Parkinson's disease (PD) is one of the most common neurodegenerative diseases. The last 5 years have been marked by rapid developments in understanding the pathophysiology of PD as well as by the introduction of a number of new drugs for symptomatic treatment of the disease. On the other hand, the diagnosis of PD is still made purely on clinical grounds. Due to continuing advances in therapy, it is increasingly important to recognize PD in its earliest stages and to distinguish it from other causes of parkinsonism, for which prognosis and response to treatment differ. This article reviews the epidemiology of PD and then elaborates on the diagnosis and differential diagnosis.

Sexual dysfunction is common among patients with epilepsy, but many clinicians do not include inquiries about this aspect of the patient's health in their routine evaluations. This article presents approaches for taking a sexual history and for discussing sexual problems. The utility of standardized sexual dysfunction questionnaires is reviewed and the important elements of appropriate and effective counseling are highlighted.

While the public health perspective prioritizes large populations of affected individuals, our job as clinicians is to help one patient at a time. Over the last 10–20 years, there has been marked improvement in pharmacologic and psychosocial interventions available for patients with anxiety disorders (Slide 8).

The use of antidepressants, particularly the serotonergic and serotonergic noradrenergic agents, have received increased attention as first-line treatment for most of the anxiety disorders, including panic disorder, social phobia, posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). Antidepressants are often used as first-line therapy for anxiety disorders because of their broad spectrum of efficacy against common comorbidities, especially depression, and because of concern about benzodiazepine-associated dependence, abuse liability, and lack of efficacy for depression and other comorbidities (Slide 9).

These newer antidepressants have advantages over the older antidepressants, particularly the tricyclics and the monoamine oxidase inhibitors, in that they are generally better tolerated and more appropriate for use in potentially suicidal patients because they are less lethal in overdose. However, there are some side effects that may limit their use in some patients. In the case of the serotonergic antidepressants, many patients are hesitant to initiate or maintain treatment due to concerns about sexual dysfunction.

In discussions of diversion and misuse of medications in adult attention-deficit/hyperactivity disorder (ADHD), the word “misuse” is intentionally used. Abuse of a medication refers to excessive use of a drug to achieve a “high,” which may result in addiction to the medication and which causes dysfunction in a patient's life. However, misuse refers to usage of a medication without a prescription or for reasons other than that which it was prescribed. Diversion refers to the diverting of legally prescribed medication into illegal use by other than the patient. Sahakian and Morein-Zamir recently discussed the use of cognitive-enhancing drugs by individuals with a variety of disorders as well as off-label and non-prescription use by the general public. In addition to inappropriate use of medications, patients with ADHD often turn to other substances that are detrimental to their health, such as nicotine.

Attention-deficit/hyperactivity disorder (ADHD) is a lifelong condition that begins in childhood and continues with adult manifestations related to the core symptoms. Approximately 50% to 75% of children with ADHD continue to meet criteria for the disorder as adolescents and adults. Adults with the disorder increasingly present to primary care physicians, psychiatrists, and other practitioners for diagnosis and treatment. Understanding the diagnosis of ADHD in adults requires knowledge of age-dependent decline of symptoms over time. Retrospective recall of symptoms and impairment are valid methods of diagnosing the disorder. ADHD is also a brain disorder with a strong neurobiologic basis, complex etiology, and genetic component. Genetic and environmental vulnerabilities give rise to abnormalities in the brain and subsequent behavioral and cognitive deficits, which may produce the symptoms associated with ADHD. Magnetic resonance imaging studies of ADHD have provided evidence that abnormalities in the brain are caused by the disorder itself rather than treatment of the disorder. Psychiatric comorbidity is common among patients with ADHD and tends to complicate treatment. Acute and long-term use of long-acting stimulant formulations (methylphenidate and amphetamine compounds) have shown robust efficacy and tolerability consistent with the treatment response established in children with ADHD. Non-stimulant medications have demonstrated efficacy as well, and may be preferred in patients with tic and substance use disorders.

In this expert roundtable supplement, Timothy E. Wilens, MD, reviews the epidemiology and clinical presentation of adult ADHD. Next, Joseph Biederman, MD, provides an overview of recent advances in the neurobiology of ADHD. Thomas J. Spencer, MD, reviews stimulant treatment of adult ADHD, and Lenard A. Adler concludes with a discussion of non-stimulant trials in adult ADHD.

