ISSUE:Many individuals with total blindness can develop a circadian rhythm disorder—called non-24 sleep wake syndrome—because they cannot detect light to resynchronize their sleep–wake cycles. A new melatonin 1 and melatonin 2 agonist tasimelteon improves sleep in these patients, resetting their circadian sleep–wake clocks.

Introduction: Generalized anxiety disorder (GAD) is a chronic illness with psychic and somatic symptoms that do not respond uniformly in the first weeks of treatment.

Methods: A post-hoc analysis of pooled data from five placebo-controlled, double-blind, randomized studies in non-depressed GAD patients treated with venlafaxine extended release (ER) or placebo was performed to determine the temporal response of psychic and somatic symptoms to treatment over 8 weeks. Two of the studies included extension phases of up to 6 months, the results of which were also analyzed here.

Results: The earliest symptoms to respond included both psychic symptoms (anxious mood, tension, behavior at interview) and somatic muscular, cardiovascular, and respiratory symptoms. The last symptoms to respond included the psychic symptoms of insomnia and fear and the somatic sensory, gastrointestinal and autonomic symptoms, perhaps in part because of drug-related side effects. Continuing treatment beyond 8 weeks in venlafaxine ER responders for up to 6 months of total treatment results not only in additional improvement in early-responding symptoms, but also in the improvement of late-responding symptoms, perhaps due in part to the development of tolerance to antidepressant side effects.

Conclusion: Serious consideration should be given to maintaining partial responders to venlafaxine ER treatment on the same treatment for ≥3–6 months.

Autism spectrum disorder (ASD) is a neurobiological developmental symptom complex characterized by early onset of deficits in verbal and nonverbal communication skills, socio-communicative function, and repetitive behaviors. The well-documented increased frequency of seizures and abnormal electroencephalographic (EEG) findings in ASD support the concept that the central nervous system dysfunction has a neurobiological basis. We review the prevalence of seizures and EEG abnormalities in children with ASD and explore the possible clinical significance of this correlation.

Escitalopram is the newest selective serotonin reuptake inhibitor (SSRI) available for use in the United States. It has been approved for the treatment of major depression and generalized anxiety disorder. It is the S-enantiomer of the SSRI citalopram and is highly serotonin specific as it has minimal effect on the reuptake of dopamine or norepinephrine. It is also a well-tolerated medication, with a side-effect profile comparable to the other SSRIs. While a number of side effects have been seen during escitalopram therapy, such as insomnia, nausea, and increased sweating, there are no reported cases of serotonin syndrome associated with escitalopram therapy to date. We present the case of a 24-year-old woman who developed serotonin syndrome after an increase in her escitalopram to 30 mg/day. We will review the diagnostic criteria of serotonin syndrome and the clinical scenarios in which serotonin syndrome can develop. We will also discuss the proposed treatments and role that polypharmacology may play in the development of this clinical entity.

Background: Many randomized controlled trials of the pharmacotherapy and psychotherapy of obsessive-compulsive disorder (OCD) have been undertaken. Several meta-analyses of these trials, and a number of expert consensus guidelines, have been published. This article summarizes these works, and suggests future research directions.

Methods: Meta-analyses of OCD were assessed with the QUORUM statement and the Oxman and Guyatt rating scale, and consensus guidelines on the treatment of OCD were assessed with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Current principles in the treatment of OCD, and gaps in our knowledge, were reviewed.

Results: Selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy are currently viewed as the first-line treatments of choice for adult and pediatric OCD.There is also good evidence for the efficacy of atypical antipsychotics in the augmentation of patients refractory to SSRIs. Important questions remain for the field.

Conclusions: There have been significant advances in both the pharmacotherapy and psychotherapy of OCD. Nevertheless, there is a paucity of longer-term trials, data on symptom remission and functional improvement, and data on treatment effectiveness in wider clinical practice. It is hoped that improved understanding of the mechanisms underlying OCD will lead to future advances.

