The American Journal of 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 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., 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 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 , 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 , and hallucinations toms relating to anxiety also help pre- high incidence of 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 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 tolerance, distractibility, and increased tion, hyperactivity, impulsivity). The if pediatric bipolar disorder is incorrectly talkativeness (1, 6). Bipolar disorder may overlapping prevalence of these symp- labeled as ADHD (1). Further complicat- be present if overlapping symptoms in- tom clusters in both ADHD and pediat- ing the matter is that ADHD is the most tensify during a mood episode (7). Chil- ric bipolar disorder do not significantly prevalent comorbidity with pediatric bi- dren with ADHD may have initial in- differentiate the two disorders (8). polar disorder, at 60%–90% (1, 4). While somnia, but this is due to hyperactivity, there are 20 Food and Drug Administra- and the child feels tired the following RATING SCALES tion-approved medications for ADHD, day. there are no medications approved to Rating scales such as the Child Behav- treat children younger than 10 years old ior Checklist comprise another modal- SYMPTOM PROFILES with bipolar disorder (5). A multifaceted ity for distinguishing pediatric bipolar approach to differential diagnosis is nec- Certain symptom profiles in children disorder from ADHD. In one study, the essary in order to accurately differentiate are useful to predict future onset of bi- parent of each participant completed pediatric bipolar disorder from ADHD, polar disorder, thereby differentiating the Child Behavior Checklist, account- including symptom profiles, family his- from ADHD at an early age. Retrospec- ing for any symptoms observed dur- tory, and future techniques in imaging tive rating scales completed by parents ing ages 4–18. The Severe Dysregula- and other biomarkers. The present arti- reveal that the total number of certain tion Profile within the checklist sums cle is a review of these various diagnostic dysfunctional symptoms in children is the attention, aggression, and anxious/ domains to facilitate differentiation and much higher prior to childhood onset depressed subscales. A score of 2 stan- decrease confusion between these two bipolar disorder than before ADHD (8). dard deviations above the mean on this illnesses. These symptoms also coincide with ear- Severe Dysregulation Profile suggests lier age at onset and have more rapid bipolar type I disorder in children (9). accumulation prior to pediatric bipo- The manifestation of bipolar disorder DIAGNOSTIC CRITERIA lar disorder. A subgroup of dysfunc- predicted by the Severe Dysregulation Individuals with pediatric bipolar dis- tion symptoms relating to mania (brief Profile is one that includes prominent order may have increased activity, poor or extended mood elevation, pressured delinquent behavior, aggression, with-

The American Journal of Psychiatry Residents’ Journal 3 drawal, somatic complaints, anxiety, dren with a , rather than Proton magnetic resonance spec- depression, and . Chil- ADHD or disruptive behavior disor- troscopy is another research imag- dren in this category have an earlier age ders (12). ing modality showing promise for at onset, higher tendency for psychiatric The utility of family history to pre- differentiating bipolar disorder from hospitalization, and greater comorbidity dict bipolar disorder versus ADHD is ADHD. By measuring the ratios of cer- with other conditions such as major de- further supported by research into fa- tain cerebral metabolites, proton mag- pression, oppositional defiant disorder, milial association of the two disorders netic resonance spectroscopy can sug- , , and gen- and the degree of bipolar and ADHD gest patterns characteristic of specific eralized . Overall, this symptoms in parents of children with disorders (15). Certain cerebral metab- pattern indicates a more severe form of either bipolar disorder or ADHD. One olites are useful to characterize these bipolar disorder. Using the Severe Dys- study examined children with comor- ratios: creatine plus phosphocreatine regulation Profile score, the sensitivity bid bipolar disorder and ADHD, as (Cr), myo- compounds (Ino), and specificity for distinguishing bipo- well as children with bipolar disorder and glutamate plus glutamine (Glx). lar disorder from ADHD are 57% and alone, ADHD alone, and neither disor- In one study, children with ADHD 92%, respectively (9). der. The rate of parental manic symp- exhibited a higher Glx-to-Cr ratio in toms was similar in the comorbid and the prefrontal cortex and frontal lobe, bipolar-alone groups, and this rate was compared with healthy controls (15). FAMILY HISTORY significantly greater than the rates in This finding aligns with the hypoth- In addition to characteristic symp- the ADHD alone and neither disorder esis that abnormal glutamate func- tom profiles, a child’s family history groups. ADHD symptoms in parents tion in terminal areas of dopaminergic can inform the risk of bipolar disorder of children with bipolar disorder alone neurons contributes to ADHD. Phar- compared with ADHD. Both disorders were significantly less frequent than macotherapeutic strategies exploit are highly heritable (1), and a history symptoms in parents of children with this purported mechanism, as dopa- of bipolar disorder in the family por- ADHD (alone or comorbid) and also no mine inhibits glutamate release from tends at least a five-fold increase in greater than symptoms in parents of prefrontal cortical afferents in the risk for a child to develop bipolar dis- children with neither diagnosis. Over- nucleus accumbens, and stimulants order (10). Furthermore, children with all, parental symptomatology specifi- increase extracellular dopamine by comorbid bipolar disorder and ADHD cally matched the child’s constellation blocking dopamine reuptake. tend to have a group of relatives with of both manic and ADHD symptoms, In the above-mentioned study, a this same combined condition, sug- separately. These findings therefore higher ratio of Ino-to-Cr was present gesting that there may be a distinct ge- demonstrate the heritability of each in the and frontal netic subtype of combined bipolar and disorder separately with coincident gray matter in children with bipolar ADHD (11). overlap (13). disorder (15). This finding supports One standardized tool for distill- the implication of inositol-1-phos- ing family history into diagnostic risk phate and the phosphatidylinositol IMAGING AND OTHER stratification is the Family Index of Risk cycle in affective disorders (15). In BIOMARKERS for Mood issues. This inexpensive and fact, mood stabilizers, such as lith- clinically practical method for gather- Beyond symptom reports and fam- ium, valproate, and carbamazepine, ing family history has been shown to ily history, future diagnostic clarifica- reduce inositol levels (15). Addition- improve detection of pediatric bipolar tion between pediatric bipolar disorder ally, children with ADHD alone have disorder (12). The assessment consists of and ADHD may come by way of imag- significantly higher ratios of Glx-to- 25 checkboxes in an array of questions ing techniques and other biomarkers. Ino than do children with combined about mental health history (regard- Functional MRI has shown differences ADHD and bipolar disorder. In the ing suicide, depression, mania, hospi- in amygdala activity when children rate future, Glx-to-Ino ratio could be used talization, and substance use) for each their of fear in neutral faces. to differentiate between youths with of several relatives (including the pri- Children with ADHD demonstrate left ADHD who do or do not have comor- mary caregiver’s grandparents, parents, amygdala hyperactivity compared with bid bipolar disorder (15). aunts and uncles, siblings, and other children with bipolar disorder or no children). The Family Index of Risk for mental illness (14). These findings high- CONCLUSIONS Mood score consists of the sum of items light the amygdala’s role in mediating endorsed for established risk factors re- emotional processing and comprehend- A multidimensional combination of lated to bipolar disorder. ing facial affect. Interestingly, children several clinical risk factors like fam- In a study using the Family Index of with bipolar disorder and severe mood ily history and early mood dysregula- Risk for Mood, a simple sum of famil- dysregulation were more afraid of neu- tion symptoms, combined with imag- ial mood issues discriminated children tral faces than healthy or ADHD-posi- ing differences or other biomarkers, with bipolar disorder from all other tive comparison subjects. can suggest high index of suspicion for cases. High scores were specific to chil- pediatric bipolar disorder. Through

