Early-onset schizophrenia: studying the links between cognitive and clinical dimensions.

BACKGROUND: Early-onset schizophrenia (EOS), a rare and severe chronic psychiatric condition, is defined by an onset of schizophrenia symptoms before the age of 18. Core symptoms also include cognitive impairments. However, little is known about links between psychiatric symptoms of EOS and cognitive abilities. OBJECTIVE: To explore the clinical and neurocognitive profiles of EOS patients and their links. METHOD: EOS patients have been phenotyped using standardised psychiatric assessments for DSM-5 diagnoses (K-SADS-PL) and for symptoms (PANSS and SANS), together with neurocognitive evaluations. RESULTS: The EOS sample (n = 27, 12.4 +/-3.2 years) presented hallucinations (83%), negative symptoms (70%) and delusion (59%). 81% of patients presented comorbidities such as anxiety disorders (33%), autism spectrum disorder (26%) and attention-deficit hyperactivity disorder (26%). Patients presented borderline intellectual deficiency (total IQ = 72.5 +/-4.7), with low performances in working memory subtest. We highlight a positive correlation between the IQ and intensity of positive symptoms (PANSS) and between the IQ and a first treatment being administered at an older age. We also highlight a negative correlation between the IQ and attention items of SANS. CONCLUSION: Cognitive skills are correlated with symptom intensity in EOS patients. An older age of onset seems to be a protective factor for cognitive development.

Drug-related catatonia in youths: real-world insights from the WHO Safety Database.

Catatonia is characterized by psychomotor alterations and reduced contact with the environment. Initially linked to schizophrenia, it also occurs in mood disorders or organic conditions. In children, catatonia remains poorly delineated, despite dramatically increasing the risk of premature death. As data on pediatric drug-induced catatonia bears many uncertainties, we aimed to characterize its age-dependent patterns, using real-world data from the WHO safety database (VigiBase®).VigiBase® was queried for all reports of catatonia registered up to December 8th 2022. Reports involving patients <18 years were classified into 3 groups: ≤23 months, 2-11 years, and 12-17 years. Disproportionality analyses relied on the Reporting Odds Ratio (ROR), and the positivity of the lower end of the 95% confidence interval of the Information Component (IC) was required to suspect a signal. Catatonia was evoked in 421 pediatric reports. In infants, vaccines were leading. In children, the main signals involved haloperidol (ROR 104.3; 95% CI 45.6-238.5), ondansetron (ROR 40.5; 95% CI 16.5-99.5), and ciclosporin (ROR 27.4; 95% CI 13.8-54.1). In adolescents, chlorpromazine (ROR 199.1; 95% CI 134.8-294.1), benzatropine (ROR 193; 95% CI 104.1-361.6), and olanzapine (ROR 135.7; 95% CI 104.6-175.9) reached the highest RORs. In infants, catatonia was related to vaccines, it was ascribed to multiple drugs in children, and mainly to psychotropic drugs in adolescents. Less suspected drugs, such as ondansetron, were highlighted. Despite limitations inherent in spontaneous reporting systems, this study supports that a careful anamnesis is warranted to separate catatonia associated with medical conditions from drug-induced catatonia in pediatric patients.

[Identifying cognitive and emotional markers in relation to auditory-verbal hallucinations in pediatric population: Physalis study]. / Identification de marqueurs sociaux et émotionnels associés à l'hallucination acoustico-verbale (HAV) en population pédiatrique : étude Physalis.

