Etiopathogenesis in the Development of Borderline Personality Characteristics in Children and Adolescents. / Çocuk ve Ergenlerde Borderline Kisilik Özelliklerinin Gelisiminde Etyopatogenez.

The validity and clinical significance of the characteristics of borderline personality disorder (BPD) in adolescents are increasingly being recognized. The persistence of BPD characteristics in adolescence is high and is associated with negative interpersonal, academic, professional, and financial outcomes. In the literature, BPD characteristics observed in children and adolescents are explained with psychodynamic theories, developmental models, and evolutionary approaches. Emotional dysregulation, interpersonal dysfunction, impulsivity, and self-harming behavior, negative life events, temperament characteristics, neuropsychological dysfunctions, neuroanatomical, genetic, hormonal, and immunological factors may play a role in BPD etiopathogenesis. This review aims to address different approaches and relevant factors for the development of BPD. The articles published between 1968-2021 in the PubMed database were reviewed, and prominent studies were selected for evaluation. The importance of invalidating environment, epistemic freezing and hypermentalization, complex or attachment trauma is emphasized in psychodynamic and developmental literature. In the evolutionary approach, on the other hand, romantic relationships and the onset of reproduction are emphasized as the reason for the emergence of symptoms during adolescence, and it is argued that BPD is related to the rapid life history strategy. It is stated that a decrease in volume in the orbitofrontal cortex and anterior cingulate cortex, which are involved in top-down emotional processing, and an increase in the activity of thalamus and hippocampus regions, which are involved in bottom-up emotional processing are observed in adolescents with BPD characteristics when compared to healthy controls. It is thought that the increase in activation in the superior temporal gyrus and precuneus observed in adolescents with BPD features is a neural indicator of hypermentalization, and the increase in activation in the insula is a neural indicator of social pain. It has been reported that the decrease in resting heart rate and the increase in heart rate variability observed in adolescents with BPD symptoms are associated with the activation of the parasympathetic system. BPD in adolescents is a disorder that challenges clinicians in terms of diagnosis, differential diagnosis, and treatment. It is crucial to evaluate the factors related to etiopathogenesis in BPD in a multifaceted and detailed manner. Keywords: Borderline Personality Disorder, Difficulty in Emotion Regulation, Mentalization, Trauma, Self-harming Behavior, Temperamental Characteristics.

Long-Term Effects of Lithium Use on Children and Adolescents: A Retrospective Study from Turkey.

Background: The aim of this study was to evaluate the long-term effects of lithium treatment on white blood cell (WBC) count, serum creatinine, and thyroid-stimulating hormone (TSH) levels in children and adolescents with bipolar disorder (BD) and non-BD in a Turkish children and adolescent sample. Methods: The study is based on retrospective chart review. Children and adolescent patients with BD and non-BD prescribed lithium in a mental health and neurological disorders hospital between 2012 and 2017 were included in the study. Data were collected from the electronic medical files. Laboratory values for WBC count, serum creatinine, and TSH levels at baseline within the week before the onset of lithium, and at 1st, 3rd, 6th, and 12th month of treatment were recorded. Results: A total of 143 patients (82 females, 61 males; 100 BD, 43 non-BD) aged 9-18 were included. Non-BD diagnoses were psychotic and schizoaffective disorders, unipolar depression, attention-deficit/hyperactivity disorder, conduct disorder, severe mood dysregulation syndrome, borderline personality disorder, and autism. Mean age of the participants were 15.90 ± 1.16 years for the bipolar group and 14.88 ± 1.79 years for the nonbipolar group. Patients with BD reported more adverse effects. There was a statistically significant increase in WBC counts and TSH levels at any time point. A statistically significant elevation in serum creatinine was found at 3rd and 12th month of treatment. During the course of lithium treatment, WBC counts exceeded 13,000 in 14 (9.8%) patients, and TSH levels exceeded 5.5 mU/L in 41 patients (28.6%). Twenty-one (14.68%) patients were started on thyroxin replacement. Basal TSH levels and duration of the lithium treatment were higher in the participants with TSH levels exceeding 5.5 mU/L. Lithium maximum dose, lithium blood level, basal TSH level, and duration of treatment were higher in the participants receiving thyroxin replacement. No patients had serum creatinine levels exceeding the normal reference values. Conclusion: Our study suggests that lithium is a generally safe and tolerable agent for children and adolescents with BD and non-BD; however, close monitoring of thyroid functions particularly in patients with a higher basal TSH level and longer duration of lithium use is important.