The American Journal of Psychiatry Residents’ Journal 4 attention-deficit/hyperactivity disorder. J KEY POINTS/CLINICAL PEARLS Am Acad Child Adolesc Psychiatry 2013; • Symptoms of behavioral dysfunction, such as temper tantrums, aggression, ir- 52:537–546 ritability, and poor frustration tolerance, are more common antecedents of pe- 7. Goldstein BI: Recent progress in under- standing pediatric bipolar disorder. Arch diatric bipolar disorder than of attention deficit hyperactivity disorder (ADHD). Pediatr Adolesc Med 2012; 166:362–371 Depressive symptoms and those symptoms typical of ADHD, including inat- 8. Post RM, Findling RL, Luckenbaugh DA: tention, hyperactivity, and impulsivity, are not statistically useful to predict the Number, severity, and quality of symptoms onset of bipolar disorder versus ADHD. discriminate early-onset bipolar disorder from attention-deficit/hyperactivity disor- • High scores on the Family Index of Risk for Mood issues are most specific der. Psychiatr Ann 2014; 44:416–422 to children with a mood disorder, rather than ADHD or disruptive behavior 9. Uchida M, Faraone SV, Martelon M, et al: disorder. Further evidence that severe scores in the • Children with ADHD demonstrate left amygdala hyperactivity compared with aggression/anxiety-depression/attention subscales of child behavior checklist (se- children who have bipolar disorder. By measuring ratios of certain cerebral me- vere dysregulation profile) can screen for tabolites, proton magnetic resonance spectroscopy is another imaging modal- bipolar disorder symptomatology: a condi- ity that holds promise in differentiating bipolar disorder from ADHD. tional probability analysis. J Affect Disord 2014; 165:81–86 10. Hodgins S, Faucher B, Zarac A, et al: Chil- timely recognition of a child’s risk for man, Department of Psychiatry, George dren of parents with bipolar disorder. A population at high risk for major affective bipolar disorder—rather than a prema- Washington School of Medicine. disorders. Child Adolesc Psychiatr Clin N ture diagnosis of ADHD—intervention Am 2002; 11:533–553 including early family-focused therapy REFERENCES 11. Uchida M, Davis J, Wozniak J: Familiality may mitigate the effects of otherwise and indicators of risk for bipolar disorder in misdiagnosed and unmanaged pediat- 1. Sala R, Gill MK, Birmaher B: Differentiat- youth with attention-deficit/hyperactivity ing pediatric bipolar spectrum disorders ric bipolar disorder. disorder. Psychiatr Ann 2014; 44:423–427 from attention-deficit/hyperactivity disor- 12. Algorta GP, Youngstrom EA, Phelps J, et al: der. Psychiatr Ann 2014; 44:410–415 An inexpensive family index of risk for mood Dr. Goodwin is a third-year resident in the 2. Singh MK, Ketter T, Chang KD: Distin- issues improves identification of pediatric bi- Department of Psychiatry and Behavioral guishing bipolar disorder from other psy- polar disorder. Psychol Assess 2013; 25:12–22 Sciences, George Washington University, chiatric disorders in children. Curr 13. Arnold LE, Mount K, Frazier T, et al: Pedi- Washington, DC. Psychiatry Rep 2014; 16:516 atric bipolar disorder and ADHD: family 3. Polanczyk G, de Lima M, Horta BL, et al: history comparison in the LAMS clinical Previously presented in Grand Rounds of The worldwide prevalence of ADHD: a sys- sample. J Affect Disord 2012; 141:382–389 the Department of Psychiatry and Behav- tematic review and metaregression analy- 14. Brotman MA, Rich BA, Guyer AE, et al: ioral Sciences, George Washington Uni- sis. Am J Psychiatry 2007; 164:942–948 Amygdala activation during emotion pro- versity, Feb. 12, 2015. 4. Kowatch RA, Youngstrom EA, Danielyan cessing of neutral faces in children with se- A, et al: Review and meta-analysis of the vere mood dysregulation versus ADHD or The author thanks Robert Post, M.D., Pro- phenomenology and clinical characteris- bipolar disorder. Am J Psychiatry 2010; of mania in children and adolescents. fessor, Department of Psychiatry, George 167:61–69 Bipolar Disord 2005; 7:483–496 Washington School of Medicine, and Di- 15. Moore CM, Biederman J, Wozniak J, et al: 5. Post RM: Differentiating pediatric bipolar dis- Differences in brain chemistry in children rector, Bipolar Collaborative Network, order from attention-deficit/hyperactivity and adolescents with attention deficit hy- Bethesda, Md.; Lisa Catapano, M.D., Ph.D., disorder. Psychiatr Ann 2014; 44:406–408 peractivity disorder with and without co- Residency Program Director, Department 6. Seymour KE, Pescosolido MF, Reidy BL, et morbid bipolar disorder: a proton magnetic of Psychiatry, George Washington School al: Emotional face identification in youths resonance spectroscopy study. Am J Psy- of Medicine; and James Griffith, Chair- with primary bipolar disorder or primary chiatry 2006; 163:316–318

The American Journal of Psychiatry Residents’ Journal 5 ARTICLE The Challenge of Diagnosing and Managing Attention Deficit Hyperactivity Disorder in the Traumatized Child

Muhammad Puri, M.D., M.P.H.

The detrimental effects of childhood ing the importance of screening regu- emergency department. The children trauma result in a variety of behavioral larly for trauma prior to arriving at an were asked about the nature of their and emotional symptoms, as well as ADHD diagnosis. injuries, which were either acciden- abnormalities in cognitive and neuro- Failure to detect the early signs and tal or due to physical abuse. The study biological processes. The literature sup- symptoms of PTSD in children can re- concluded that the children present- ports that patients with posttraumatic sult in misdiagnosis and delay of effec- ing with trauma-related injuries had disorder (PTSD) often have ad- tive treatments (5). ADHD and PTSD higher mean scores for impulsivity and ditional deficits in attention, execu- can also coexist in children who are vic- hyperactivity in comparison to those tive functions, memory, and learning tims of , presenting treated for non-trauma-related injury (1). Children often respond to trauma a diagnostic challenge and complicat- (8). This study raises thought-provok- through dissociation, which can be mis- ing the treatment plan (4). This topic is ing questions about the relationship be- interpreted as deficits in attention (2). also relevant because when ADHD and tween traumatic events and ADHD-like The focus of the present review is to PTSD coexist, children often present symptoms, and further research on the raise awareness of the importance of with greater clinical severity and psy- trauma-ADHD relationship will help screening for trauma prior to diagnos- chosocial dysfunction (6). guide diagnosis and treatment. ing attention deficit hyperactivity dis- DSM-5 has shifted its focus to be- order (ADHD) in the pediatric popula- havioral aspects of trauma, which can CHILDHOOD TRAUMA AND tion and to acquaint providers with the further complicate the clinical pic- THE DEVELOPMENT OF appropriate guidelines for diagnosis and ture. While diagnostic criteria still in- PSYCHOPATHOLOGY treatment in cases with co-occurrence clude re-experiencing in the form of of these disorders. One early theory by Spitz (7) discuss- flashbacks and , as well as ADHD is a neurodevelopmental dis- ing the impact of childhood trauma hy- avoidance, hypervigilance is now more order presenting with symptoms of in- pothesized that traumatic events expe- behaviorally defined with a focus on attention, hyperactivity, and impulsiv- rienced before the generation of stable hyperarousal in the form of aggressive ity present for at least 6 months in two memory may lead to changes in later and at times agitated conduct. DSM-5 or more settings that interfere with personality development and hinder the also includes another criterion labeled quality of life (3). ability to form close interpersonal at- “negative cognitions and mood,” which The prevalence of ADHD is 5%, with tachments. Spitz further hypothesized may manifest as diminished interest, a male-to-female ratio of 3:1 (2). PTSD, that despite lacking recollection of the feelings of estrangement, and lapses like adjustment and acute stress disor- trauma, children might subsequently in memory (3). Interestingly, children der, is one of the few psychiatric diag- display symptoms of anxiety, impulsiv- are more likely to develop symptoms of noses triggered by an external event, ity, and poor concentration (7). PTSD than adults (9). However, a child’s namely physical, sexual, or psychologi- A community-based epidemiology ability to verbalize past trauma may be cal abuse or neglect. The disorder was study was conducted to screen pediat- limited as a result of certain biological formally recognized in 1989 when it was ric trauma patients in the emergency processes resultant from the trauma incorporated in DSM-III-R (4). A child department for ADHD (8). The Con- (10), and thus clinicians may need to rely with PTSD often presents with distinct ners’ Parent Rating Scale, widely used on other resources beyond simply self- symptomatology from adults; symptoms in ADHD evaluation, was utilized to as- report to screen for trauma. in children include aggression, difficul- sess the effect of trauma on patients ages ties with concentration, and trouble 3–17 who presented to the emergency DIAGNOSTIC INSTRUMENTS IN modulating arousal (3). Consequently, department. The control group con- EVALUATING TRAUMA IN CHILDREN PTSD may present similarly to ADHD. sisted of patients in the same age group The diagnostic challenge ascends from who were not exposed to trauma. One The U.S. Department of Veterans Affairs the considerable symptomatic overlap hundred and eight children participated has reported several PTSD inventory between the two disorders, underscor- in this study during their visit to the scales and diagnostic tools, which can

The American Journal of Psychiatry Residents’ Journal 6 be utilized when a history of trauma is elevating the risk of misdiagnosis. Dis- PTSD by decreasing sympathetic out- known or suspected. These scales vary rupted neurobiology and physiology flow (16). in cost and time required to conduct the may explain some of the symptomatic assessment, but none is considered su- similarities between the two disor- Managing ADHD perior to the other (11). ders. The sympathetic nervous system Psychological therapies, such as be- is physiologically set off in response havioral therapies, school-based inter- Childhood PTSD Interview. to danger; however, this response be- ventions, interpersonal , The Childhood PTSD Interview is a 95- comes futile in cases of protracted social skills training, neuro-feedback, item semistructured interview available childhood trauma, as the child is un- and family therapy, are recommended, in child and parent versions assessing able to escape from the potential dan- along with the use of medications (17). DSM-IV PTSD diagnosis (12). ger. The child is in a chronic state of Stimulant medications, such as methy- hyperarousal, conditioned to continu- phenidate and dextroamphetamines, Child PTSD Symptom Scale. ously survey the environment for dan- are first-line medications; however, The Child PTSD Symptom Scale is a ger. This results in excessive processing nonstimulant medications, such as 24-item self-report questionnaire with of stimuli that overburdens the child’s amoxapine, a , a 7-item scale to assess functional im- cognitive reserve, creating a clinical as well as atomoxetine, a norepineph- pairment and a 17-item PTSD symptom picture of anxiety, impaired attention, rine reuptake inhibitor, can also be scale. The score range is 1–4, with a and poor concentration due to inability used (18). Clonidine, a nonstimulant score of 4 indicating increased severity to tune out extraneous information (4). medication, can be used to treat both of PTSD (12). ADHD and PTSD (18). MANAGING THE SYMPTOMS OF Children’s PTSD Inventory. ADHD AND PTSD WITH LIMITED CONCLUSIONS The Children’s PTSD Inventory is a cli- TREATMENT OPTIONS nician-administered measure for ages The experiences of significant trauma 6–18 based on DSM-IV diagnostic crite- Managing PTSD in childhood can harvest ever-lasting ria for PTSD (12). Management of PTSD is challenging be- effects. Clinical manifestations are cause of noncompliance and a dropout variable, complicating the diagnostic Clinician-Administered PTSD Scale rate of up to 81.1% during treatment (13). workup and resulting in misdiagnosis. for Children and Adolescents. Children can benefit from psychother- A historical view of the large percent- The Clinician-Administered PTSD apy, such as exposure therapy, mindful- age of children diagnosed with ADHD Scale for Children and Adolescents is a ness-based meditation, extensive educa- over the years has prompted the Ameri- 33-item clinician-administered PTSD tion, eye-movement desensitization and can Psychiatric Association to reassess scale for ages 8–18 measuring the inten- reprocessing, and trauma-focused cog- the diagnostic criteria and treatments sity and frequency of symptoms, with a nitive-behavioral therapy (14). Pharma- for ADHD. The Centers for Disease total of 5 points for each symptom (12). cotherapy can be supportive, although Control and Prevention reported 6.4 Clinicians should provide compul- no clear-cut medication guidelines exist million children ages 4–17 with the di- sory screening for trauma in children and management remains the same for agnosis of ADHD as of 2001, and the who struggle with attention or present children and adults. However, most psy- percentage continues to grow each year. with hyperactivity/hyperarousal. These chiatrists agree that selective serotonin There has been approximately a 5% per- symptoms could be directly linked to reuptake inhibitors and prazosin, an year increase in the diagnosis of ADHD childhood trauma, or they may be a re- alpha blocker, are the first choice (15). from 2003 to 2011 (19). These findings flection of underlying ADHD. There However, carbamazepine can be used to may, in part, be explained in that child- is also a possibility that these children help control flashbacks (16). Clonidine hood trauma is overlooked, resulting in may actually be suffering from both and propranolol can be used to prevent misdiagnosis of PTSD as ADHD. The PTSD and ADHD (4).