Irritable bowel syndrome (IBS) is one of over 20 functional gastrointestinal disorders. There is considerable overlap of IBS with panic disorder as well as other anxiety disorders and depression. It has been proposed that the high prevalence of psychiatric disorders in clinical samples of IBS patients is a result of self-selection of individuals with anxiety and depression, which drives treatment-seeking behavior. Over the past several years, data from some community studies have shown that there is a high prevalence of psychiatric disorders in individuals with IBS who never sought treatment. This suggests that there may be a more fundamental linnk between IBS, anxiety and mood disorders, such as shared pathophysiology.

This month's issue of CNS Spectrums brings together reviews on the brain-gut axis, each of which provides a unique perspective, which is complementary to the other reviews.

Kirsten Tillisch, MD, and Emeran A. Mayer, MD, review the neurobiology of visceral sensation, focusing on visceral hyperalgesia in IBS. In their paper, the importance of expectancy, comorbidity, gender, and other issues on pain perception is discussed. One of the most fascinating points the authors make is that extra-intestinal functional disorders, such as fibromyalgia, which often coexists with IBS, may affect somatic perception and pain thresholds. The observation that these disorders not only co-exist, but can affect each other raises an important and often overlooked issue for researchers. Comorbid disorders should be assessed and taken into account when conducting studies in patients with IBS. The authors highlight advances in methodology and new conceptual frameworks for understanding the functional gastrointestinal disorders (FGIDs) as well as remaining gaps in our knowledge about visceral hyperalgesia.

As an individual with autism, I have learned that, unfortunately, some therapists and physicians are unaware of autistics' overly acute senses, specifically hyperacute hearing. For example, the birthday party fun of noise-makers for a normal child was torture for me. There are many first-person reports of people with autism who, like me, find certain loud sounds intolerable.

Some children and adults with autism also have visual sensitivity problems. I enjoyed visually stimulating things such as flags or automatic supermarket doors, but individuals with severe visual sensitivities cannot tolerate even fluorescent lights. In her book, Somebody Somewhere, autistic Donna Williams describes how the flicker from fluorescent lights causes her visual overload. A study conducted by Coleman et al indicates that fluorescent lights can increase repetitive behavior in children with autism.

Autistic sensory problems are highly variable. When I was a child, I liked to play with running water; however, another child with autism may not be able to tolerate the same sound. I was attracted to automatic supermarket doors and I liked to watch them move. Another autistic child or adult may scream and run away from these same automatic doors because sudden movement hurts his or her eyes. Maybe a small anomaly in my visual processing caused me to be attracted to the movement of the doors. A greater anomaly may cause another individual to avoid the same stimulus. Waterhouse et al found it puzzling that I was attracted to strong visual stimuli, yet high-pitched auditory stimuli hurt my ears.

Pharmacoepidemiology, the study of the effects of drugs in large numbers of people, is a relatively new discipline that applies the methods of epidemiology to clinical pharmacology. Premarketing clinical trials remain the only way to scientifically determine whether a drug is causally effective, yet these trials do not provide information that allows for estimates about rare, late, or off-label toxicities associated with the drug in question. Increasing concern about common and debilitating adverse effects of medications has highlighted the need for enhanced postmarketing surveillance to follow up on clinical trials. There is a further concern regarding the broader issue of the risk-benefit ratio of certain medications. Computerized databases are a good source of information on which to lay the foundations of postmarketing research. A system of cross-linked computerized medical records may better enable researchers and physicians to realistically monitor postmarketing safety and incorporate monitoring benefits. The same research could also elucidate the net public health effect of regulatory decisions. The Veterans Affairs database in the United States and PHARMO in the Netherlands may represent good models on which to base future postmarketing surveillance studies.

In this expert roundtable supplement, Brian L. Strom, MD, provides an overview of the appropriate use of large computer databases in pharmacoepidemiology studies. Philip Wang, MD, DrPH, discusses the advantages of pharmacoepidemiologic studies over clinical trials in correctly detecting drug safety issues. Francesca Cunningham, PharmD, reviews a large computer database that is currently in use within the VA healthcare system, and Ron M.C. Herings, PharmD, PhD, discusses the development of the PHARMO system in the Netherlands.