OBJECTIVES: Auditory-verbal hallucinatory experiences (AVH) represent a prevalence of 12% in the general pediatric population. They are most often considered as a transient and benign developmental phenomenon, associated with mood and anxiety disorders. The persistence of AVHs for several years and into adolescence would represent a poor prognosis of progression into a psychiatric disorder, and more particularly psychotic disorder. The alteration of social and emotional cognitive markers are described as prodromal of this unfavorable progression which should be considered within the continuum between subclinical and clinical signs of the "psychosis phenotype". The objective of this study was to assess these markers in children and adolescents with AVH and their correlation with the presence and persistence of hallucinations. METHODS: Multicenter prospective case-control study, longitudinal over 6months. Patients were included based on the presence of HAV on clinical examination. Forty subjects aged 8 to 16years from a clinical pediatric population were included. They were divided into two groups according to the Diagnostic Interview Schedule for Children-Child version (DISC-C): a group with AVH ("AVH+"), and a group without HAV ("AVH-"). A diagnosis of schizophrenia spectrum disorder was a non-inclusion criterion according to the criteria of DSM-5 (K-SADS-PL). This group was matched to the control group without AVH (AVH-) according to sex, age (±6months) and associated psychiatric diagnoses assessed by the MINI-Kid. The marker of social cognition was assessed with the NEPSY II test. The emotional marker was assessed with the self-questionnaires: EED IV, which highlights the emotions currently being felt by the subject, and the BAVQ-R, which categorizes the child's emotions in reaction to AVH. RESULTS: No significant link was found between the social and emotional cognition markers and the presence of AVH at T0. At 6months, 50% of subjects in the AVH+ group suffered from persistent AVH and 18% progressed to a diagnosis of schizophrenia spectrum disorder. The persistence of AVH was not significantly correlated with the marker of social cognition, but it was significantly correlated with the presence of negative emotions (sadness, fear, hostility and anger) and inversely correlated with emotions of joy. CONCLUSION: In this study, AVH experiences in the pediatric population are not linked to markers of social cognition, but negative emotions appear as early markers of AVH persistence. GOV IDENTIFIER: NCT02567500.

[Child psychiatry in pediatric intensive care unit]. / Pédopsychiatrie en unité de soins intensifs pédiatriques.

A study was conducted in the pediatric intensive care and resuscitation unit of the Nice pediatric hospitals, University Hospital Center Lenval (06) from January to March 2015. Its objective was to describe the events and child psychiatric interventions experienced by young patients. Of the 181 individuals managed during the research, 63 met the inclusion criteria.

A novel microduplication in INPP5A segregates with schizophrenia spectrum disorder in the family of a patient with both childhood onset schizophrenia and autism spectrum disorder.

Childhood-Onset Schizophrenia (COS) is a very rare and severe psychiatric disorder defined by adult schizophrenia symptoms occurring before the age of 13. We report a microduplication in the 10q26.3 region including part of the Inositol Polyphosphate-5-Phosphatase A (INPP5A) gene that segregates with Schizophrenia Spectrum Disorders (SSDs) in the family of a female patient affected by both COS and Autism Spectrum Disorder (ASD). Phenotyping and genotyping (including CGH-array) were performed for mother, healthy sister, and affected child according to the GenAuDiss protocol (NCT02565524). The duplication size is 324 kb and is present in a patient with COS and in her mother with SSD, but not in the patient's healthy sister. INPP5A encodes a membrane-associated 43 kDa type I inositol 1,4,5-trisphosphate (InsP3) 5-phosphatase. This protein is found both in mouse and human brains and we found that its Drosophila homologue 5PtaseI is specifically expressed in the central nervous system. Hydrolyzed products from InsP3 5-phosphatases mobilize intracellular calcium, which is relevant for dendritic spine morphogenesis in neurons and altered in both schizophrenia and ASD. These may constitute arguments in favor of this gene alteration in the pathophysiology of COS.

[The psychologist in paediatric intensive care, liaison and separation]. / Le psychologue en réanimation pédiatrique, liaison et séparation.

The relationship between the interventions of liaison psychiatry and those of general medicine is essential. The psychologist, notably, plays an important role in a paediatric intensive care unit. A double temporality, somatic and psychological, is to be taken into account in order to hear, beyond the individual, what the subjet has to say.

Lithium as a rescue therapy for regression and catatonia features in two SHANK3 patients with autism spectrum disorder: case reports.

BACKGROUND: Phelan-Mc Dermid syndrome is a contiguous disorder resulting from 22q13.3 deletion implicating the SHANK3 gene. The typical phenotype includes neonatal hypotonia, moderate to severe intellectual disability, absent or delayed speech, minor dysmorphic features and autism or autistic-like behaviour. Recently, point mutations or micro-deletions of the SHANK3 gene have been identified, accompanied by a phenotype different from the initial clinically description in Phelan McDermid syndrome. CASE PRESENTATION: Here we present two case studies with similar psychiatric and genetic diagnosis as well as similar clinical history and evolution. The two patients were diagnosed with autism spectrum disorders in childhood and presented regression with catatonia features and behavioural disorders after a stressful event during adolescence. Interestingly, both patients presented mutation/microdeletion of the SHANK3 gene, inducing a premature stop codon in exon 21. Different pharmacological treatments (antipsychotics, benzodiazepines, mood stabilizer drugs, antidepressants, and methylphenidate) failed to improve clinical symptoms and lead to multiple adverse events. In contrast, lithium therapy reversed clinical regression, stabilized behavioural symptoms and allowed patients to recover their pre-catatonia level of functioning, without significant side effects. CONCLUSION: These cases support the hypothesis of a specific SHANK3 phenotype. This phenotype might be linked to catatonia-like deterioration for which lithium use could be an efficient treatment. Therefore, these cases provide an important contribution to the field of autism research, clinical genetics and possible pharmacological answers.