Relationship of Temperament Differences with Diagnosis, Severity and Accompanying Psychiatric Symptoms in Autism Spectrum Disorder.

Introduction: Temperament differences were shown in children with autism spectrum disorder (ASD); however, associations of temperament with ASD severity and accompanying psychiatric symptoms have yet to be studied. Methods: We evaluated 58 ASD-diagnosed children's temperaments through disorder severity and psychiatric symptoms and compared them with 58 typically developed children. We utilized the Children's Behavior Questionnaire-Short Form, The Strengths and Difficulties Questionnaire (SDQ). The Childhood Autism Rating Scale (CARS) was used to evaluate psychiatric symptoms and ASD severity levels of children. Results: Negative affect, effortful control, and perceptual sensitivity were found lower in ASD-diagnosed children and decreased with ASD severity. Effortful control was also found negatively correlated with scores of behavioral problems, hyperactivity, and total difficulties. Besides, anger/frustration was found predictive for conduct and peer problems, and total difficulty scores. Conclusion: Further studies are needed to verify and expand these pioneer findings.

Factitious Disorder Presenting with Stuttering in Two Adolescents: The Importance of Psychoeducation.

A factitious disorder (FD) is a diagnostic entity in which patients intentionally act physically or mentally ill without obvious benefits and without being consciously aware of a clear underlying motive. Most pediatric FD cases have been reported as Munchausen syndrome by Proxy; however, pediatric disease symptoms can also be intentionally falsified by child and adolescent patients. To our knowledge, in the medical literature, an FD patient presenting with stuttering has not been previously reported. In this case report, we aimed to discuss the diagnosis and treatment process of FDs in children and adolescents by reporting the cases of two FD patients presenting with stuttering according to the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition. Both patients improved with psychoeducation and early confrontation.

One-Year Follow-Up of Heroin-Dependent Adolescents Treated with Buprenorfine/Naloxone for the First Time in a Substance Treatment Unit.

The aims of the present study were to evaluate 1-year retention in program and buprenorphine/naloxone (BUP/NAL) treatment, and abstinence of heroin-dependent adolescents. The present study included the follow-up information of 112 heroin dependent adolescents who took BUP/NAL treatment for the first time in a specific inpatient unit. Retention and abstinence were assessed by self-report and urine drug screen at each visit. Mean age was 16.9 years, with 101 (90.2%) male. Program retention was 81.3% at day 30, and 24.1% at 1 year, while retention in BUP/NAL treatment was 69.6% at day 30 and 16.1% at 1 year. Rates of abstinence were 69.0% at day 30 and 10.3% at 1 year. There was a significant positive correlation between duration of inpatient treatment and program retention, treatment retention, abstinence (p < 0.05 for all), and between the dose and treatment retention, abstinence (p < 0.05 for both). Patients with comorbid psychiatric disease were more likely to be retained in treatment for 3 months, and in program for 6 months (p < 0.05, for all). Patients who completed inpatient treatment were more likely to be retained in treatment for 1 year, and in program for 9 months, and to be abstinent for 1 year (p < 0.05, for all). Findings suggested that starting BUP/NAL treatment in an inpatient unit might result in better outcomes compared to literature. Duration of inpatient treatment, the completion of inpatient treatment, BUP/NAL dose, and having a comorbid psychiatric disease seemed to be important factors for heroin-dependent adolescents in retention and abstinence within 1-year period.

Impact of end-stage renal disease on psychological status and quality of life.

BACKGROUND: The aim of this study was to assess depression, anxiety, and quality of life (QOL) in a cohort of children and adolescents with end-stage renal disease (ESRD), to compare these findings with healthy controls, and to evaluate the association between these psychological symptoms, QOL, and clinical variables related to ESRD. METHODS: Thirty-two children and adolescents 8-18 years of age were enrolled in the study. The sociodemographic data were evaluated. Questionnaires were used to evaluate the psychological status and QOL of the patients and healthy controls. RESULTS: There was a significant difference in mean depression score, which was significantly higher for the ESRD patients. Mean state anxiety score was significantly lower for ESRD patients than for controls. Regarding QOL score, there were significant differences between the ESRD patients and control groups for both child-rated and parent-rated QOL scores, which were significantly lower for ESRD patients. Trait anxiety was a negative predictor of all subscales of the Pediatric Quality of Life Inventory 4. CONCLUSIONS: End-stage renal disease was related to significant morbidity and poorer QOL. The assessment and enhancement of QOL and comorbid psychiatric disorders in ESRD should be a part of disease management.