ADHD OR ADHD-LIKE SYNDROME KEY POINTS/CLINICAL PEARLS • Attention deficit hyperactivity disorder (ADHD) and posttraumatic stress disor- Failure to report abuse to clinicians is der (PTSD) can also coexist in children who are victims of childhood trauma, common due to fear, shame, and dif- presenting a diagnostic challenge. ficulty with recall, presenting major barriers for providers in detecting • Failure to detect the early signs and symptoms of PTSD in children can result in PTSD and increasing the likelihood of misdiagnosis and delay of effective treatments. misinterpreting symptoms as ADHD • The relationship between traumatic events and ADHD-like symptoms and fur- (4). In children, the clinical similari- ther research on the trauma-ADHD relationship will help guide diagnosis and ties between these two disorders can treatment. be greater than their differences, thus

The American Journal of Psychiatry Residents’ Journal 7 consequences of incorrectly diagnos- Disorders: DSM-5. Washington, DC, Amer- 11. Nader KO, Kriegler JA, Blake DD, et al: Cli- ing and/or treating PTSD as though it ican Psychiatric Publishing, 2013 nician-Administered PTSD Scale for Chil- dren and Adolescents. Washington, DC, were ADHD may perpetuate and exac- 4. Cuffe SP, McCullough EL, Pumariega AJ: Comorbidity of attention deficit hyperac- National Center for PTSD, 1996 erbate PTSD symptoms. There is ongo- tivity disorder and post-traumatic stress 12. US Department of Veterans Affairs: http:// ing research to further explore this pre- disorder. J Child Fam Studies 1994; www.ptsd.va.gov/professional/assess- dicament and to develop more effective 3:327–336 ment/child/index.asp methods of diagnosing and managing 5. Burger FL, Lang CM: Diagnoses commonly 13. Burstein A: Treatment noncompliance in PTSD in children. missed in childhood: long-term outcome patients with post-traumatic stress disor- and implications for treatment. Psychiatr der. Psychosomatics 1986; 27:37–40 Dr. Puri is a first-year fellow at Institute of Clin North Am 1998; 21:927–940 14. Taylor S: Advances in the treatment of post- Living, Hartford, Conn. 6. Vasterling JJ, Brailey K, Constans JI, et al: traumatic stress disorder: cognitive-behav- Attention and memory dysfunction in post- ioral perspectives. New York, Springer, 2004 traumatic stress disorder. Neuropsychol- The author thanks Dr. Edward Hall, Chief 15. Bisson JI: Pharmacological treatment to ogy 1998; 12:125 prevent and treat post-traumatic stress dis- of Child Unit, Bergen Regional Medical 7. Spitz RA: Hospitalism: an inquiry into the order. Torture 2008; 18:104–106 Center, and Dr. Tahira Akbar, Research Fel- genesis of psychiatric conditions in early 16. Ostrowski S A, Delahanty DL: Prospects low, Bergen Regional Medical Center. childhood. Psychoanal Study Child 1945; 1:53 for the pharmacological prevention of post- 8. Ertan C, Özcan ÖÖ, Pepele MS: Paediatric traumatic stress in vulnerable individuals. REFERENCES trauma patients and attention deficit hy- CNS drugs 2014; 28:195–203 peractivity disorder: correlation and signif- 17. Fabiano GA, Pelham Jr WE, Coles EK, et al: 1. Yehuda R, Golier JA, Halligan SL, et al: icance. Emerg Med J 2012; 29:911–914 A meta-analysis of behavioral treatments Learning and memory in holocaust survi- 9. Fletcher KE: Childhood posttraumatic for attention-deficit/hyperactivity disor- vors with PTSD. Biol Psychiatry 2004; 55: stress disorder. Child Psychopathol 1996; der. Clin Psychol Rev 2009; 29:129–140 291–295 242–276 18. Wigal SB: Efficacy and safety limitations of 2. Campbell SB: Attention-deficit/hyperac- 10. Rauch SL, van der Kolk BA, Fisler RE, et al: attention-deficit hyperactivity disorder tivity disorder, in Handbook of Develop- A symptom provocation study of posttrau- pharmacotherapy in children and adults. mental Psychopathology. New York, matic stress disorder using positron emis- CNS Drugs 2009; 23:21–31 Springer, 2000, pp. 383–401 sion tomography and script-driven 19. Centers for Disease Control and Preven- 3. American Psychiatric Association: Diag- imagery. Arch Gen Psychiatry 1996; tion: http://www.cdc.gov/ncbddd/adhd/ nostic and Statistical Manual of Mental 53:380–387 data.html

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The American Journal of Psychiatry Residents’ Journal 8 ARTICLE Pediatric Anti-NMDA Receptor Encephalitis

Vanita Sahasranaman, M.D.

Autoimmune synaptic encepha- or hypoventilation (1, 3). Movement receptor clusters without affecting cell lopathy syndromes are a group of seri- disorders were observed significantly viability, dendritic complexity, or other ous, yet treatable, disorders arising from more often in cases of anti-NMDA re- synaptic receptors; this is reversible targeting neuronal synaptic ceptor encephalitis (63%; p<0.01) com- upon removing the antibodies from the . Among these conditions, an- pared with enteroviral and West Nile culture media. These findings, along tibodies to the N-methyl-D-aspartate virus cases, which demonstrate no with the apparent lack of complement- (NMDA) receptor are the most common such findings (4). mediated mechanisms, may explain and best understood (1). First described The most common presentations in the potential reversibility of symptoms, in 2005 in four young women with ovar- children under 12 years old are abnor- even in patients who have been severely ian teratomas (2), anti-NMDA receptor mal behaviors, seizures, movement dis- ill or with a low level of consciousness encephalitis is a multistage neuropsy- orders, and vague, nonspecific behav- for several months (3, 13). chiatric illness. The condition predomi- ior changes such as new-onset temper nantly affects children and young adults, tantrums and changes in mood or per- EPIDEMIOLOGY has a strong female preponderance, and sonality. Parents also report changes is associated with ovarian teratomas. in speech, including reduced speech, Anti-NMDA receptor encephalitis is a With prompt, aggressive treatment, mutism, , and perseveration (3, leading cause of autoimmune encepha- 80% of diagnosed patients experience 9). Autonomic dysfunction, severe car- litis in children and adolescents. Forty complete or near-complete recovery. diac dysrhythmias, and clinically sig- percent of cases present in individuals Symptom relapse has been reported in nificant cardiac pauses are less frequent younger than 18 years old. The condi- 20% of children (1, 3–5). in children compared with adults (3). tion has been identified as the second Anti-NMDA receptor encephalitis has most common cause of encephalitis in occurred both with and without tumor this age range, exceeded only by acute CLINICAL PRESENTATION association; up to 40% of cases occur disseminated encephalomyelitis (3, 14). Anti-NMDA receptor encephalitis typi- without detection of a tumor. Most tu- In a cohort of 761 patients ≤30 years old cally starts with a prodromal phase of mors are found in females between 12 with encephalitis of unknown origin, fever, headache, or viral-like symptoms and 45 years old (4). Ovarian teratomas one study identified anti-NMDA recep- (1). This can be followed in a few days occur most often, but other neoplasms, tor encephalitis four times more fre- to weeks by onset of psychiatric and be- such as breast, lung, pancreatic, and quently than herpes simplex virus-1 en- havioral problems, including anxiety, thymic carcinomas, have also been re- cephalitis and six times more frequently paranoid thoughts, grandiose or hyper- ported (5, 6). In males, association with than encephalitis caused by West Nile religious delusions, and . This tumors, such as testicular teratomas, is virus or varicella zoster virus. Absolute evolves into a fulminant stage charac- rare. In one study of 107 male patients, rates of anti-NMDA receptor encephali- terized by decreased level of conscious- only 6% of patients, all adults, presented tis were higher than those of enteroviral ness, seizures, dyskinesias, choreoath- with neoplasms of any kind. Detection encephalitis, at 41% versus 38%, with all etoid movements, autonomic instability, of teratomas or other tumors is less com- values reaching statistical significance and central hypoventilation, which may mon in preadolescent children (6, 10). (p<0.01) (4). Median age of symptom require ventilator support (5–9). onset is around 21 years, which is simi- Initial presentation includes psy- lar to that of encephalitis due to viral PATHOPHYSIOLOGY chosis, memory deficits, seizures, and etiologies (herpes simplex virus-1, var- language disintegration. Regardless of Anti-NMDA receptor encephalitis re- icella zoster virus, West Nile virus, en- the initial presentation, more than 90% sults from immunoglobulin G antibod- terovirus). Eighty percent of cases occur of patients develop at least three of the ies against the glutamate N1 subunit of in females (5). Male sex is associated following groups of symptoms within the NMDA receptor on the cell surface with bimodal age distribution. Associ- one month of onset: psychiatric disor- (11, 12). Injection of patients’ antibod- ated germ cell tumors are found more ders, memory disturbance, speech dis- ies into cultures of dissociated rat hip- often in Asian and African American order, seizures, dyskinesias, decreased pocampal neurons shows a titer-de- patients; this suggests a possible genetic consciousness, autonomic instability, pendent decrease of synaptic NMDA risk for developing the condition (5, 6).