Relationship between social cognition and emotional markers and acoustic-verbal hallucination in youth with post-traumatic stress disorder: Protocol for a prospective, 2-year, longitudinal case-control study.

INTRODUCTION: Auditory-verbal hallucinatory experiences (AVH) have a 12% prevalence in the general pediatric population. Literature reports a higher risk of developing AVH in post-traumatic stress disorder (PTSD). The persistence of AVHs during adolescence represents a risk of evolution into psychotic disorders. Social cognition and emotional markers could be considered prodromes markers of this evolution. The objectives of this prospective observational study are to observe social cognition and emotional markers correlation with the presence and persistence of AVH over two years and with the evolution of PTSD and psychotic diagnosis. METHODS AND ANALYSIS: This prospective case-control study, longitudinal over two years (with an interim reassessment at six months and one year), will include 40 participants aged 8 to 16 years old with a diagnosis of PTSD and without a diagnosis of psychosis according to the criteria of DSM-5 (K-SADS-PL). Subjects included are divided into two groups with AVH and without AVH matched by gender, age and diagnosis. The primary outcome measure will be the correlation between social cognition and emotional makers and the presence of AVH in the PTSD pediatric population without psychotic disorders. The social cognition marker is assessed with the NEPSY II test. The emotional marker is assessed with the Differential Emotion Scale IV and the Revised Beliefs About Voices Questionnaire. The secondary outcome measures are the correlation of these markers with the persistence of AVH and the evolution of the patient's initial diagnosis two years later. DISCUSSION: The originality of our protocol is to explore the potential progression to psychosis from PTSD by cognitive biases. This study supports the hypothesis of connections between PTSD and AVH through sensory, emotional and cognitive biases. It proposes a continuum model from PTSD to psychotic disorder due to impaired perception like AVH. TRIAL REGISTRATION: Clinical trial registration: ClinicalTrials.gov Identifier: NCT03356028.

Somatic and Posttraumatic Stress Symptoms in Children and Adolescents in France.

Importance: Somatic symptoms are a major concern among the pediatric population because of frequency and burden. The association between adverse childhood experiences and somatic symptoms in adults is well established but less is known concerning somatic symptoms in young people. Objective: To explore the frequency and intensity of somatic symptoms in children and adolescents exposed to traumatic events. Design, Setting, and Participants: This cross-sectional study was conducted from January 1 to December 31, 2021, at the Nice Pediatric Psychotrauma Referral Center in Nice, France. Participants included pediatric outpatients, aged 7 to 17 years, who were referred to the center. Statistical analysis was performed in January 2022. Exposure: All participants experienced at least 1 traumatic event during life. Main Outcome and Measure: Somatic and posttraumatic stress symptoms were assessed using the Patient Health Questionnaire-13 (PHQ-13) and Child PTSD Checklist (CPC). Posttraumatic stress disorder (PTSD) and non-PTSD groups were defined based on CPC symptoms severity score. In the hypothesized association between somatic symptoms and posttraumatic stress symptoms (PTSS), PTSD and non-PTSD groups were compared, correlations between PTSS and severity of CPC were analyzed, and a regression model was performed. Results: There were 363 participants included (mean [SD] age, 13.58 [0.25] years; 174 [47.9%] female, 189 [52.1%] male). Compared with the non-PTSD group, the PTSD group presented with a higher mean (SD) number of somatic symptoms (7.0 [2.5] vs 4.0 [2.5] symptoms; t360 = 11.7; P < .001), and higher mean (SD) intensity (10.4 [4.6] vs 4.8 [3.7] points; t360 = 12.6; P < .001). Most of the explored somatic symptoms positively correlated with the intensity of PTSS and their functional alterations (eg, PTSS intensity correlated with stomach pain symptoms [r = .30; P < .001]; and with headaches symptoms [r = .44; P < .001]). In the regression model, the combination of migraines, palpitation, nausea, tiredness, and sleep disorders explained 6.5% of the variance in the PTSD group. (F1,341 = 22.651; P < .001). Conclusions and Relevance: In this cross-sectional study, somatic symptoms were positively correlated with PTSS both in frequency and intensity among youths. These results suggest that the systematic screening for somatic symptoms in youths with traumatic exposure should be a routine evaluation procedure.