Body dysmorphic disorder (BDD) is a condition characterized by an intense preoccupation with an imagined or slight defect in physical appearance. Although there is a general consensus that psychosocial factors play a major role in the development of BDD, there is some evidence suggesting that an organic somatosensorial disturbance may also exist in this condition. Several psychiatric and neurological disorders, including the interparietal syndrome, Gertsman's syndrome, inferoparietal syndrome, phantom limb syndrome, genital retraction syndrome, panencephalitis, cerebrovascular syndromes, and pharyngeal streptococcia affecting the basal ganglia, can present with somatosensorial disturbances similar to BDD. The cerebral pathology in all these disorders appears to be localized in the parietal-occipital region, indicating that cerebral involvement may also be associated with BDD. An interdependence exists between cerebral regions through integrated neural networks that enable efficient processing of information. Disturbances in these association pathways can lead to an imbalance in the extensive cerebral loops. Therefore, it is possible that a defect in information-processing may play a role in the pathogenesis of BDD.

Anxiety is common in the elderly and can present as a primary anxiety disorder or as a symptom of another disorder. Generalized anxiety disorder, in particular, is a common syndrome in late life. Anxiety symptoms are also common features of late-life depression and dementia. Treatment of anxiety in elderly persons has typically involved the use of benzodiazepines, which are often effective but problematic because they are associated with increased risk of cognitive impairment, falls, and fractures. Based on their safety and efficacy, antidepressants, particularly serotonergic medications, are considered first-line treatment for most anxiety disorders as well as anxiety symptoms of major depressive disorder. Psychotherapy, particularly cognitive-behavioral therapy, may be effective in these disorders as well; research is underway to adapt this therapy to the needs of elderly persons. Anxiety symptoms in dementia are poorly understood but may respond to atypical antipsychotics, serotonergic antidepressants, or mood stabilizers. Overall, the research in late-life anxiety has not caught up to the literature in late-life depression and, for the most part, treatment recommendations must be extrapolated from studies in young adults.

Objective: This study was conducted to describe Axis I sexual diagnoses of 60 males arrested for possession of child pornography obtained via the Internet and/or attempting to meet children via the Internet.

Methods: Data was obtained from a chart review of evaluations conducted on 60 males referred for a psychosexual evaluation following an arrest for possession of child pornography and/or attempting to meet children. All crimes involved use of the Internet. Information obtained from the chart review was entered into SAS. All diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Simple descriptive statistics were computed and cross tabulations were tested for significance using χ2 or Fisher's Exact test.

Results: Of the total sample, 40% had at least one paraphilia. Thirty-one percent had a diagnosis of pedophilia and 18% of a paraphilia not otherwise specified (NOS). Thirty-three percent had a sexual disorder NOS, characterized by hypersexuality. Seventy percent of the total sample had an Axis I disorder that antedated and was judged to be contributory to the behavior leading to their arrest.

Conclusions: This sample of men arrested for committing crimes against children and adolescents via the Internet has a high incidence of lifetime sexual and other psychopathology.

Agitation and aggression in adult psychiatric patients with psychoses and in persons with dementia increase the burden of disease and frequently cause hospitalization. The implementation of currently available management strategies and the development of new ones is hindered by inconsistent terminology that confuses agitation with aggression. This confusion is maintained by many rating scales that fail to distinguish between these two syndromes. We review the frequently used rating scales with a particular focus on their ability to separate agitation from aggression. Agitation and aggression are two different syndromes. For example, reactive aggression is often precipitated by rejection of care and may not be associated with agitation per se. We propose, in treatment studies of behavioral symptoms of dementia and challenging behaviors in psychoses, that outcomes should be evaluated separately for agitation and aggression. This is important for investigation of drug effectiveness since the medication may be effective against one syndrome but not the other. Separate assessments of agitation and aggression should be a general principle of trial design with particular salience for registration studies of medications proposed for approval by the U.S. Food and Drug Administration and other regulatory bodies.

Epidemiologic studies have consistently demonstrated a greater incidence of depressive disorders and anxiety among women. Many women experience these conditions during the reproductive years. The dramatic expanse of literature focusing on the use of medications often has failed to pay homage to the potential impact of the disorders. When considering the extant human and laboratory data on mental illness and stress during pregnancy and the postpartum period, it is evident that some degree of exposure (be it treatment or illness) always occurs. The primary goal of the risk-benefit assessment for the treatment of mental illness during these periods is to assist patients and their families in choosing the path of potential exposure that possesses the least risk for them. Once this decision is made, the goal is to limit the number of exposures for the fetus/neonate.