The American Journal of Psychiatry Residents’ Journal 9 IMAGING TABLE 1. Differential Diagnosis for Anti-N-Methyl-D-Aspartate Receptor Encephalitisa MRI Infectious T2-fluid-attenuated MRI studies in Bacterial Pneumococcus children and adults have shown cor- Mycoplasma Syphilis tical, subcortical, and cerebellar ab- normalities. Brain MRI is abnormal in Viral Enterovirus Varicella zoster virus about 55% of cases, including cortical Herpes simplex virus and subcortical T2-fluid attenuated in- HIV version recovery signal abnormalities Human herpes virus-6 that sometimes occur with transient Epstein-Barr virus cortical meningeal enhancement. T2- Cytomegalovirus Arbovirus fluid attenuated inversion recovery sig- Rabies virus nal abnormalities are also seen in the Fungal Cryptococcus brainstem and cerebellum, despite the Toxoplasma fact that related symptoms are rare. In Autoimmune Systemic lupus erythematosus children, MRI abnormalities occur less Anti-phospholipid syndrome frequently than in adults. One study of Sjogren’s syndrome a series of 32 children diagnosed with Angitis (primary or systemic) anti-NMDA receptor encephalitis found Hashimoto’s encephalopathy that 31% had abnormal MRI (3). CNS vasculitis Malignancy Other paraneoplastic syndromes due to primary malignancy EEG Toxic Carbon monoxide EEG is abnormal in almost all patients Methanol with anti-NMDA receptor encephalitis. Cyanide Drugs of abuse EEG usually shows diffuse background slowing in the delta-theta range, though Endocrine Hashimoto’s thyroiditis Grave’s disease some patients may have focal slowing. Electrographic seizures during continu- Hematological Porphyria ous EEG monitoring occur in approxi- Neurological Multiple sclerosis mately 60% of patients (3). Thirty per- Psychiatric Schizophreniform disorder cent of adult patients with anti-NMDA receptor encephalitis have a unique EEG control disorder Neuroleptic malignant syndrome pattern called “extreme delta brush,” a Serotonin syndrome nearly continuous combination of delta frequency waves with superimposed fast a For more details on the differential diagnosis, see Gable et al. (4), Florance et al. (10), Granerod et al. (14), activity in the beta range occurring in a and Kruse et al. (20). symmetric and synchronous pattern in- volving all head regions. This pattern occurred independently of sedation and DIAGNOSIS MRI of the abdomen and pelvis is the test of choice to identify ovarian teratomas (3). episodes of dystonia or abnormal move- The typical patient is a previously healthy Serological tumor markers (CA-125, beta- ments. Whether or not this pattern also young female presenting with acute, se- hCG, alpha-fetoprotein, or testosterone) occurs in children with anti-NMDA re- vere emotional distress and cognitive dis- are negative in many patients (16). Pa- ceptor encephalitis is an issue still under turbance (16). Diagnosis is confirmed by tients with anti-NMDA receptor enceph- investigation (15). the presence of NMDA-receptor antibod- alitis may meet DSM criteria for , ies in serum or CSF. Intrathecal synthesis psychotic disorder, or catatonic disorder of immunoglobulin G antibodies occurs DIFFERENTIAL DIAGNOSIS due to a general medical condition. in virtually all patients; antibody levels in Differential diagnoses include acute psy- CSF correlate better with symptom out- chosis, temporal lobe seizures, toxic and come than serum immunoglobulin G anti- TREATMENT metabolic disorders (including drug in- body levels (17). All patients should be ex- Medical gestion), focal brain lesions, or enceph- amined for an underlying tumor, mainly Initial treatment includes acyclovir alitides (viral or autoimmune). Neuro- an ovarian teratoma or a testicular germ- until herpes simplex virus encephalitis leptic malignant syndrome should be cell tumor. The most useful screening can be excluded. Tumor removal, when considered given muscle rigidity, auto- tests are MRI or CT of the abdomen and appropriate, and prompt immunothera- nomic instability, and elevated creati- pelvis, ultrasound of the pelvis, or trans- pies improve outcomes. First-line im- nine kinase (16) (Table 1). vaginal ultrasound if appropriate (16). munotherapies include corticosteroids,

The American Journal of Psychiatry Residents’ Journal 10 cohort study. Lancet Neurol 2013; 12:157–165 KEY POINTS/CLINICAL PEARLS 6. Dalmau J, Lancaster E, Martinez-Hernandez • Suspect anti-NMDA receptor encephalitis in a previously healthy young female E, et al: Clinical experience and laboratory in- with viral-like symptoms rapidly progressing to altered behavior/consciousness vestigations in patients with anti-NMDAR en- cephalitis. Lancet Neurol 2011; 10:63–74 and autonomic instability. 7. Luca N, Daensgsuwan T, Dalmau J, et al: • First-line treatment: immunotherapy; use neuroleptics with caution given po- Anti-N-methyl-D-aspartate receptor en- tential for dystonia, seizures, and cardiac arrhythmias. cephalitis: a newly recognized inflamma- tory brain disease in children. • Eighty percent of patients experience complete or near-complete Rheum 2011; 63:2516–2522 8. Goldberg E, Taub K, Kessler S, et al: Anti- NMDA receptor encephalitis presenting intravenous immunoglobulin, or plasma patients improve up to 2 years after ini- with focal nonconvulsive status epilepticus exchange; however, in 30%–40% of tial presentation. Autonomic instability, in a child. Neuropediatrics 2011; 42:188–190 cases, these treatments fail (1). level of consciousness, seizures, and dys- 9. Armangue T, Titulaer M, Malaga I, et al: Increasing evidence shows that ritux- kinesias improve first. After patients re- Pediatric anti-NMDAR encephalitis: clini- imab is an effective alternative, either gain consciousness, however, psychiatric cal analysis and novel findings in a series of 20 patients. J Pediatr 2013; 162:850–862 with intravenous immunoglobulin and symptoms can re-emerge, with manifes- 10. Florance N, Davis R, Lam C, et al: Anti-N- steroids or after first-line immunothera- tations such as behavioral disinhibition, methyl-D aspartate receptor (NMDAR) en- pies (18). Cyclophosphamide is consid- impulsivity, problems with attention and cephalitis in children and adolescents. ered in children with caution only after planning, and memory deficits (1). Annal Neurol 2009; 66:11–18 exhausting all other treatment modali- Fully recovered patients may have 11. Furukawa H, Singh S, Mancusso R, et al: Sub- ties due to adverse effects (malignancy, detectable antibody levels in serum or unit arrangement and function in NMDA re- infertility). Efficacy of azathioprine or CSF, leading to immune response re- ceptors. Nature 2005; 438:185–192 mycophenolate mofeteil in preventing activation. Symptom relapse has been 12. Gresa-Arribas N, Titulaer M, Torrents A, et al: Diagnosis and significance of antibody relapse remains unknown (1, 19). reported in 20% of children. This may titers in anti-NMDA receptor encephalitis, require continued treatment, including a retrospective study. Lancet Neurol 2014; Psychiatric neuroleptics, or short-term treatment 13:167–177 Evidence-based psychiatric manage- during symptom exacerbation (1). After 13. Hughes EG, Peng X, Gleichmann AJ, et al: ment is equivocal. Case reports show recovery, females should be screened Cellular and synaptic mechanisms of anti- periodically for 2 years for ovarian tera- NMDA receptor encephalitis. J Neurosci that benzodiazepines may improve ag- 2010; 30:5866–5875 tomas (6). Mortality is low, at 7% in 24 itation and insomnia, 14. Granerod J, Ambrose H, Davies N, et al: agents may improve dystonias, and car- months after initial presentation (1). Causes of encephalitis and differences in bidopa-levodopa may effectively treat their clinical presentations in England: a muscle rigidity; however, in other cases, Dr. Sahasranaman is a fourth-year resident multicenter, population based, prospective in the Department of Psychiatry at Rosa- patients had minimal to no response to study. Lancet Infect Dis 2010; 10:835–844 lind Franklin University of Medicine and these treatments. Neuroleptics used to 15. VanHaerents S, Stillman A, Inoa V, et al: Science, North Chicago, Ill. Persistent ‘extreme delta brush’ in a patient treat must be used cautiously with anti-NMDA receptor encephalitis. due to potential for dystonia, seizures, Behav Case Rep 2014; 2:67–70 and cardiac arrhythmias. REFERENCES 16. Mann A, Grebenciucova E, Lukas R: Anti-N- ECT and benzodiazepines may be 1. Peery H, Day G, Dunn S, et al: Anti-NMDA methyl-D-aspartate-receptor encephalitis: di- effective for associated catatonia. Case receptor encephalitis. The disorder, the di- agnosis, optimal management, and challenges. reports show that ECT may be effective agnosis and the immunobiology. Autoim- Ther Clin Risk Manag 2014; 10:517–524 in adults with anti-NMDA-receptor-as- mun Rev 2012; 11:863–872 17. Salvucci A, Devine I, Hammond D, et al: Pediatric anti-NMDA receptor encephali- sociated catatonia. In younger patients, 2. Vitaliani R, Mason W, Ances B, et al: Para- neoplastic encephalitis, psychiatric symp- tis. Pediatric Neurol 2014; 50:507–510 ECT may be a useful adjunct to benzodi- toms, and hypoventilation in ovarian 18. Ishiura H, Matsuda S, Higashihara M, et al: azepines and immunotherapy; one case teratoma. Annal Neurol 2005; 58:594–604 Response of anti-NMDA receptor encepha- described a 14-year-old girl who showed 3. Armangue T, Pedrol M, Dalmau J: Autoim- litis without tumor to immunotherapy in- dramatic improvement in malignant mune encephalitis in children. J Child cluding rituximab. Neurology 2008; catatonia with this combination (20). Neurol 2012; 27:1460–1469 71:1921–1923 4. Gable M, Sheriff H, Dalmau J, et al: The fre- 19. Dalmau J, Gleichmann A, Hughes E, et al: quency of autoimmune N-methyl-D-aspar- Anti-NMDA-receptor encephalitis: case OUTCOMES tate receptor encephalitis surpasses that of series and analysis of the effects of antibod- individual viral etiologies in young individ- ies. Lancet Neurol 2008; 7:1091–1098 When rapidly identified and treated, the uals enrolled in the California Encephalitis 20. Kruse J, Jeffrey J, Davis M, et al: Anti-N- prognosis is good. A cohort study of 360 Project. Clin Infect Dis 2012; 54:899–904 methyl-D-aspartate receptor encephalitis: patients found that 80% of patients ex- 5. Titulear M, McCracken L, Gabilondo I, et al: a targeted review of clinical presentation, perienced near-complete or full recov- Treatment and prognostic factors for long- diagnosis, and approaches to pharmacolog- term outcome in patients with anti-N- ical management. Annal Clin Psychiatry ery. Another study suggested that some methyl-D-aspartate receptor encephalitis: a 2014; 26:e1–e9