Psychiatric outcomes in outpatients affected by long COVID: A link between mental health and persistence of olfactory complaint.

BACKGROUND: Anosmia was one of the main symptoms of coronavirus disease 2019 (COVID-19). A psychiatric history (i.e., depression) may be an independent contributor to the risk of COVID-19 diagnosis, and COVID-19 survivors appear to have an increased risk of neuropsychiatric sequelae (bidirectional association). AIM: To compare the rate of psychiatric disorder among post-COVID patients without anosmia vs patients with persistent olfactory complaints. METHODS: We conducted a prospective case control study from March 2020 to May 2021. Patients recruited at the ENT department of Nice University Hospital had a subjective olfactory complaint (visual analogue scale) for over 6 wk and a molecular or CT-proven severe acute respiratory syndrome coronavirus 2 diagnosis confirmed by serology. Post-COVID patients without persistent olfactory disorders were recruited at the university hospital infectiology department. Psychiatric medical histories were collected by a psychiatrist during the assessments. RESULTS: Thirty-four patients with post-COVID-19 olfactory complaints were included in the first group of the study. Fifty percent of the patients were female (n = 17). The group's mean age was 40.5 ± 12.9 years. The control group included 32 participants, of which 34.4% were female (n = 11), and had a mean age of 61.2 ± 12.2 years. The rate of psychiatric disorder among post-COVID patients with olfactory complaints was significatively higher (41.7%) than among patients without (18.8%) (χ2 = 5.9, P = 0.015). CONCLUSION: The presence of a psychiatric history may constitute a potential risk factor for the development of long COVID due to persistent anosmia. It therefore seems important to establish reinforced health monitoring after a COVID 19 infection in at-risk patients. Further prospective, translational, and collaborative studies are needed to extrapolate these results to the general population.

Cardiac and metabolic safety profile of antipsychotics in youths: A WHO safety database analysis.

A significant heterogeneity prevails in antipsychotics (APs) safety monitoring recommendations. Youths are deemed more vulnerable to cardiometabolic side effects. We aimed to assess age-dependent reporting of cardiac and metabolic disorders in youths, relying on the WHO safety database (VigiBase®). VigiBase® was queried for all reports of cardiac, glucose, lipid and nutritional disorders involving APs. Patients <18 years were classified as pediatric population. Disproportionality analyses relied on the Information Component (IC): the positivity of the lower end of its 95 % confidence interval was required to suspect a signal. We yielded 4,672 pediatric reports. In disproportionality analysis, nutritional disorders were leading in youths (IC 3.9 [3.9-4.0]). Among healthcare professionals' reports, stronger signals were detected in youths than in adults. Children had the greatest signal with nutritional disorders (IC 4.7 [4.6-4.8]). In adolescents, aripiprazole was ascribed to non-alcoholic steatohepatitis (NASH). Our findings, based on real-world data, support the hypothesis of a greater propensity for nutritional disorders in youths, despite limitations of pharmacovigilance studies. We suggest specific safety profiles, such as aripiprazole and NASH. Pending more answers from population-based studies, a careful anamnesis should seek for risk factors before AP initiation. A cautious monitoring is warranted to allow earlier identification of side effects.

Study protocol: how does parental stress measured by clinical scales and voice acoustic stress markers predict children's response to PTSD trauma-focused therapies?