The last 4 years have seen a rapid burst of development of medications used to treat epileptic seizures. While none of these medications has replaced the “standards” in the field, they collectively offer additional treatment options for patients, particularly for those with difficult-to-control seizures. As experience with these novel medications grows, each will occupy its own niche in the treatment strategy for patients with epilepsy.

Schizophrenia is a neurodevelopmental disorder associated with persistent symptomatology, severe functional disability, and residual morbidity characteristic of neurodegenerative brain diseases. The illness begins with genetic susceptibility and generally expresses itself after puberty through subtle changes that begin during the prodromal stage. Symptoms get progressively worse and tend to become more resistant to treatment with each relapse. Evidence for a neuroprotective effect of some forms of early treatment is beginning to emerge. While the underlying mechanisms remain uncertain, atypical antipsychotics may counteract some of the progressive deteriorative effects by enhancing synaptic plasticity and cellular resilience. However, identifying and treating patients in the earliest disease states presents methodological challenges as there is no consensus on the best methods of intervention and differences in at-risk children are not readily detectable or substantial enough to predict which ones will develop schizophrenia.

In this expert roundtable supplement, Jeffrey A. Lieberman, MD, reviews the historical context of progressive deterioration in schizophrenia. Next, Diana O. Perkins, MD, MPH, reviews some of the challenges to early identification of illness as well as the impact of early versus delayed treatment. Finally, L. Fredrik Jarskog, MD, focuses on the neurobiology of functional progression in schizophrenia as well as pharmacology and the potential for neuroprotection.

The lumping together of the seven deadly sins—pride, covetousness, jealousy, sloth, lust, gluttony, and anger—is, of course, a theological categorization rather than a medical nosology. Nevertheless, these seven sins are oddly reminiscent of various symptoms of a common medical disorder—one that has received increasing neuroscientific investigation in recent years—obsessive-compulsive disorder (OCD). Is such a parallel between sin and symptom purely coincidental, or is modern neurobiology able to provide a more coherent explanation?

Interestingly, the term “obsession” derives from the Roman Catholic concept of obsession—a state of being possessed by the devil. Indeed, obsessions—defined as recurrent intrusive and senseless thoughts and images—are some of the most overwhelming and distressing of psychiatric symptoms. While it is true that hallucinations and delusions lead to a loss of contact with reality, people with obsessions suffer from the very fact that they cannot resist ideas that they know full well to be irrational. Thus, OCD sufferers find themselves having to perform compulsions—recurrent rituals that relieve anxiety—but which are not realistically connected to the preceding obsessions or are clearly excessive.

The obsessive-compulsive (OC) spectrum is a group of related disorders that appear to share symptomatology, neurobiology, and treatment response with obsessive-compulsive disorder. To collect data on the appreciation of the OC spectrum concept among clinicians, 800 participants completed a questionnaire to help determine their understanding and appreciation of this concept, at a workshop on the OC spectrum.

The optimal management of fibromyalgia (FM) is comprised of both pharmacologic and nonpharmacologic approaches. This multidimensional approach is preferred given that FM is not only a pain condition, but involves a number of other symptoms as is reflected in the new clinical criteria being developed by Wolfe and colleagues. Proper management of FM should be informed through multidimensional assessment of the clinically relevant domains described previously in this supplement. Pharmacologic and nonpharmacologic approaches work together to provide the broadest possible coverage of these domains, minimize the impact of each domain on functioning and well-being, and facilitate long-term adaptations to one's lifestyle.

The use of nonpharmacologic strategies in the management of FM has varying levels of evidence. The strongest evidence currently exists for aerobic exercise, cognitive-behavioral therapy (CBT), and for patient education or self-management. Moderate evidence exists for strength training, acupuncture, hypnotherapy, and biofeedback modalities. Weaker evidence exists for manual massage therapy. Currently, there is no evidence of long-term benefit for tender point injections or flexibility exercise modalities, although these options may be beneficial in the short term. This article will focus on the three areas that have the strongest evidence base: patient education, exercise, and CBT.

Educational programs are typically offered in the context of primary care or in specialty practices. In their simplest form, these programs try to dispel myths about FM and provide patients with the most up-to-date knowledge about the condition.