A Retrospective Investigation of Clozapine Treatment in Autistic and Nonautistic Children and Adolescents in an Inpatient Clinic in Turkey.

OBJECTIVE: The aim of this retrospective study is to examine the clinical outcomes and safety of clozapine in children and adolescents with schizophrenia or other psychotic disorders/autism spectrum disorder (ASD) or affective disorders. METHODS: The inpatient and outpatient files of all children and adolescents treated with clozapine over a period of 34 months (from October 2011 to July 2014) were reviewed. Demographic and clinical data were examined to describe clinical and metabolic findings, dosing, and tolerability of clozapine treatment in youth with schizophrenia, other psychotic disorders, ASD, or bipolar disorder. RESULTS: The 37 pediatric patients included 26 patients with schizophrenia or other psychotic disorders, 7 patients with ASD complicated by schizophrenia or other psychotic disorders or affective disorders, and 4 patients with ASD only. In all groups (n = 37) there was a significant reduction (p < 0.001) in Brief Psychiatric Rating Scale (BPRS) points after clozapine treatment during the inpatient period (38.78 ± 27.75 days). In patients with schizophrenia or other psychotic disorders co-occurring with ASD or not (n = 31), there was a significant improvement in psychotic symptoms according to Positive and Negative Syndrome Scale (PANSS) total scores and subscores (p < 0.001). Of the 26 patients with schizophrenia or other psychotic disorders, 8 (30.8%) showed a positive response (>30% symptom reduction on BPRS). In patients with ASD complicated by schizophrenia or other psychotic disorders or bipolar disorders (n = 7), there was a significant reduction (p = 0.017) in BPRS scores after clozapine treatment. The discontinuation rate for clozapine was 10.8%, and the most frequently observed side effect was hypersalivation (54.1%). Neutropenia associated with clozapine was observed in only one patient (2.7%). CONCLUSIONS: Clozapine seems to be effective and safe in children and adolescents with schizophrenia or other psychotic disorders co-occuring with ASD or not. There is a need for further studies for determining the efficacy of clozapine in children and adolescents with bipolar affective disorder or ASD.

The Assessment of Family Functions, Dyadic Adjustment, and Parental Attitude in Adolescents with Substance Use Disorder.

INTRODUCTION: Family structure and family attitudes have been reported to be important factors in the development of substance use disorders. In this study, we aimed to assess the relationship between substance use and family functions, parental attitude, and parental dyadic adjustment of adolescents with substance use disorder. METHODS: The study was conducted on 50 patients, comprising 9 female and 41 male adolescents between the ages of 14 and 18 years, treated at Bakirköy Mental Health Hospital, Substance Abuse Research, Treatment and Education Center for Children Adolescents (ÇEMATEM), Turkey, with the diagnosis of substance use disorder according to DSM-5 and their parents and a control group comprising 50 healthy adolescents without any psychopathology or substance use disorder and their parents. The study was designed as a matched case-control study for age and gender. Sociodemographic Data Form (SDF), Parental Attitude Scale (PAS), Dyadic Adjustment Scale (DAS), and Family Assessment Device (FAD) were applied to both groups. RESULTS: When the study and control groups were compared with regard to the PAS, the study group scores determined for "involvement-acceptance," "psychological autonomy," and "control-supervision" dimensions were significantly lower than the control group scores. Compared with the control group, dyadic adjustment was lower in terms of "dyadic cohesion," "dyadic consensus," and "affectional expression." Living with biological parents and the togetherness of parents were lower in the study group. "Problem solving," "communication," "roles," "affective responsiveness," "affective involvement," "behavior control," and "general functioning" dimension scores according to FAD were also significantly higher in the study group. CONCLUSION: Compared with togetherness of the controls, the dyadic adjustment of their parents was lower and family functions as perceived by the parents and adolescents were unhealthier in the adolescents using substances. These findings indicate that the family functions, dyadic adjustment, and parental attitude styles need to be assessed in the risk groups to determine familial risk factors and to structure protective measures. These assessments may guide clinicians and policy-makers toward good clinical practice and help build protective measures.

[First Episode Psychosis: Relationship of Symptoms, Initial Treatment and Clinical Response]. / Ilk Psikoz Atagi: Belirtiler, Tedavi Baslangici ve Klinik Yanit Iliskisi.