INTRODUCTION: Post-traumatic stress disorder (PTSD) symptoms in youth are influenced by parental anxiety and stress. When parents have high levels of stress or have developed PTSD themselves, children tend to show more anxiety symptoms. Parental stress can affect the severity of children's PTSD and lower the success of recovery. However, the influence of parental stress on the effectiveness of trauma-focused therapies (eye movement desensitisation and reprocessing and cognitive behavioural therapy) has not yet been investigated to our knowledge. Hence, we will measure parental stress (using both validated scales and vocal acoustic markers) and investigate how it influences children's PTSD recovery. METHOD AND ANALYSIS: Sixty children between the ages of 7 and 15 years who experienced type 1 trauma will be recruited at the Nice Pediatric Psychotrauma Center in France. We plan to measure stress using two different approaches. We will ask parents to answer validated scales of stress and mood in general. Stress will also be measured using vocal acoustic markers. Parents will be recorded while narrating their child's trauma and during the narrative of a positive and neutral recall of events. Child participants will have to complete anxiety, PTSD and depression scales before the beginning of the trauma-focused therapy and after 3 months of treatment.Linear mixed effects models and differential statistics, such as significance testing corrected for multiple testing, will be used to determine the validity of speech features for the proposed hypotheses. Repeated measures analysis of variance will be performed on the clinical scales scores according to parental stress. Correlations will be performed between clinical scales of parents and children according to time of assessment. ETHICS AND DISSEMINATION: This study was approved by the Committee for the Protection of Individuals of the University of Nice Sophia Antipolis (CERNI) on 21 February 2022, under the number CER2022-015.All participants will be informed that this is an observational study and their consent taken prior to the experiment. Participants will be informed that they can withdraw from the study at any time and that it would not affect the care provided. TRIAL REGISTRATION NUMBER: CER AVIS n° 2022-015.

Impact of the 7/14/2016 Nice terrorist attack on pediatric emergency department visits thanks to syndromic surveillance: a descriptive study.

Objective: Study the impact of 14th July 2016 Nice terrorist attack on Pediatric Emergency Department (PED) visits by youth under 18 years of age. Methods: PED visits diagnoses (ICD10) were clustered and analyzed based on retrospective data from the syndromic surveillance system of the Children's university hospital of Nice (Southern France). The studied period ranges from 2013 to 2019, i.e., 3 years before and after the terrorist attack of 14th July 2016. Results: Among 416,191 PED visits, the number of visits for stress in 4-17 years old appeared to increase in the 3 years after the attack compared to the 3 years before, particularly in September 2016 (acute effect) with 11 visits compared to an average of 2.3 visits per month from September 2013 to 2016 (p = 0.001827). In September 2017, we noticed 21 visits compared to an average of 4.8 visits per month during the following period (2013-2019). In 2017, PED visits for stress among 4-17 year olds were higher in comparison to the other years of the study: 107 visits compared to an annual average of 57. Conclusion: To our knowledge, this is the first study of the use of the pediatric care system before and after a terrorist attack involving syndromic surveillance. This suggests acute and long-term effects of the terrorist attack on PED use by youth for mental health issues. Further studies of the pediatric care system involving syndromic surveillance are needed in the context of mass violent events, such as terrorist attacks.

July 14th 2016 Nice Terrorist Attack Court Trial: A Protocol on Sleep Quality and Somatic Symptoms as Markers of Risk for Traumatic Reactivation in Adolescents Exposed to This Attack.

The court trial of the 14th of July 2016 terrorist attack in Nice (France) opened in September 2022 and ended in December 2022. Engaging in court proceedings, whether as a victim or a witness, can lead to a significant risk of traumatic reactivation (i.e., the re-emergence of post-traumatic stress symptoms). The present protocol aimed to improve knowledge of the pathophysiology of traumatic reactivation due to the media coverage of the trial by assessing sleep disturbances and somatic symptoms that could reappear if there is a traumatic reactivation. Method and Analysis: This is a monocentric longitudinal study, with recruitment solely planned at the Nice Pediatric Psychotrauma Center (NPPC). We intended to include 100 adolescents aged 12 to 17 years who were directly or indirectly exposed to the attack and included in the "14-7" program). Assessments began one month before the trial, in August 2022, and were scheduled once a month until the end of the trial. A smartwatch recorded sleep activity. Somatic and PTSD symptoms and sleep were assessed through validated questionnaires. The main analyses comprised the variance and regression analyses of predictors of clinical evolution over time. Ethics and Dissemination: The National Ethics Committee "NORD OUEST III" approved the "14-7" program protocol (number 2017-A02212-51). The specific amendment for this research was approved in April 2022 by the same national ethical committee. Inclusions started in August 2022.