The American Journal of Psychiatry Residents’ Journal 11 CASE REPORT A Patient With Guillain-Barré Syndrome Masquerading as Conversion Disorder

Taranjeet Singh Jolly, M.D.

Guillain-Barré syndrome is an immune- noglobulins and plasmapharesis have ducted in the emergency department. mediated acute polyradiculoneuritis made a significant change in the course On admission to inpatient psychiatry, most frequently preceded by an un- of the illness (9). the patient was reported to have poor specific infection (1). Guillain-Barré The present case report describes sleep, poor appetite, and increasing irri- syndrome is the most common cause Guillain-Barré syndrome, with symp- tability for the past 3 weeks. Her parents of acute flaccid paralysis in healthy in- toms similar to conversion disorder, in a reported self-harmful behavior, such as fants and children (2). It occurs world- young child. “hitting her head on the wall,” when wide, with an overall incidence of 1 to she became frustrated. Her behaviors 2 per 100,000 per year (3, 4). While all were particularly worse since her re- CASE age groups are affected, the incidence cent hospitalization. Mental status ex- is lower in children than in adults and “Sarah” is an 8-year-old Caucasian girl amination results were significant for increases by approximately 20% with with no prior psychiatric history who an obese, 8-year-old Caucasian girl who every 10-year increase in age beyond the was taken to our emergency depart- was irritable, belligerent, and crying first decade of life. Guillain-Barré syn- ment for mood outbursts, crying spells, on examination. We were unable to as- drome occurs rarely in children younger and difficulty ambulating. For the past sess her mood, thought process, thought than 2 years old but can occur in infants 3 weeks, she had intermittent back and content, and perceptual disturbances (5, 6). Males are affected approximately hip pain. Early in the course of illness, because the patient was not cooperat- 1.5 times more often than females in all she had 3 days of fevers up to 102°F, and ing. Her family history was significant age groups. her pediatrician diagnosed a viral syn- for depression and anxiety on both the Guillain-Barré syndrome manifests drome and recommended conservative maternal and paternal sides. She had a as rapidly evolving areflexic motor pa- treatment. She presented to an outside normal birth and early developmental ralysis with or without sensory distur- hospital with progressive back and hip history with no delay in her develop- bance, the usual pattern being ascend- pain and difficulty walking, along with mental milestones. She had no pertinent ing flaccid paralysis. Weakness typically crying spells. An X-ray of her abdomen psychiatric history. Her medical history evolves over hours to a few days and is revealed constipation. A head CT, MRI was significant for a history of consti- frequently accompanied by tingling dy- of the right hip, and MRI of the lumbar pation, and she had been treated with saesthesias in the extremities (7). Au- spine were all read as normal. She was polyethylene glycol for the past year. tonomic involvement is common, the treated for her constipation and medi- Her examination was positive for usual manifestations being loss of vaso- cally cleared despite being unable to absent reflexes in the upper and lower motor control with wide fluctuations in ambulate throughout her hospitaliza- limbs and narrow-based gait. Her evalu- blood pressure, postural hypotension, tion. Psychiatry was consulted, and she ation was negative for eye, ear nose and and cardiac arrhythmias (7). Accord- was diagnosed with major depressive throat, respiratory, cardiology, gastro- ing to pediatric literature, children usu- disorder with possible “conversion dis- intestinal, genitourinary, dermatologic, ally recover in shorter time than adults, order” manifesting as gait disturbance, and endocrine abnormalities. Vitals with a mortality rate of 3%–5%. Severe with recommendation for inpatient psy- signs were within normal limits. neurological disability leading to ven- chiatric treatment. Pediatric neurology was consulted tilatory insufficiency and autonomic The patient was brought to our emer- because of concerns for absent reflexes failure are the main causes of death (1, gency department 5 days after her dis- and gait disturbances. Neurological ex- 8). Although the etiology is not clearly charge from the hospital with ongoing amination revealed decreased hip flex- known, about 70% of cases are preceded difficulty ambulating and worsening ion 3/5 bilaterally, as well as absent re- by acute infectious processes 1–3 weeks mood outbursts. A review of her records flexes. The patient’s gait was narrow before the onset of neurologic symp- from the recent hospitalization was based; with use of a walker, she was able toms. Electro-physiologically Guillain- made, and acute medical or neurological to lift both feet off the ground, flex her Barré syndrome is characterized by causes were ruled out in the emergency knees, and flex her hips, with frequent acute motor axonal neuropathy. Immu- department. No further tests were con- imbalance backwards and near falls.

The American Journal of Psychiatry Residents’ Journal 12 Neurology recommended CT head, worked with her on pain and relaxation TABLE 1. Common Conditions a MRI–L spine and T-spine, and MRI of techniques, as well as on development of Misdiagnosed as Conversion Disorder hip. The initial preliminary diagnosis coping skills. By the time of discharge Condition was diffuse/multifocal polyneuropathy. from the rehabilitation unit, the patient Frontal lobe epilepsy MRI hip was unremarkable. had hip flexion 4/5 and ankle dorsi-flex- Amyotropic lateral sclerosis MRI of lumbar spine was notable for ion 4/5. She was discharged back to her Myasthenia gravis mild thickening and smooth enhance- home with recommended physical ther- Multiple sclerosis ment of the pial surface of the conus and apy at home. No further follow-up infor- cauda equina nerve roots in the lum- mation was made available. CNS tumor bosacral region, which was most likely Peripheral nerve palsy consistent with an inflammatory condi- DISCUSSION Cerebrovascular accident tion such as Guillain-Barré syndrome. Systemic lupus erythematosus At this time, the patient was transferred a For more details on these conditions, see Crimlisk Conversion disorder is defined as a to the neurology service for further et al. (14) and Moene et al. (15). symptom or deficit in voluntary motor workup for inflammatory processes. She function in patients without an anatomic was monitored for ascending paralysis, or physiologic basis. Conversion disor- depression). In children, symptoms are with specific examination for symptoms der is also called functional neurologi- most commonly related to motor func- such as urinary retention or respiratory cal symptom disorder in DSM-5. It can tion and often start following emotional depression. Her workup was consis- consist of the following subtypes: with stress or minor injury. In most cases, tent with the diagnosis including MRI weakness or paralysis, with abnormal a detailed history identifies domestic with nerve root enhancement. A lum- movement (e.g., tremor, dystonic move- stress, feelings of parental rejection, bar puncture was performed, which re- ment, myoclonus, gait disorder), with unresolved grief, and/or problems at vealed cytoalbuminologic dissociation swallowing symptoms, with speech school (11). Physical examination often with elevated protein (261 mg/dL) but symptoms (e.g., dysphonia, slurred provides early diagnosis without exten- relatively normal white blood cell count speech), with attacks or seizures, with sive laboratory evaluation or ancillary (8/cu mm). Electromyogram revealed anesthesia or sensory loss, with special studies. Key findings include reciprocal increased distal latencies and mildly de- sensory symptom (e.g., visual, olfactory, contraction during attempts to move ap- creased amplitudes. or hearing disturbance), or with mixed parently paralyzed muscle groups, pres- Investigations (conducted in neu- symptoms. A high rate of misdiagnosis ence of normal tendon reflexes in flaccid rology service) for CSF glucose levels, of conversion symptoms was reported extremities, or physically implausible mononuclear CSF, immunoglobulin G, in early studies, but this rate has been presentations. Successful treatment in- immunoglobulin A, and complete meta- only 4% on average in studies of this di- volves early referral for psychiatric care bolic panel revealed no abnormalities. agnosis since 1970 (Table 1) (13). In chil- and avoidance of extensive investigation Elevated CSF protein (261 mg/dL [range: dren, conversion disorder occurs more for an organic cause. Although the oc- 15 mg/dL–45 mg/dL]) was observed. commonly in girls than in boys and is currence of Guillain-Barré syndrome in Intravenous immunoglobulin treat- most prevalent in children between the children is relatively rare, it is the most ment was initiated and continued for 5 ages of 10 and 15 (11, 12). Risk factors common cause of acute flaccid paraly- days (400 mg/kg/day). Immunoglobulin include prior sexual abuse and preex- sis in infants and children during the A was within normal limits. The patient isting psychiatric disease (e.g., anxiety, post-polio eradication era. It is impor- was tested for cytomegalovirus, her- pes simplex virus, Epstein-Barr virus, enterovirus, varicella zoster virus, and KEY POINTS/CLINICAL PEARLS West Nile virus, with all negative re- sults. Psychiatry was consulted for fol- • Guillain-Barré syndrome is the most common cause of acute flaccid paralysis low-up, and we recommended continu- in healthy infants and children, with an overall incidence of 1 to 2 per 100,000 per year. ation of (10 mg/day) to help with depression. The patient was also • The incidence of Guillain-Barré syndrome is lower in children than in adults started on gabapentin (100 mg b.i.d.) and increases by approximately 20% with every 10-year increase in age beyond for neuropathic pain. Physical medicine the first decade of life. and rehabilitation was involved, and the • In children, conversion disorder occurs more commonly in girls than boys and patient was receiving regular physical is most prevalent in children between the ages of 10 and 15. Risk factors in- therapy. Behavioral was also clude prior sexual abuse and preexisting psychiatric disease (e.g., anxiety, de- consulted for behavioral management pression). during the treatment. The patient was • It is important to consider and rule out neurological and general medical discharged from the inpatient unit to causes of acute change in mental status or gait disturbance before considering the physical rehabilitation unit, and she a diagnosis of conversion disorder or psychogenic gait disorder. was seen by behavioral psychology who

