enforcement Administration as a drug of concern. In 2017, the U.S. Food and Drug Administration started issuing a series of warnings about kratom, and by early 2018, it released a statement identifying 44 deaths related to kratom use. The Centers for Disease Control and Prevention has also reported 91 deaths directly linked to kratom use in 2019. Although its safety profile needs additional research for clarification, there have been reports of kratom-induced or kratom-related respiratory depression, hypothyroidism, secondary hypogonadism, hyperprolactinemia, psychosis, and seizures. We report a case of kratom-induced tonic-clonic seizures in a 27-year-old Caucasian male with a psychiatric history of anxiety, attention-deficit/hyperactivity disorder, benzodiazepine use disorder, and opioid use disorder. He was hospitalized after a witnessed tonic-clonic seizure. There was no significant metabolic abnormality on laboratory testing. Spinal cord and brain imaging were unremarkable, whereas his urine toxicology was positive for opioids only, which was likely a false-positive result due to cross-reactivity with his sleeping aids. He was evaluated by the Consultation-Liaison Psychiatry team for psychotic symptoms. On evaluation, the patient's psychosis had resolved, but he endorsed racing thoughts, significant anxiety, and insomnia. He admitted to drinking three to four 8-mL bottles of Kratom daily for one-and-a-half years to self-medicate his anxiety after losing his health insurance. In the hospital, he was treated with anxiolytics, counseled to abstain from Kratom use, and was referred for substance use disorder treatment. This case highlights the life-threatening complications of Kratom that is easily available online.

The Role of Physical Examinations in Psychiatry as Illustrated in a Case of Neuroleptic Malignant Syndrome Versus Viral Encephalitis: A Case Report and Literature Review.

Although a standard psychiatric evaluation includes a physical examination, there are no guidelines on the components of a comprehensive physical examination during psychiatric patient encounters. The mental status examination is frequently considered the psychiatric physical examination equivalent. We report a 59-year-old male inpatient on a medical unit who had hyperthermia, an altered mental status, muscle rigidity, and elevated white blood cell count and creatine phosphokinase level. He had been taking risperidone 1 mg orally every 12 hours for two months. His primary treatment team suspected Neuroleptic Malignant Syndrome (NMS), but the consulting psychiatrist detected equivocal findings on physical examination and recommended a broader differential diagnosis. Further investigations revealed the possibility of an infection. The patient was positive for immunoglobulin G (IgG) antibodies to HSV-1 and HSV-2 on cerebrospinal fluid analysis. He was then treated for Herpes Simplex Encephalitis (HSE) with an oral course of acyclovir. Although NMS was low in the diagnostic ranking, given the possibility of an atypical form and the lethality of this condition if untreated, he also received intravenous lorazepam at 2 mg every six hours. He experienced full resolution of his symptoms and was stable for discharge. HSE and NMS are two examples of neuropsychiatric disorders with similar presenting symptoms. HSE frequently presents with predominantly psychiatric symptoms, such as paranoia, hallucinations, and an altered mental status. Consequently, it is typically not the first diagnosis that comes to mind, especially when these symptoms occur in a patient already being treated by a psychiatrist. Confirmation bias is the tendency for an individual to focus on the information that aligns with one's preconceptions and to ignore information that defies it. Due to this bias, physicians may attribute all symptoms of a known psychiatric patient to a psychiatric cause, instead of considering an organic etiology. In this case, the evaluation by the psychiatrist was crucial in guiding the treatment team to a diagnosis of HSE. This is important since a delayed treatment of HSE can be fatal. The literature review reveals a general consensus among psychiatrists on the value of physical examinations in patient care. In spite of this, the majority of psychiatrists seldom perform physical examinations due to concerns over skill atrophy and the potential that doing so may change the therapeutic dynamic. Others have disputed these claims and have argued that physical examinations in a psychiatric setting will not only strengthen the perception of a psychiatrist as a physician by the patient but will also allow for better care of psychiatrically ill patients. Psychiatrists should remember that they are oftentimes the sole healthcare provider for psychiatric patients and that these patients may not have the access to primary care physicians and may lack the ability to explain their symptoms or advocate for themselves. Therefore, incorporating an emphasis on performing physical examinations during psychiatry residency training and in continuing medical education programs for psychiatrists is essential.

Effectiveness of Gabapentin in Reducing Cravings and Withdrawal in Alcohol Use Disorder: A Meta-Analytic Review.

