The American Journal of Psychiatry Residents’ Journal September 2015 Volume 10 Issue 9 Inside IN THIS ISSUE 2 Pediatric Neuropsychiatry: A Conceptual Framework Aaron J. Hauptman, M.D. 3 Advances in Differentiating Pediatric Bipolar Disorder From Attention Deficit Hyperactivity Disorder Ross E. Goodwin, M.D. 6 The Challenge of Diagnosing and Managing Attention Deficit Hyperactivity Disorder in the Traumatized Child Muhammad Puri, M.D., M.P.H. 9 Pediatric Anti-NMDA Receptor Encephalitis Vanita Sahasranaman, M.D. This month’s issue features articles on the topic of Pediatric Neuropsychiatry. In 12 A Patient With Guillain-Barré an editorial, Aaron J. Hauptman, M.D., discusses the relevance of utilizing the neu- Syndrome Masquerading as ropsychiatric approach in the complex care of children. Ross E. Goodwin, M.D., Conversion Disorder examines diagnostic differences between pediatric bipolar disorder and attention Taranjeet Singh Jolly, M.D. deficit hyperactivity disorder (ADHD), emphasizing the deleterious effects of mis- 15 Delineating PANDAS/PANS diagnosis. Muhammad Puri, M.D., M.P.H., analyzes the challenge of diagnosing Diagnosis ADHD in traumatized children. Vanita Sahasranaman, M.D., examines pediatric Jennifer Severe, M.D. anti-N-methyl-d-aspartate encephalitis, including discussion on clinical presen- tation, pathophysiology, and treatment. Taranjeet Singh Jolly, M.D., investigates 18 Clinical Topics in Child and a case of Guillain-Barré syndrome masquerading as conversion disorder in an Adolescent Psychiatry 8-year-old female patient. Jennifer Severe, M.D., provides discussion on delineat- Reviewed by Venkata B. Kolli, ing pediatric autoimmune neuropsychiatric disorders associated with streptococ- M.B.B.S., M.R.C.Psych. cal infections and pediatric acute-onset neuropsychiatric syndrome in the case of 19 Residents’ Resources an 8-year-old patient. Lastly, Venkata B. Kolli, M.B.B.S, M.R.C.Psych., presents a review of Clinical Topics in Child and Adolescent Psychiatry. Editor-in-Chief Guest Section Editor Editors Emeriti Rajiv Radhakrishnan, M.B.B.S., M.D. Aaron J. Hauptman, M.D. Sarah B. Johnson, M.D. Molly McVoy, M.D. Senior Deputy Editor Associate Editors Joseph M. Cerimele, M.D. Katherine Pier, M.D. Rafik Sidaros, M.B.B.Ch. Janet Charoensook, M.D. Sarah M. Fayad, M.D. Deputy Editor Monifa Seawell, M.D. Hun Millard, M.D., M.A. Staff Editor Misty Richards, M.D., M.S. Angela Moore EDITORIAL Pediatric Neuropsychiatry: A Conceptual Framework Aaron J. Hauptman, M.D. What is the purpose of pediatric neu- The neurologist cross-correlation with acquired brain ropsychiatry distinct from the separate injury. notions of neurology and psychiatry? traditionally focuses on This is not to say that to be an ef- There are ways to approach conditions fective clinician every doctor needs to traditionally within the catchment of localizable symptoms, know every fact about each surrounding psychiatry but with an acute sense of discipline. But one hopes, as psychia- the neurobiological, just as one can at- the child psychiatrist trists, we can integrate neurobiological tend to historically neurological con- on behavioral and understanding into our appreciation of ditions with attention to behaviors, development, attachment, and trauma psychodynamics, and developmental psychological and gain further understanding of the courses affected. One might argue that a myriad forms of brain injury and its psy- good psychiatrist or neurologist is doing phenomena. chiatric impacts while interacting in this already, but special knowledge and creative ways with colleagues in neurol- skill sets are needed in the complex care ogy, behavioral pediatrics, and other pe- of children whose conditions exist in advent of neuroimaging, DSM theoreti- diatric subspecialties. It is less a call for watershed or overlapping realms; hence, cal shifts, increased appreciation of the a new fund of knowledge as it is a call neuropsychiatry. primacy of brain as influencing behav- for our curiosity to lead us to explore A good example of such integration ior, etc. (2). what underlies development, brain in- is in traumatic brain injury (TBI). Neu- This neuropsychiatric approach to jury, and behavioral manifestations of ropsychiatric approaches to work-up addressing illness becomes a study not mental illness. and management of children with TBI only of injury but of context, not of dis- Dr. Hauptman is a fourth-year resident in are strongly recommended (1). Why? entangling behaviors from their neural the Department of Child and Adolescent Pediatric TBI can result in neurocog- roots but of reintegrating them (4). In nitive, attentional, mood, psychotic, medicine, we have grown accustomed Psychiatry at New York University and the anxiety, and personality changes; it to