OBJECTIVE: It was aimed to explore the relationship of clinical psychopathology and treatment response with "duration of untreated psychosis" (DUP) and "duration of untreated illness"(DUI) in 15-20 years old (mean age: 17,34 ± 1.69) inpatients in Turkey. METHOD: Mood disorders with psyhotic features were grouped as affective psychoses (18 patients, mean age: 17,28 ± 1,75); schizophrenia, schiozophreniform disorder and other psychotic disorders were grouped as non-affective psychoses (25 patients, mean age: 17,38 ± 1,68). 43 patiens (11 females, 32 males) were evaluated for acute treatment response with Positive and Negative Scale-PANSS and Clinical Global Impressions Scale-CGI. RESULTS: Mean DUP was determined as 6,5 ± 12,4 weeks, mean DUI was determined as 37,8 ± 49,8 weeks. For the affective psychosis (AP) group; mean DUP was 1,9 ± 1,2 weeks, mean DUI was 24,6 ± 37,1 weeks, for the non-affective psychosis (NAP) group; mean DUP was 9,8 ± 15,5 weeks, mean DUI was 47,3 ± 55,9 weeks. Treatment response was better for the non-affective psychosis group and for the patients who had earlier access to treatment. Shorter DUP and DUI was related with better PANSS negative symptom severity at the time of the discharge. CONCLUSION: Better treatment response related with shorter DUP and DUI reveals the significance of early treatment for the disease prognosis.

Sociodemographic characteristics and drug abuse patterns of adolescents admitted for substance use disorder treatment in Istanbul.

BACKGROUND: Adolescent substance use is an increasing major health problem in developing countries. OBJECTIVES: To evaluate the sociodemographic characteristics and drug abuse patterns of children and youth seeking treatment in Turkey. METHODS: This retrospective study reviewed the demographic and clinical data of substance users who visited the substance addiction treatment clinic for children and youth in Bakirköy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery in Istanbul, between January 2011 and December 2012. RESULTS: The sample comprised of 1969 children and youth aged between 11 and 20 (346 female and 1623 male). Cannabis (60.1%), followed by solvents/inhalants (38.3%) and ecstasy (33.4%), were the most prevalent substances used. The use of solvents/inhalants was more common among males, whereas ecstasy and cocaine use were more common among females. The mean age for the onset of substance use was 13 years. The proportion of polysubstance use was 60.2%. There was a mean duration of 2.28 ± 1.91 years between the first substance use and seeking treatment. The risk factors for most of the drug usage were onset of substance use at a young age, gender, treatment admission at older ages, higher parental criminal history, and having substance using parents or relatives. CONCLUSION: Findings of the very early onset of substance and polysubstance use indicated easy accessibility of legal and illicit substances by children and youth in Istanbul. These findings on Turkish children and youth who seek substance use treatment can be useful in developing preventive early interventions and treatment facilities.

Comparing brain magnetic resonance spectroscopy findings of pediatric treatment-naive obsessive-compulsive disorder patients with healthy controls.

OBJECTIVE: It is believed that biochemical alterations in different brain regions are involved in the pathophysiology of obsessive-compulsive disorder (OCD) in children and adolescents. The aim of this study was to explore possible metabolic variations between pediatric OCD cases and healthy controls in brain regions which were implicated in OCD pathophysiology. METHOD: Children and adolescents between 8 and 16 years of age with OCD (n:15) and case matched healthy controls (n:15) were recruited for the study. After detailed clinical and neuropsychological evaluations, all subjects underwent the multiregional magnetic resonance spectroscopy (MRS) procedure with a long echo time (TE:135). RESULTS: Significantly lower n-acetylaspartate (NAA) ratios in the left inferior frontal gyrus, right occipital grey matter, left anterior cingulate cortex and lower choline (Cho) ratios in right and left anterior cingulate cortex and higher Cho ratio in left lenticular nucleus was observed in the OCD group. Also we found a negative correlation between OCD duration and left insular cortex NAA/Cho ratio. CONCLUSION: We found significant metabolic alterations in the brain regions which were implicated in OCD pathophysiology. Lower NAA and Cho ratios in anterior cingulate cortex and lower NAA ratios in the left inferior fronyal gyrus containing lateral orbitofrontal cortex can be possibly related to higher activation in OCD patients. Also further studies of the occipital lobes and insula should be continued in OCD.