OBJECTIVE: The current meta-analysis synthesizes previous findings on the effect of gabapentin on alcohol withdrawal and craving. DATA SOURCES: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, a search for relevant English-language literature published between January 1999 and February 2019 was conducted using PubMed and Google Scholar with the keywords alcohol use disorder, alcohol dependence, alcohol withdrawals, alcohol craving, "gabapentin in alcohol use, consumption," and "gabapentin in alcohol withdrawals." STUDY SELECTION AND DATA EXTRACTION: Studies were included wherein gabapentin was used as an adjunctive or primary treatment of alcohol dependence/withdrawal. Studies included participants diagnosed with alcohol use disorder using DSM-IV, DSM-IV-TR, DSM-5, or the International Classification of Diseases, Tenth Revision (ICD-10). The search, as well as data extraction, was carried out by 3 blinded authors to preserve precision, using a template in Microsoft Excel to extract the needed data. Following the review of the initial 65 returns, 2 authors independently judged each trial by applying the inclusionary and exclusionary criteria, and any remaining disagreements were resolved by involving a third independent author. A total of 10 studies met the inclusion criteria and were selected for analysis. Subjects in these 10 studies were pooled using standard techniques of meta-analysis. DATA SYNTHESIS: Three sets of meta-analyses examined outcomes from (1) single-group pretest-posttest changes, (2) posttest differences between independent groups, and (3) differences in pretest-posttest change scores between independent groups. Statistically significant effect sizes were found for craving (P < .01) and withdrawal (P < .01, P < .001) in the meta-analysis of single-group pretest-posttest outcome changes and were associated with a high level of heterogeneity. In contrast, the meta-analyses of posttest differences between independent groups-that of differences in pretest-posttest change scores between independent groups-did not yield significant effect sizes. CONCLUSIONS: Our analysis of pooled data provides evidence that the use of gabapentin to manage alcohol withdrawal symptomatology and related cravings is at least moderately effective. However, given the limited number of available well-designed studies, these findings require further support through more rigorously designed studies.

Phenytoin Augmentation of Levetiracetam Treatment: A Case of Forced Normalization With Emergence of Psychosis.

Forced normalization is the emergence of psychoses following stabilization of seizures in an uncontrolled epileptic patient. The current study is a case of forced normalization, a phenomenon characterized by normalization of electroencephalogram (EEG) findings and resolution of seizures. This case report is unique and rare because the patient meets the diagnostic merit of forced normalization, which occurred due to a nonconventional method of seizure control management. We discuss the recognition and differential diagnoses of such cases, understanding the phenomenon of forced normalization and treatment strategies, which may help clinicians in their clinical practice.

Adding Psychotherapy to the Naltrexone Treatment of Alcohol Use Disorder: Meta-analytic Review.

Background It remains unclear if naltrexone combined with psychotherapy is superior to naltrexone alone in treating alcohol use disorders (AUD). The current meta-analysis examined the hypothesis that psychotherapy is a significant moderator that influences AUD-related outcomes and that naltrexone combined with psychotherapy is associated with significantly better AUD-related outcomes than naltrexone alone. Methods A total of 30 studies (Nnaltrexone = 2317; Nplacebo = 2056) were included. Random effects model meta-analyses were carried out for each of the studied outcomes. Subsequently, the random effects model pooled estimates from studies with and without psychotherapy were compared using a Wald test. A mixed-effect model, incorporating psychotherapy as a moderator, was used to examine the impact of psychotherapy on treatment outcomes. Results Naltrexone had a significant treatment effect on abstinence relapse and Gamma-Glutamyl Transferase levels, but not cravings. The pooled estimates for studies with and without psychotherapy were not significantly different for any of the studied outcomes. Psychotherapy was not a significant moderator in the mixed effects models for any of the studied outcomes. Conclusions Naltrexone treatment is efficacious in reducing alcohol consumption, but not reducing cravings. Adding psychotherapy on top naltrexone did not result in any significant additional benefit for AUD patients.

"Too Much Sex and Alcohol": Beliefs, Attitudes, and Behaviors of Male Adolescents and Young Men Who have Sex with Men in Ghana.