the disintegrated divvying between Guest Section Editor for this issue of the both interacts with family dynamics fields: the present volume argues that Residents’ Journal. and requires management of medical integration is feasible, an alternative to REFERENCES injury-associated complications (1). silos. The neurologist traditionally focuses This issue of the Residents’ Journal 1. Max JE: Neuropsychiatry of Pediatric on localizable symptoms, the child psy- includes conditions historically con- Traumatic Brain Injury. Psychiatr Clin chiatrist on behavioral and psychologi- sidered primarily by the neurologist; North Am 2014; 37:125–140 cal phenomena. The child requires a similarly, it includes those traditionally 2. Arciniegas DB: Introduction, in Behavioral highly integrated skill set outside the viewed as behavioral. What is unique Neurology and Neuropsychiatry. Edited by purview of either specialty alone as about considering these conditions Arciniegas DB, Anderson CA, Filley CM. traditionally realized. through the lens of neuropsychiatry New York, Cambridge University Press, 2013, pp 1–12 The historical divide between neu- is that each is framed in the context of rology and psychiatry is traced by some the other. Á propos of this philosophy, 3. Demertzi A, Liew C, Ledoux D, et al: Dual- to the philosophical mind-body prob- for example, anti-N-methyl-d-aspartate ism persists in the science of mind. Annal N lem and the centuries-old debate within encephalopathy, might be considered Y Acad Sci 2009; 1157:1–9 medicine between dualism and mate- with close attention to its frequent be- 4. Yudofsky SC, Hales RE: Neuropsychiatry: rialism (2). A conceptual separation of havioral presentation that results in 75% back to the future. J Nerv Ment Dis 2012; mental and physical, though still pres- of cases being seen first by psychiatrists 200:193–196 ent (3), has decreased somewhat with a (5). Similarly, antisocial personality dis- 5. Kayser MS, Dalmau J: Anti-NMDA recep- philosophical shift in both psychiatry order would be viewed closely attending tor encephalitis in psychiatry. Curr Psychi- and neurology (2). This was aided by the to neurocircuitry, neurochemistry, and atry Rev 2011; 7:189–193 The American Journal of Psychiatry Residents’ Journal 2 ARTICLE Advances in Differentiating Pediatric Bipolar Disorder From Attention Deficit Hyperactivity Disorder Ross E. Goodwin, M.D. Pediatric bipolar disorder and attention concentration, and increased impul- speech, racing thoughts, bizarre behav- deficit hyperactivity disorder (ADHD) sivity, but these features are episodic, ior, grandiosity or delusions) is signifi- share many symptoms in common, in- occurring several days at a time. In cantly more common prior to pediatric cluding impulsivity, inattention, hyper- pediatric bipolar disorder, increased bipolar disorder as well. Similarly, more activity, and irritability (1). Both disor- impulsivity or inattention are accompa- common antecedent symptoms are ders are prevalent in childhood, with nied by elevated mood, grandiosity, and those relating to behavioral dysfunction prevalence rates of 1%–3% for pediatric other specific bipolar features such as (temper tantrums, aggression, irritabil- bipolar disorder and 5% for ADHD (1–3). flight of ideas, decreased need for sleep, ity, poor frustration tolerance). Symp- Further blurring their distinction is the hypersexuality, and hallucinations toms relating to anxiety also help pre- high incidence of depression in ADHD, (DSM-5). While children with ADHD dict pediatric bipolar disorder, but only a common characteristic also of bipolar may show significant changes in mood after the age of 5, since in younger chil- disorder (1). Mistakes in the differential within the same day, such lability differs dren the quantity of anxiety symptoms diagnosis between ADHD and pediatric from a manic episode, which must last is similar in both conditions and thus bipolar disorder lead to deleterious im- 4 or more days. Pediatric bipolar dis- not useful for differentiation (8). pacts on child development and higher order is also less common than ADHD Other symptoms are not as useful for rates of abuse, suicidality, and legal trou- (DSM-5). predicting which child will develop bi- ble (1). Prompt and accurate diagnosis of As stated previously, both pediatric polar disorder versus ADHD. These in- bipolar disorder is crucial, as early treat- bipolar disorder and ADHD include hy- clude depressive symptoms, as well as ment improves prognosis, and stimulants peractivity, impulsivity, low frustration symptoms typical in ADHD (inatten- or antidepressants can exacerbate mania tolerance, distractibility, and increased tion, hyperactivity, impulsivity). The if pediatric bipolar disorder is incorrectly talkativeness