Sydenham's chorea is currently recognized as the only neurologic sequela of rheumatic fever. Recent evidence suggests that there may be a spectrum of neurobehavioral disturbances, particularly including tics and obsessive-compulsive disorder, that develops following streptococcal infection by the process of molecular mimicry, whereby antibodies directed against bacterial antigens cross-react with brain targets. This proposed postinfectious, immune-mediated condition has been termed “pediatric autoimmune neuropsychiatric disorders after streptococcal infection” (PANDAS). This article reviews research evidence in favor and also against the PANDAS concept and discusses the implications of the hypothesis.

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent chronic condition that affects people of all ages, including young children, school-aged children, adolescents, and adults. Symptoms can be noted as early as preschool age, tend to progress into functionalimpairment and behavioral problems in later childhood, and typically persist into adulthood. Contrary to previous belief, the disorder does not resolve with puberty for the majority of children; rather, the symptoms are manifested differently throughout the lifecycle. Presentation in adults is heavily biased toward inattentive symptoms, which are less likely to draw notice than hyperactive or impulsive symptoms and may contribute to the underrecognition of ADHD in this patient population. Diagnosis is particularly difficult due in large part to the pronounced comorbidity of psychiatric disorders in this patient population. Identification may be even more difficult in adults than children as the diagnostic criteria are not as clear, adults have difficulty remembering symptoms prior to 7 years of age, and there is a high prevalence of comorbid psychiatric disorders in adults. Early identification and treatment of symptoms of ADHD in preschool-age children is essential to effective long-term management of the disorder. Both medication and behavioral treatments appear to alleviate the symptoms of ADHD, and evidence suggests that discontinuation of treatment leads to the reemergence of the condition. Efforts are currently continuing toward understanding the genetic underpinnings of ADHD.

This expert review supplement will address the prevalence, comorbidity, treatment issues, and special considerations surrounding ADHD management throughout each stage of the lifecycle beginning with ADHD in preschool-aged children, continuing with school-aged children and adolescents, and ending with adulthood.

Despite advances in the treatment of acute cerebral infarction, the most effective method of reducing stroke morbidity and mortality is the identification and modification of stroke risk factors. Modifiable stroke risk factors include hypertension, atrial fibrillation, hypercholesterolemia, cigarette smoking, hyperhomocystinemia, and carotid stenosis. Improved identification of individuals at increased stroke risk due to these factors can reduce individual risk and the cost to society of the consequences of stroke.

In the United States, more individuals suffer disability from stroke than from any other disease, and as many as 11 of the 43 presidents have been affected. In this article, the authors review the cases of the United States presidents who have had strokes, some of which have occurred while the president was in office, having a direct effect on the country.

It is well established that migraine is a multifactorial disorder. A deep understanding of migraine should be based upon both the underlying traits and the current states affected by different physiological, psychological, and environmental factors. At this point, there is no framework fully meeting these criteria. Here, we describe a broader view of the migraine disorder defined as a dysfunctional brain state and trait interaction. In this model, we consider events that may enhance or diminish migraine responsivity based on an individual’s trait and state. This could provide an expanded view for considering how migraine attacks are sometimes precipitated by “triggers” and sometimes not, how these factors only lead to migraine attacks in migraine patients, or how individuals with an increased risk for migraine do not show any symptoms at all. Summarizing recent studies and evidence that support the concept of migraine as a brain state–trait interaction can also contribute to improving patient care by highlighting the importance of precision medicine and applying measures that are able to capture how different traits and states work together to determine migraine.

Suicide risk assessment is now a core competency requirement in the residency training of psychiatrists.The purpose of suicide risk assessment is to identify modifiable or treatable acute, high-risk suicide factors, and available protective factors that inform patient treatment and safety management.The standard of care varies according to state statutory definitions. Heretofore, most states adopted an average physician or “ordinarily employed standard.” Currently, more states are adopting a “reasonable, prudent physician” standard. No single source or authority defines the standard of care for suicide risk assessment. Evidence-based psychiatry can inform clinicians' suicide risk assessments. Carefully documented risk assessments will assist the courts in evaluating clinicians' decision-making process.

In the mid-1970s, attention-deficit/hyperactivity disorder (ADHD) was still believed to be a childhood disorder that disappeared with the onset of adolescence. At this time, Wender studied a cohort of adults presenting with ADHD-like symptoms, all of whom had been diagnosed with ADHD in childhood. Wender prescribed psycho-stimulants, which successfully produced a response in the adults, thus fostering research into adult ADHD.