ISSUE:Current psychiatric diagnoses are defined “top-down” based upon clinical phenomenology, but may give way to defining mental illnesses “bottom-up” based upon genetic and molecular factors that regulate information processing in neuronal circuits, and that can be visualized with neuroimaging techniques.

Patients with psychiatric catatonias vs those with medical catatonias may differ in catatonic phenomenology. To determine if these could be distinguished, the following methods were used: 1) a review of the literature; 2) a chart review; and 3) a prospective series. The literature review of 467 report of medical catatonias yielded 240 cases that met research criteria. A chart review of 47 episodes of catatonia revealed a higher frequency of negativism in patients with medical catatonias. Prospective data obtained from rating scales revealed an increased frequency of echophenomena in patients with medical catatonias; however, no discriminate pattern of catatonic signs for medical catatonias arose. Overall, catatonic signs appear to share a similar distribution. These findings suggest that psychiatric and medical catatonias are indistinguishable based upon catatonic signs.

A 56-year-old male presented with compulsive hoarding along with attention-deficit/hyperactivity disorder and schizotypal personality disorder. Hoarding has been described as difficult to treat both pharmacologically and behaviorally, and this patient's comorbid conditions also contributed to his overall impairment. The patient's treatment regimen of fluvoxamine, amphetamine salts, and risperidone, along with behavioral therapy, has helped with hoarding behaviors, motivation, procrastination, and increased socialization. Hoarding may be a unique subtype of obsessive-compulsive disorder with poorer prognosis and distinct neuroanatomic dysfunction. Augmentation with stimulants may provide benefits in aspects of hoarding such as procrastination, especially in patients with comorbid attention-deficit hyperactivity disorder.

Bipolar disorder is an etiologically complex syndrome that is dearly heritable. Multiple, genes, working singly or in concert, are likely to cause susceptibility to bipolar disorder. Bipolar disorder genetics has progressed rapidly in the last few decades. However, specific causal genetic mutations for bipolar disorder have not been identified. Both candidate gene studies and complete genome screens have been conducted. They have provided compelling evidence for several potential bipolar disorder susceptibility loci in several regions of the genome. The strongest evidence suggests that bipolar disorder susceptibility loci may lie in one or more genomic regions on chromosomes 18, 4, and 21. Other regions of interest, including those on chromosomes 5 and 8, are also under investigation. New approaches, such as the use of genetically isolated populations and the use of endophenotypes for bipolar disorder, hold promise for continued advancement in the search to identify specific bipolar disorder genes.

Until recently, several weeks of treatment were required in order to obtain a clinically significant antidepressant response using pharmacotherapy. The present study, using the mouse forced swimming test, investigated possible antidepressant augmentation strategies, together with the probable mechanisms involved in such potentiations. It is clear from this and other similar studies that it is possible to enhance the activity of antidepressant drugs with the addition of other compounds (ie, clonidine, quinine, glyburide, pindolol, or buspirone). These data indicate that direct/indirect manipulation of serotonergic receptor systems potentiates the effect antidepressant drugs (ie, selective serotonergic reuptake inhibitors) in the mouse forced swimming test, and thus establish this model as a reliable preclinical tool for the investigation of possible antidepressant augmentation strategies. It also appears that this model can be used as a method for identifying the mechanisms involved in such treatment strategies.

This article reviews the literature regarding the impact of cosmetic surgery on health-related quality of life (QOL). Studies were identified through PubMed/Medline and PsycINFO searches from January 1960 to December 2011. Twenty-eight studies were included in this review, according to specific selection criteria.

The procedures and tools employed in cosmetic surgery research studies were remarkably diverse, thus yielding difficulties with data analysis. However, data indicate that individuals undergoing cosmetic surgery began with lower values on aspects of QOL than control subjects, and experienced significant QOL improvement post-procedurally, an effect that appeared to plateau with time.

Despite the complexity of measuring QOL in cosmetic surgery patients, most studies showed an improvement in QOL after cosmetic surgery procedures. However, this finding was clouded by measurement precision as well as heterogeneity of procedures and study populations. Future research needs to focus on refining measurement techniques, including developing cosmetic surgery–specific QOL measures.