The American Journal of Psychiatry Residents’ Journal 13 tant to consider and rule out neurologi- 4. Sejvar JJ, Baughman AL, Wise M, et al: have we moved beyond the couch? Curr cal and general medical causes of acute Population incidence of Guillain-Barré Treat Opt Neurol 2011; 13:255 syndrome: a systematic review and meta- change in mental status or gait distur- 11. Gelauff J, Stone J, Edwards M, et al: Dis- analysis. Neuroepidemiology 2011; 36:123 bance before considering a diagnosis of ability, distress and unemployment in neu- 5. Carroll JE, Jedziniak M, Guggenheim MA: rology outpatients with symptoms conversion disorder or psychogenic gait Guillain-Barré syndrome: another cause of ‘unexplained by organic disease.’ J Neurol disorder. the “floppy infant.” Am J Dis Child 1977; Neurosurg Psychiatry 2011; 82:810. 131:699 12. Gelauff J, Stone J, Edwards M, et al: The Dr. Jolly is a child and adolescent psychia- 6. Buchwald B, de Baets M, Luijckx GJ, et al: prognosis of functional (psychogenic) mo- try fellow at the Johns Hopkins Hospital, Neonatal Guillain-Barré syndrome: block- tor symptoms: a systematic review. J Neu- Baltimore. ing antibodies transmitted from mother to rol Neurosurg Psychiatry 2014; 85:220 child. Neurology 1999; 53:1246 13. Stone J, Smyth R, Carson A, et al: System- 7. Dhadke SV, Dhadke VN, Bangar SS, et al: REFERENCES atic review of misdiagnosis of conversion Clinical profile of Guillain Barré syndrome. symptoms and “hysteria.” BMJ 2005; 1. Korinthenberg R, Schulte Monting J: Natu- J Assoc Physicians India 2013; 61:168–172 331:989 ral history and treatment effects in Guil- 8. Pi-Lien H, Chang W, Huang L, et al: A clini- 14. Crimlisk HL, Bhatia K, Cope H, et al: Slater lain-Barré syndrome: a multicenter study. cal and electrophysiologic survey of child- revisited: 6 year follow-up study of patients Arch Dis Child 1996; 74:281–287 hood Guillain-Barre syndrome. Pediatr with medically unexplained motor symp- 2. Koul R, Al-Futaisi A, Chacko A, et al: Clini- Neurol 2004; 30:86-91 toms. BMJ 1998; 316:582–586 cal characteristics of childhood Guillain- 9. Jones HR Jr: Guillain-Barré syndrome: 15. Moene FC, Landberg EH, Hoogduin KA, et Barré syndrome. Oman Med J 2008; perspectives with infants and children. Se- al: Organic syndromes diagnosed as con- 23:158–161 min Pediatr Neurol 2000; 7:91 version disorder: identification and fre- 3. Yuki N, Hartung HP: Guillain-Barré syn- 10. Rosebush PI, Mazurek MF: Treatment of quency in a study of 85 patients. J drome. New Eng J Med 2012; 366:2294 conversion disorder in the 21st century: Psychosom Res 2000; 49:7–12

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The American Journal of Psychiatry Residents’ Journal 14 CASE REPORT Delineating PANDAS/PANS Diagnosis

Jennifer Severe, M.D.

Researchers have continued to inves- prompted her parents to seek medical fection and formulated the diagnostic tigate symptoms of pediatric autoim- care. Around the time of her presenta- criteria for PANDAS (Table 1). The con- mune neuropsychiatric disorders as- tion, Mary had been undergoing signifi- current group A streptococcal infection sociated with streptococcal infections cant stressors, including that she and in association with the acuity of symp- (PANDAS) and pediatric acute-onset her parents had been in the process of tom onset constitutes the cornerstone neuropsychiatric syndrome (PANS). relocating to another state and they for PANDAS diagnosis as shown in the The present case report is of an 8-year- were moving in and out with relatives. above case report. In one study, children old girl diagnosed with PANDAS. She had to change schools as a result with elevated antistreptolysin O titer of these frequent relocations. On two showed a pattern toward greater OCD recent occasions, she had witnessed severity and, consequently, more im- CASE her mother faint, which generated a paired neurocognitive processing (3, 4). “Mary” is an 8-year-old Caucasian girl great deal of anxiety. She cultured posi- Strangely enough, a higher susceptibil- with a medical history of asthma. She tive for group A the day ity to group A streptococcal infections is is an only child, high-achieving, and a of her presentation to the emergency reported in youths with tics and/or OCD perfectionist. She has no prior psychi- department. She was put on amoxicil- compared to healthy controls, estimated atric history, and her family history is lin but was switched to clindamycin at 0.42 versus 0.28 infections per subject positive only for anxiety in both par- after the first dose due to developing per year, respectively (1). An additional ents and an aunt. She presented to a pe- an allergic reaction. She was assessed risk factor may be a maternal autoim- diatric emergency department with 2 by a child psychiatrist and began treat- mune history, particularly Hashimoto’s weeks of sudden emergence of random ment with fluoxetine and in-home thyroiditis (5). and intense intrusive thoughts, which cognitive-behavioral therapy (CBT) Researchers continue to explore etio- she referred to as “pops” (indicating the with her mother, with the working logic factors other than group A strepto- thoughts “popping” into her head). She diagnosis of PANDAS. Titration of coccal infection linked to the condition, categorized the pops by topic, ranging her fluoxetine dose was very slow due and concurrent infection with myco- from sexualized obsessions (including to emergence of increased restless- plasma pneumonia, Borrelia burgdor- sex, pregnancy, giving birth, and see- ness with an increase from 5 mg to 10 feri, influenza, and Epstein-Barr virus ing genitals of others, which prompted mg daily. Four months after her ini- have been reported (1, 3, 6, 7). Nonin- online searches on sex and episodes of tial presentation, her symptoms sub- fectious etiologies, such as autoimmune masturbation) to violent thoughts in- sided except for episodic anxiety. Her and inflammatory diseases and perhaps volving killing herself or others (shoot- mother stated, “We are seeing smiles.” certain psychosocial stressors, also ing or stabbing) and obsessional ideas warrant consideration (1, 3, 6, 7). The about swearing and making racist com- countless cases of sudden-onset OCD DISCUSSION ments. She used to enjoy going to church with or without disorder failing to with her parents but could no longer tol- Disease Overview reasonably meet the rigid and limited erate it due to experiencing intense ha- Symptoms of PANDAS and PANS are criteria for PANDAS prompted a group tred against God and emerging doubts progressively coming to light, yet the of experts at the National Institutes of about the veracity of the Bible. diagnoses remain controversial. Since Health to widen the scope of the syn- At the same time, the patient also de- Sydenham and Osler in the mid-19th drome in 2010 (6), and thus PANS was veloped a sore throat, which was accom- century, researchers have dedicated ef- designated as a single diagnostic cate- panied with fear of choking on small forts toward investigating the potential gory (Table 1). Presently, PANDAS is re- objects such as candy and popcorn, con- associations between bacterial infection garded as a subtype of PANS. trasted with irresistible thoughts of put- and new-onset of obsessive compulsive For some researchers, PANDAS/ ting bottle caps into her mouth. She be- disorder (OCD), tics, and Sydenham PANS is seen as “a yet-unproven hy- came anxious and distraught, wishing in children (1). In 1998, Swedo pothesis” (8); for others, it is a real but her life was less complicated and wish- et al. (2) observed a novel group of 50 not well-defined clinical entity (9). The ing she was dead. This presentation, patients with OCD and as- incidence of PANS OCD is yet to be de- along with 24 hours of poor oral intake, sociated with group A streptococcal in- termined, though estimated at 0.2%–

