Emotional and behavioral dyscontrol after traumatic brain injury.

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.

Neurocognitive performance in children with ADHD and OCD.

Attention-deficit/hyperactivity Disorder (ADHD) and obsessive-compulsive disorder (OCD) have both been linked to dysfunction in the cortico-striato-thalamo-cortical circuitry (CSTCC). However, the exact nature of neurocognitive deficits remains to be investigated in both disorders. We applied two neuropsychological tasks that tap into different functions associated with the CSTCC, namely a serial reaction time (SRT) task, developed to assess implicit sequence learning, and a delay aversion (DA) task in order to assess abnormal motivational processes. The performance data of boys with ADHD (n=20), OCD (n=20) and healthy controls (n=25), all aged 10-18 years, were compared. Subjects with ADHD less frequently chose the larger, more delayed reward compared to those with OCD and controls, while subjects with OCD showed impaired implicit learning. In contrast, the ADHD group was unimpaired in their implicit learning behavior and the OCD group was not characterized by a DA style. Within the OCD-group, severity of obsessions was associated with implicit learning deficits and impulsive symptoms with DA in the ADHD-group. This double dissociation highlights the distinct cognitive dysfunctions associated with ADHD and OCD and might possibly point to different neural abnormalities in both disorders.

Script-driven imagery of self-injurious behavior in patients with borderline personality disorder: a pilot FMRI study.

OBJECTIVE: Self-injurious behavior (SIB) is one of the most distinctive features of borderline personality disorder (BPD) and related to impulsivity and emotional dysregulation. METHOD: Female patients with BPD (n = 11) and healthy controls (n = 10) underwent functional magnetic resonance imaging while listening to a standardized script describing an act of self-injury. Experimental sections of the script were contrasted to the neutral baseline section and group-specific brain activities were compared. RESULTS: While imagining the reactions to a situation triggering SIB, patients with BPD showed significantly less activation in the orbitofrontal cortex compared with controls. Furthermore, only patients with BPD showed increased activity in the dorsolateral prefrontal cortex during this section and a decrease in the mid-cingulate while imagining the self-injurious act itself. CONCLUSION: This pattern of activation preliminary suggests an association with diminished emotion regulation, impulse control as well as with response selection and reappraisal during the imagination of SIB.

Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity: a meta-analysis.

Since the first reports of neurofeedback treatment in Attention Deficit Hyperactivity Disorder (ADHD) in 1976, many studies have investigated the effects of neurofeedback on different symptoms of ADHD such as inattention, impulsivity and hyperactivity. This technique is also used by many practitioners, but the question as to the evidence-based level of this treatment is still unclear. In this study selected research on neurofeedback treatment for ADHD was collected and a meta-analysis was performed. Both prospective controlled studies and studies employing a pre- and post-design found large effect sizes (ES) for neurofeedback on impulsivity and inattention and a medium ES for hyperactivity. Randomized studies demonstrated a lower ES for hyperactivity suggesting that hyperactivity is probably most sensitive to nonspecific treatment factors. Due to the inclusion of some very recent and sound methodological studies in this meta-analysis, potential confounding factors such as small studies, lack of randomization in previous studies and a lack of adequate control groups have been addressed, and the clinical effects of neurofeedback in the treatment of ADHD can be regarded as clinically meaningful. Three randomized studies have employed a semi-active control group which can be regarded as a credible sham control providing an equal level of cognitive training and client-therapist interaction. Therefore, in line with the AAPB and ISNR guidelines for rating clinical efficacy, we conclude that neurofeedback treatment for ADHD can be considered "Efficacious and Specific" (Level 5) with a large ES for inattention and impulsivity and a medium ES for hyperactivity.

[Psychoanalytic psychotherapy and the ADHD-triad (impulsivity, hyperactivity and attention deficit disorder)]. / Psychoanalytische Psychotherapie und ADHD-trias (Impulsivität, Hypermotorik und Aufmerksamkeitsstörungen).

A brief survey of the psychoanalytically oriented literature regarding the symptom triad of ADHD is followed by the discussion of frequently found disturbances in infantile development, attachment, object relations (regulation of drives and affects, ego functions) of the role of infantile trauma (object loss) and psychic conflict. In the analytic-psychotherapeutic process with a child, the ADHD-symptom-triad may manifest itself e.g. as intrapsychic conflict on the level of the self-representation or of the representation of central self-object-relations (characterized by an insufficient containing-/holding-function), as impairment of self-regulative functions, as inconsistent symbolizing capacity or as deficient regulating and controlling capacity of the ego. The multitude of factors involved does not allow a generalisation of neither the etiology or the pathogenesis of this symptom triad. This is particularly evident in a therapeutic procedure which is relation oriented. In a first interview the authors illustrate the capacity of a ten year old boy (diagnosed as ADHD patient) to make use of the analytic therapeutic dialogue and to present his intrapsychic experiences and problems in a figurative and narrative performance. Finally some specific technical features of low or high frequent analytic psychotherapy with ADHD children are shown: according to the foremost pregenital form of relations--manifested mostly by intensive self esteem problems, narcissistic aggressiveness and motor impulsivity--the transference and counter-transference movements proceed predominantly by projective and introjective identifications. Containment of the difficulties by the therapist is often paralleled for a long period of time by assistance in regulation and by limit setting for the child. Translation of action into language and transformation of intrapsychic processes within the psyche of the therapist into helpful interventions for the child require a continuous adjustment to the inconsistent ego functions and the fragile self esteem of the child. The additional use of stimulant drugs, the work within the family and/or the social context and the high need for research in the analytical field are briefly discussed at the end.

Factors associated with parent-reported suicide threats by children and adolescents with community-diagnosed bipolar disorder.

BACKGROUND: It has recently been suggested that indicators of suicidality in youth may differ for different diagnostic groups []. Aggression, impulsivity and risk-taking behaviors may be strong indicators of suicidality in children and adolescents with symptoms of bipolar disorder. METHODS: Parents completed the Child Bipolar Questionnaire (CBQ) via a secure, Internet-based data acquisition system. In multivariate modeling analyses, with age and sex as covariates, CBQ items that were most closely correlated with parent-reported suicide threat were identified. The strength of this multifactor association was then examined among subjects reported to have a community diagnosis of bipolar disorder compared to those who did not. RESULTS: In order of strength of association, the CBQ items most closely correlated with parent-reported suicide threat were: hallucinations, cursing/foul language, low energy/withdrawal, imagery-gore/violence, destroys property, poor self-esteem, excessive risk-taking, and excessive anxiety/worry. Of these 8 CBQ items, 3 (low energy, poor self-esteem, and anxiety/worry) have a dysphoric orientation, but the items with the strongest associations are related to psychosis, aggression and impulsivity. The association of the 8 CBQ items with suicidal threats was found to be much stronger in subjects with a reported prior or current bipolar diagnosis, compared with all other subjects. LIMITATIONS: Child report data is not available. Parent report data has not yet been validated by research diagnostic interview. CONCLUSIONS: The presence of aggression and impulsivity are importantly related to suicidal threats independently of the risk associated with dysphoria in children and adolescents who have been assigned a diagnosis of bipolar disorder or exhibit some symptoms of the disorder. This may have implications for treatment with antidepressant medication when the diagnosis of bipolar disorder may be present.