Iatrogenic triggers for anorexia nervosa and bulimia nervosa: A WHO safety database disproportionality analysis.

Eating disorders, characterized by abnormal eating, weight control behaviors or both include anorexia nervosa (AN) and bulimia nervosa (BN). We investigated their potential iatrogenic triggers, using real-world data from the WHO safety database (VigiBase®). VigiBase® was queried for all AN and BN reports. The reports were classified as `pediatric' or `adult' according to age. Disproportionality analyses relied on the Information Component (IC), in which a 95% confidence interval lower-end positivity was required to suspect a signal. Our queries yielded 309 AN and 499 BN reports. Isotretinoin was disproportionately reported in pediatric AN (IC 3.6; [2.6-4.3]), adult AN (IC 3.1; [1.7-4.0]), and pediatric BN (IC 3.9; [3.0-4.7]). Lamivudine (IC 4.2; [3.2-4.9]), nevirapine (IC 3.7; [2.6-4.6]), and zidovudine (IC 3.4; [2.0-4.3]) had the highest ICs in adult AN. AN was associated with isotretinoin, anticonvulsants in minors, and antiretroviral drugs in adults. In adults, BN was related to psychotropic and hormonally active drugs. Before treatment initiation, an anamnesis should seek out mental health conditions, allowing the identification of patients at risk of developing or relapsing into AN or BN. In addition to misuse, the hypothesis of iatrogenic triggers for AN and BN should also be considered.

Assessment of PTSD and posttraumatic symptomatology in very young children: A systematic review.

CONTEXT: Very young children are said to be a vulnerable group for exposure to trauma, and for a psychopathological response (e.g., PTSD) after a risk-exposure. The specific assessment of young children is necessary to enable them to be enrolled in an appropriate care pathway. OBJECTIVE: The objective was to identify the instruments available in the English language for the assessment of posttraumatic symptoms in very young children (from 0- to 5-year old). DESIGN: This article reports on a systematic review, conducted using the search engines Google Scholar, Science Direct, PsycArticles, and PubMed. RESULTS: Nine instruments are available to specifically assess traumatic symptomatology in very young children (0-7-year old), five instruments are available for the broader assessment of very young children (1-6-year old), six instruments are available for the assessment of traumatic symptoms in very young children and in older children (2-18-year old), one instrument did not correspond to any category. These 21 tools are adapted to different ages, built according to different objectives, and do not rely on the same diagnostic algorithm. CONCLUSION: Future research should compare the instruments quantitatively to identify those most specific and sensitive to the assessment of trauma symptoms in young children.

Case Report: Anti-NMDAR Encephalitis Presenting With Catatonic Symptoms in an Adolescent Female Patient With a History of Traumatic Exposure.

INTRODUCTION: Catatonia is a severe syndrome associated with a high proportion of underlying organic conditions including autoimmune encephalitis. The link between catatonia and psychiatric conditions such as mood disorders and schizophrenia spectrum disorders is well established while the causative effect of Post-Traumatic Stress Disorders and stress related disorders remains speculative. CASE REPORT: Here we describe the clinical case of a 14-year-old female patient presenting to the Emergency Department of a Pediatric University Hospital with acute changes in behavior five days after a sexual abuse. Acute stress reaction was suspected. Afterwards she developed catatonic symptoms alternating from stupor to excitement, resistant to the usual treatment with benzodiazepines. The first line examinations (PE, MRI, EEG) were inconclusive. The final diagnosis of anti-NMDARE was made 22 days after her admission in a University Department of Child and Adolescent Psychiatry. Her state improved after first- and second-line immunotherapy, with no signs of relapse at this day (8 months of clinical follow-up). DISCUSSION: The diagnosis of anti-NMDARE is challenging, involving a multidisciplinary approach. The neuropsychiatric features are complex, with no specific psychiatric phenotype. Several hypotheses are discussed to determine the role of an acute environmental stressors in the emergence of such complex neuropsychiatric clinical presentation (i.e., shared vulnerability, precipitators, consequences of preexisting psychiatric symptoms). CONCLUSION: Child and adolescent psychiatrists and pediatricians should be aware of the overlap between neurological and psychiatric features in the setting of anti-NMDARE. Catatonia should not be dismissed as a primary psychiatric disorder even in the context of recent traumatic exposure.