The American Journal of Psychiatry Residents’ Journal 15 TABLE 1. PANDAS/PANS Diagnostic Criteria fection, which generates cross-reactive PANDAS PANS antineuronal antibodies for both group Presence of obsessive-compulsive disorder (OCD) or An abrupt and dramatic onset of A streptococcal cellular components a tic disorder; OCD or food restriction and tissue (7, 10). This Acute symptom onset and episodic course engenders a volumetric increase of the Prepubertal symptom onset Area of dissimilarity caudate, putamen, and globus pallidus, Temporally associated with group A streptococcal which is believed to create a dopamine infection and symptom onset/exacerbations dysregulation leading to the neuro- Associated with neurological abnormalities, particu- psychiatric manifestations (1, 7, 10). As larly motoric hyperactivity and choreiform move- with most forms of psychopathology, ments quality of life is significantly affected Area of dissimilarity Symptoms are not better explained (3). The prognosis of youths diagnosed by a known neurologic or medical with PANDAS/PANS is not entirely disorder known. At least two similarly severe and acute neuropsychiatric symptoms, Differential Diagnosis including anxiety, emotional labil- PANS is a ‘‘diagnosis of exclusion’’ (7). ity and/or depression irritability, aggression and/or oppositionality, While the diagnosis of PANDAS/PANS behavioral regression, deterioration seemed more evident as the above clini- in school performance, sensory or cal case unfolded, the diagnostic de- motor abnormalities, and somatic cision-making deserves up-close and signs and symptoms (e.g., in-depth attention considering the as- or sleep disturbances) sociated psychosocial entanglement and contextual conditions. The patient 0.4% (1). Children with PANDAS/PANS affected children but also to families. was portrayed as a perfectionist by her are anecdotally described as being The prevailing theory of pathogenesis family; nonetheless, there was no clini- “changed overnight,” a perplexing and is the induction of abnormal immune cal evidence of OCD prior to her group distressing phenomenon not only to the response by group A streptococcal in- A streptococcal infection. Her anxiety

TABLE 2. Obsessive-Compulsive Disorder (OCD) Versus PANS OCDa Variable OCD PANS OCD Age at onset (years) 10 <7 Gender relatedness Age <15 years; males slightly higher than females; Nearly 5:1 male:female ratio under age 8 female/male ratio increases post puberty Course Insidious onset; not episodic Dramatic and severe onset; episodic or saw-tooth course; long-term prognosis unknown Incidence 2% of youths Unknown, estimate is 10%–20% of pediatric OCD Infectious trigger Unknown Proposed association with infection but not required Motor signs Increased findings of neurological soft signs, includ- Choreiform movements ing choreiform movements Neurocognitive findings Oculomotor response inhibition deficits; deficits in Poor attention and visual-spatial abilities; acute math set shifting and inhibition; deficits in cognitive flex- and reading deficits; impulsivity; deficits in fine mo- ibility and planning tor speed Involvement of basal ganglia Strong support Good support Immune therapy response No Some support for Intravenous immunoglobulin, antibiotics Response to CBT Yes Yes Response to Yes Yes, but may be prone to activation reuptake inhibitors Comorbidity (%) Any tic disorder: 15–30 Any tic disorder: 55.3 ADHD: 11–12 ADHD:44.6 Separation anxiety: 30–52 Separation anxiety: 21 Affective disorder: 25–62 Affective disorder: 43 Anxiety disorder: 26–75 Anxiety disorder: 31 a Reproduced with permission from Psychiatric Clinics of North America (Murphy TK et al: “Pediatric acute-onset neuropsychiatric syndrome”). Copyright © Psych Clin North Am, 2014.

The American Journal of Psychiatry Residents’ Journal 16 J Child Adolesc Psychopharmacol 2015; KEY POINTS/CLINICAL PEARLS 25:14–25 • Pediatric acute-onset neuropsychiatric syndrome (PANS) is a diagnosis of ex- 4. Lewin AB, Storch EA, Mutch PJ, et al: Neu- clusion. rocognitive functioning in youth with pe- diatric autoimmune neuropsychiatric • Careful delineation of symptoms, including the acuity and severity of onset, is disorders associated with streptococcus. essential to PANS diagnostic framework. Am J Psychiatry 2011; 23:391–398 5. Murphy TK, Storch EA, Turner A, et al: • Infectious and noninfectious etiologies have come into light in the develop- Maternal history of in ment of PANS and define the therapeutic interventions. children presenting with tics and/or obses- • Be aware of the potential behavioral activation following selective serotonin sive-compulsive disorder. J Neuroimmunol reuptake inhibitor initiation for treatment of the obsessive-compulsive disorder 2010; 229:243–247 symptoms. 6. Swedo SE, Leckman JF, and Rose NR: From research subgroup to clinical syn- drome: modifying the PANDAS criteria to describe PANS (pediatric acute-onset neu- regarding her mother’s health, her ten- to, at times, lead to tryptophan degra- ropsychiatric syndrome). Pediatr Therap dency of internalizing, her family his- dation, which may influence serotonin 2012; 2:2 tory of anxiety disorder, along with the function and induce behavioral activa- 7. Chang K, Frankovich J, Cooperstock M, et stressful disruption in schooling, peer tion following SSRI initiation (13). Con- al: Clinical evaluation of youth with pediat- relationships, and living situation, made trary to expectations, the available re- ric acute-onset neuropsychiatric syndrome tangible other anxiety-spectrum phe- search does not support tonsillectomy (PANS): recommendations from the 2013 PANS Consensus Conference. J Child Ado- notypes. PANS symptoms overlap with or adenotonsillectomy as likely affecting lesc Psychopharmacol 2015; 25:3–13 a variety of psychiatric disorders, espe- symptom progression or the presumed 8. Kurlan R, Kaplan E: The pediatric autoim- cially OCD (Table 2), as well as attention autoimmunologic response (14). mune neuropsychiatric disorders associ- deficit hyperactive disorder, separation ated with streptococcal infection anxiety disorder, generalized anxiety Clinical Implications (PANDAS) etiology for tics and obsessive- disorder, , oppositional Understanding the brain maturational compulsive symptoms: hypothesis or en- tity? practical considerations for the defiant disorder, bipolar disorder, and and developmental processes, in con- clinician. Pediatrics 2004; 113:883–886 sometimes depression (3, 7, 11). Clini- junction with the plastic reorganization 9. Macerollo A, Martino D: Pediatric autoim- cians should be mindful of children’s in response to a temporary or long-term mune neuropsychiatric disorders associated reluctance and shameful or guilty feel- PANDAS/PANS diagnosis, warrants with streptococcal infections (PANDAS): an ing to disclose the entire scope of their further inquiry. Clear identification evolving concept. Tremor Other Hyperkinet symptoms, as this can complicate the of PANDAS/PANS cases is of particu- Mov (N Y) 2013; 3:4158–4157 history. The main differential diagno- lar importance in gathering more in- 10. Giedd JN, Rapoport JL, Garvey MA, et al: sis of PANDAS/PANS also includes To- sight to address the uncertainty of the MRI assessment of children with obses- sive-compulsive disorder or tics associated urette’s syndrome, transient tic disor- condition. with streptococcal infection. Am J Psychi- der, Sydenham chorea, Wilson’s disease, atry 2000; 157:281–283 Dr. Severe is a third-year resident in the avoidant/restrictive food intake disor- 11. Bernstein GA, Victor AM, Pipal AJ, et al: der, secondary enuresis, autoimmune Department of Psychiatry, Baystate Medi- Comparison of clinical characteristics of encephalitis, and systemic autoimmune cal Center/Tufts University School of pediatric autoimmune neuropsychiatric Medicine, Springfield, Mass. disease (3, 7). A drastic course and type disorders associated with streptococcal in- fections and childhood obsessive-compul- of the symptoms are the most important sive disorder. J Child Adolesc The author thanks Bruce Waslick, M.D., for factors for an accurate diagnosis. Psychopharmacol 2010; 20:333–340 his guidance and suggestions. 12. Latimer ME, L’Etoile N, Seidlitz J: Thera- Treatment peutic plasma apheresis as a treatment for Promising therapeutic interventions for 35 severely ill children and adolescents children with PANDAS/PANS include REFERENCES with pediatric autoimmune neuropsychi- atric disorders associated with streptococ- 1) an appropriate course of antibiotics, 1. Murphy TK, Gerardi DM, Leckman JF, et cal infections. J Child Adolesc al: Pediatric acute-onset neuropsychiatric such as penicillin, cephalosporin, and Psychopharmacol 2015; 25:70–75 macrolides for treatment of underlying syndrome. Psychiatr Clin North Am 2014; 37:353–374 13. Murphy TK, Storch EA, Strawser MS: Se- bacterial infections; 2) selective sero- lective serotonin reuptake inhibitor-in- tonin reuptake inhibitors (SSRIs); 3) an- 2. Swedo SE, Leonard HL, Garvey M, et al: duced behavioral activation in the PANDAS Pediatric autoimmune neuropsychiatric tidopaminergic or prednisone for tics; 4) subtype. Prim Psychiatry 2006; 13:87–89 disorders associated with streptococcal in- 14. Pavone P, Rapisarda V, Serra A, et al: Pedi- CBT; and 5) intravenous immunoglobu- fections: clinical description of the first 50 atric autoimmune neuropsychiatric disor- lin and therapeutic plasma exchange for cases. Am J Psychiatry 1998; 155:264–271 der associated with group a streptococcal treatment-refractory cases (1, 6, 12) .It 3. Murphy TK, Patel PD, McGuire JF, et al: infection: the role of surgical treatment. Int is important to be aware that group A Characterization of the pediatric acute-on- J Immunopathol Pharmacol 2014; streptococcal infections are suspected set neuropsychiatric syndrome phenotype. 27:371–378

The American Journal of Psychiatry Residents’ Journal 17 BOOK FORUM Clinical Topics in Child and Adolescent Psychiatry

Reviewed by Venkata B. Kolli, M.B.B.S., M.R.C.Psych.