Recent studies of the pathogenesis of autism have suggested that this disorder may have an autoimmune basis in some patients. Observations have been made regarding cellular and humoral immune dysfunction, abnormalities associated with the complement system and major histocompatibility complex gene expression, differences in soluble mediators of the immune response, and the presence of antibrain and antimyelin autoantibodies. In this article, we review these experimental and clinical observations, and examine preliminary efforts using immunomodulatory therapies to treat autism.

Involuntary emotional expression disorder (IEED) is a syndrome in which emotional or affective motor control becomes dysregulated as a result of brain damage from neurological disease or as a result of brain injury. A debilitating disorder with persistent symptoms, IEED has a significant impact upon the lives of patients and caregivers, but is often overlooked or misdiagnosed. IEED is a clinically well-defined disorder, and specific criteria may be used when making a diagnosis. It must be distinguished from depression or other psychological and neurological conditions. Several assessment scales have been validated for use in IEED, in order to evaluate the baseline severity and to track the course of the disorder and response to treatment.

Cognitive dysfunction is common in many psychiatric disorders. While it has long been described as a core feature in schizophrenia, more recent data suggest qualitatively similar impairments in patients with bipolar disorder and major depressive disorder. There is compelling evidence to suggest that cognitive impairment contributes directly to functional disability and reduced quality of like across these disorders. As current treatments focus heavily on “primary” symptoms of mood and psychosis, the standard of care typically leaves cognitive deficits unmanaged. With this in mind, the field has recently begun to consider intervening directly on this important symptom domain, with several ongoing trials in schizophrenia. Fewer studies have targeted cognition in bipolar disorder and still fewer in MDD. With progress toward considering this domain as a target for treatment comes the need for consensus guidelines and methodological recommendations on cognitive trial design. In this manuscript, we first summarize the work conducted to date in this area for schizophrenia and for bipolar disorder. We then begin to address these same issues in MDD and emphasize the need for additional work in this area.

Several psychiatric disorders, including borderline personality disorder (BPD), are characterized by emotional dysregulation and impulse dyscontrol. More specifically, symptoms in patients with BPD often occur within the context of disruptions in attachment and related distortions in cognitive-affective processing of the self and others. From a neurocircuitry perspective, findings include prefrontal hypoactivity, amygdala hyperreactivity, and alterations in prefrontal-limbic interaction. Molecular pathways relevant to these circuits include the serotonergic, noradrenergic, and dopaminergic systems, and there is some evidence that pharmacotherapy with agents that act on these systems may be useful. Given the disruptions in attachment and schemas of the self and others in BPD, establishing a therapeutic alliance is crucial while psychotherapy remains the cornerstone of an integrated approach to management.

Congratulations to the scientific poster winners of the 2014 NEI Psychopharmacology Congress!

1stPLACE: Randomized controlled safety and efficacy trials of lisdexamfetamine dimesylate for adults with moderate to severe binge eating disorder (page 14)

2ndPLACE: CNS Pharmacology of Dextromethorphan (DM): New insights on potential mechanism of action and therapeutic applications (page 30)

How can neuropsychiatric disorders and syndromes be underdiagnosed and inadequately treated in individuals infected with human immunodeficiency virus? Depression in particular is among the most prevalent diagnoses and there is a solid foundation of data from controlled clinical studies that has begun to examine the efficacy of various antidepressants in HIV-infected persons. This article summarizes essential findings pertaining to the use of psychotropic medications to treat depression and other neuropsychiatric disorders in the context of immunodeficiency. This includes discussion of clinically significant treatment considerations (eg, efficacy, side effects, drug-drug interactions) derived from the existing literature. Taken together, there is compelling evidence that psychopharmacologic intervention can improve the quality of life of mentally ill HIV-infected individuals.

Functional brain-imaging studies have suggested an opposite pattern of brain activity in obsessive-compulsive disorder (OCD) and schizophrenia. Patients with OCD have higher than normal activity in the frontal lobe and caudate nucleus while patients with schizophrenia have lower than normal activity in these areas. Changes in the nature of the connections between the executive and impulse control regions of the frontal lobe and the basal ganglia might be involved in both illnesses. These findings are statistical in nature and involve structures of complex three-dimensional shapes. New technology for studying the function of these structures may be useful in exploring the relation of each structure to symptoms of specific disorders. This technology may also enable identification of anatomical and functional causes of individual differences in medication response.