BACKGROUND: Research suggests that men who have sex with men (MSM) often engage in high-risk sex and use illicit substances. OBJECTIVE: To increase understanding of HIV knowledge and vulnerability among adolescent and young adult MSM, with a focus on alcohol and drug use and transactional sex. METHODS: We conducted in-depth interviews and Focus Group Discussions (FGDs) with adolescent (aged 15-17 years) and young adult (aged 18-29 years) MSM in Kumasi, Ghana. MSM who reported recent alcohol and/or substance use or engagement in transactional sex were eligible. Questions covered HIV-related knowledge, experiences with substance-use and transactional sex, and attitudes regarding sexual risk-taking and HIV-related services. Data were analyzed thematically using NVivo 10.0 software. RESULTS: Ninety-nine MSM participated in 44 interviews and 8 FGDs. Most were attending or had completed secondary school. HIV knowledge was high, but with major gaps. Most consumed alcohol; one-fourth used drugs. Alcohol and substances were consumed to enhance pleasure during sex with another man. Transactional sex was common and positively viewed. Half of the participants used condoms inconsistently or never, and self-perceived HIV risk was high. Nearly half faced stigma-related barriers to accessing HIV-related services. CONCLUSION: As Ghana strives to achieve the UNAIDS's 90-90-90 global targets (90% of people living with HIV know their status, 90% who know their status are on sustained treatment, and 90% of those on treatment are virally suppressed), we recommend enhancing MSM-targeted prevention programs, improving care options, and increasing use of critical clinical HIV-services by ensuring that MSM receive unbiased, confidential care.

Combined use of electroconvulsive therapy and antipsychotics (both clozapine and non-clozapine) in treatment resistant schizophrenia: A comparative meta-analysis.

AIM: To assess the relative efficacies of clozapine plus Electroconvulsive Therapy (ECT) compared against non-clozapine typical and atypical antipsychotics plus ECT for the treatment of "Treatment Resistant Schizophrenia" (TRS). Primarily to assess if clozapine delivers a significant improvement over other antipsychotics when combined with ECT. DESIGN: Major electronic databases were searched between 1990 and March 2017 for trials measuring the effects of either clozapine augmented ECT, other antipsychotic-augmented ECT, or both. After the systematic review of the data, a random-effects meta-analysis was conducted measuring the relative effect sizes of the different treatment regimens. SUBJECTS: 1179 patients in 23 studies reporting the usage of ECT augmentation with antipsychotics. A total of 95 patients were tested with clozapine, and ECT (9 studies) and 1084 patients were tested with non-clozapine antipsychotics (14 studies) such as flupenthixol, chlorpromazine, risperidone, sulpiride, olanzapine, and loxapine with concurrent ECT treatment considered for systematic review. Of these, 13 studies reported pre and post-treatment scores were included in the meta-analysis. MAIN OUTCOME MEASURES: The main outcome measure was the presence and degree of both positive and negative psychotic symptoms, as measured by either of two standardized clinician administered tests, the Brief Psychiatric Rating Scale (BPRS), and the Positive and Negative Symptom Scale (PANSS). RESULTS: The comparison of the different antipsychotics established the supremacy of ECT-augmented clozapine treatment against other typical and atypical antipsychotics. The Forest Plot revealed that the overall standard mean difference was 0.891 for non-clozapine studies and 1.504 for clozapine studies, at a 95% interval. Furthermore, the heterogeneity plots showed that while clozapine studies showed no significant heterogeneity, non-clozapine studies showed an I2 statistic value at 42.19%, suggesting moderate heterogeneity. Lastly, publication bias showed asymmetrical plots and significant values of Kendal's tau and Egger's rank test. CONCLUSION: ECT augmentation technique was found to be effective in the reduction of psychometric scale scores, and the resulting improvement was significant. Clozapine maintained its stance as the most effective treatment for Treatment-Resistant Schizophrenia, followed by flupenthixol.

Ethnic differences in perceived benefits and barriers to HPV vaccine acceptance: a qualitative analysis of young African American, Haitian, Caucasian, and Latino men.

PURPOSE: To examine the attitudes toward human papillomavirus (HPV) vaccination among young men from African American, Haitian, Caucasian, and Latino backgrounds. METHODS: We used in-person surveys at an urban teaching hospital from 2010 to 2012 to examine the racial and ethnic differences in the perceived benefits and barriers to HPV vaccination and vaccine mandate acceptance among 18- to 22-year-old African American, Haitian, Caucasian, and Latino men. RESULTS: A total of 89 men participated (35% African American, 29% Haitian, 20% Latino, and 16% white). Participants from all ethnic groups perceived benefits to HPV vaccination but differed in their perceptions of barriers to vaccination as well as their acceptance of a vaccine mandate. CONCLUSIONS: Culturally competent educational messages may overcome ethnic differences in the attitudes, beliefs, and behaviors regarding vaccination among college-aged men from an urban population.