Clinical Topics in Child and Adolescent Psy- tional Health Service (United King- chiatry, edited by Sarah Huline-Dick- dom), it might be of interest to American ens, is a befitting addition to the long readers, with the recent and proposed line of high-quality publications from changes to health care delivery in the the Royal College of Psychiatrists. This United States. Throughout the book, book is of value to psychiatrists and pe- landmark child psychiatry studies (e.g., diatricians interested in the behavioral Multimodal Treatment of ADHD) are health of children and adolescents. It well described, and there are discus- discusses key mental health disorders sions on American child psychiatry prac- with childhood onset and their continu- tice. There is a balanced approach with a ation into adult life, integrating their bi- discussion of both National Institute of ological and social etiology with a focus Clinical Excellence and American Acad- on recent advances in neurosciences. emy of Child and Adolescent Psychiatry Several chapters in this book have Edited by Sarah Huline-Dickens . London, guidelines. There is a review of both the RCPsych Publications, 2014, 416 pp., $46.90 been adapted from the popular UK jour- ICD-10 and DSM-5 nosologies, improv- (U.S.). nal, Advances in Psychiatric Treatment, ing its utility for a global audience. which publishes review articles. As The book is well written, and its mentioned in the preface, the book at- of Attachment and Affect Regulation. educationally rich figures, tables, and tempts to conceptualize core topics of The latter lays the foundation for other textboxes further enhance its useful- child and adolescent psychiatry for the topics like Post-traumatic Stress Dis- ness. This book is suitable for those purpose of medical education. All of the order and Attachment: Possible Links looking for a quick update on child psy- chapters maintain this ethos, distill- with Borderline , as chiatry and at the same time can serve ing key child psychiatry concepts into a well as Management of Antisocial Per- as a practical reference guide for child meaningful and coherent manner. sonality Disorders in Childhood. The psychiatrists. With its easy-to-read The book starts off with an introduc- mid-section of the book, chapters 6–10, presentation, I believe this book to be tory chapter on Child Psychiatry and discusses pharmacological and psy- beneficial for psychiatry trainees who People Who Have Shaped It, which pro- chotherapeutic management of child- are interested in or currently training vides a background on child psychiatry hood psychiatric disorders. The book in child psychiatry. I foresee its value evolution. The selection of clinical top- then moves on to discussing common in preparing for child psychiatry in- ics and their order is well-thought-out. childhood psychiatric conditions and service examinations and American The initial chapters of the book range their management (chapters 11–22). The Board of Psychiatry and Neurology from pragmatic topics like Fabrication final chapter is on Psychiatry of Chil- board examinations. and Induction of Illness in Children, dren Aged 0–4 Years Old, an age group which discusses risk factors, diagnosis, whose psychiatric care is universally At the time this book review was accepted and management, to heavily theoretical challenging. for publication, Dr. Kolli was a child psy- but easy-to-read chapters such as Per- Even though the book seems to be chiatry fellow at Creighton University, sonality Disorders as Disorganization written with a perspective of the Na- Omaha Neb.

The American Journal of Psychiatry Residents’ Journal 18 Residents’ Resources Here we highlight upcoming national opportunities for medical students and trainees to be recognized for their hard work, dedication, and scholarship. *To contribute to the Residents’ Resources feature, contact Hun Millard, M.D., M.A., Deputy Editor ([email protected]).

OCTOBER DEADLINES

Fellowship/Award Organiza- and Deadline tion Brief Description Eligibility Contact Website

The Group for the GAP Each Fellow: PGY 2 or later at an e-mail: Frda1@ http://ourgap.org/ Advancement of Attends four GAP meetings over accredited psychiatry airmail.net or Psychiatry (GAP) Fel- 2-years; becomes a member of one residency program in the telephone: 972-613- lowship of the working GAP committees; United States or Canada; 0985 collaborates with other fellows on a have at least 2 years of Deadline: plenary presentation to the general training ahead (e.g., PGY- October 1, 2015 GAP membership; learns about 1 or 3, or first year of a group process in their GAP commit- 2-year fellowship). tee and with their fellowship group; and benefits from close interaction with peers and mentors.

Geriatric Mental American Provides residents 1-year mem- PGY 1, 2, or 3 at an e-mail: main@ http://www.aagponline. Health Foundation’s Association bership to AAGP; registration and accredited psychiatry AAGPonline.org or org/ Honors Scholarships for Geriatric travel costs to attend the AAGP residency program telephone: 703- Psychiatry Annual Meeting; Participation in an 556-9222 Deadline: (AAGP) academic project related to geriatric October 1, 2015 psychiatry under the supervision of an assigned mentor.

Geriatric Mental AAGP Provides medical students 1-year Medical students in a e-mail: main@ http://www.aagponline. Health Foundation’s membership to AAGP; registration LCME or COCA accred- AAGPonline.org or org/ General Scholarships and travel stipend to attend the ited medical school. telephone: 703- AAGP Annual Meeting; voluntary 556-9222 Deadline: participation in an academic project October 1, 2015 related to geriatric psychiatry under the supervision of an assigned mentor.

NOVEMBER DEADLINES

Fellowship/Award Organiza- and Deadline tion Brief Description Eligibility Contact Website APA/Lily Psychiatric APA This fellowship provides funding for APA RFM; psychresearch@ http://www.psychiatry. Research Fellowship 2 postgraduate psychiatry trainees, Received M.D. or D.O. psych.org org/researchers/research- under the supervision and guidance degree; training-and-career-dis- Deadline: of his/her mentor to design and Completed residency tinction-awards/psychiat- November 17, 2015 conduct a research study on a major training in general psy- ric-research-fellowship research topic. chiatry or child psychiatry prior to time fellowship commences; Not already an estab- lished investigator. American Psychiat- APF A 1-year psychiatric research fel- Received M.D. or D.O. Marilyn King http://www.psychiatry. ric Foundation (APF) lowship for three postgraduate degree; e-mail: schizophre- org/researchers/research- Schizophrenia Re- psychiatry trainees specifically to Completed residency [email protected] training-and-career- search Fellowship focus on research and personal training in general psy- or distinction-awards/ scholarship. Minimal time (less than chiatry or child psychiatry telephone: 703-907- schizophrenia-research- Deadline: 15%) will be devoted to teaching, prior to time fellowship 8653 fellowship November 17, 2015 patient care, consultation, or other commences; duties. The protection of time for Not already an estab- research should be assured by the lished investigator. department chairman.

The American Journal of Psychiatry Residents’ Journal 19 Author Information for The Residents’ Journal Submissions

Editor-in-Chief Senior Deputy Editor Deputy Editor Rajiv Radhakrishnan, M.B.B.S., M.D. Katherine Pier, M.D. Hun Millard, M.D., M.A. (Yale) (Icahn School of Medicine) (Yale)

The Residents’ Journal accepts manu- questions based on the article’s article type should also include a scripts authored by medical students, resi- content. Limited to 1,500 words, table of Key Points/Clinical Pearls dent physicians, and fellows; manuscripts 15 references, and one figure. with 3–4 teaching points. authored by members of faculty cannot be This article type should also accepted. include a table of Key Points/ 7. Drug Review: A review of a To submit a manuscript, please visit Clinical Pearls with 3–4 teaching pharmacological agent that http://mc.manuscriptcentral.com/appi- points. highlights mechanism of action, ajp, and select “Residents” in the manu- efficacy, side-effects and drug- script type field. 4. Clinical Case Conference: A interactions. Limited to 1,500 presentation and discussion of words, 20 references, and one 1. Commentary: Generally includes an unusual clinical event. Limited figure. This article type should descriptions of recent events, to 1,250 words, 10 references, also include a table of Key Points/ opinion pieces, or narratives. and one figure. This article type Clinical Pearls with 3–4 teaching Limited to 500 words and five should also include a table of Key points. references. Points/Clinical Pearls with 3–4 teaching points. 8. Letters to the Editor: Limited 2. History of Psychiatry: Provides a to 250 words (including 3 historical perspective on a topic 5. Original Research: Reports of references) and three authors. relevant to psychiatry. Limited to novel observations and research. Comments on articles published 500 words and five references. Limited to 1,250 words, 10 in The Residents’ Journal will references, and two figures. This be considered for publication 3. Treatment in Psychiatry: This article type should also include a if received within 1 month of article type begins with a brief, table of Key Points/Clinical Pearls publication of the original article. common clinical vignette and with 3–4 teaching points. involves a description of the 9. Book Review: Limited to 500 evaluation and management of 6. Review Article: A clinically words and 3 references. a clinical scenario that house relevant review focused on officers frequently encounter. educating the resident physician. Abstracts: Articles should not This article type should also Limited to 1,500 words, 20 include an abstract. include 2-4 multiple choice references, and one figure. This

Upcoming Themes

Please note that we will consider articles outside of the theme.

Psychiatry and the Humanities Integrated Care/ Race/Ethnicity and Psychiatry If you have a submission related to Mental Health Care Delivery If you have a submission related to this this theme, contact the Section Editor If you have a submission related to theme, contact the Section Editors Vivek Datta, M.D. this theme, contact the Section Editor Jacqueline Landess, M.D., J.D. ([email protected]) Connie Lee, M.D. (jacqueline.landess@ ([email protected]) ucdenver.edu) and Aparna Atluru, M.D. ([email protected])

*If you are interested in serving as a Guest Section Editor for the Residents’ Journal, please send your CV, and include your ideas for topics, to Rajiv Radhakrishnan, M.B.B.S., M.D., Editor-in-Chief ([email protected]).

The American Journal of Psychiatry Residents’ Journal 20