• Fundamentals
    • 1

      Laboratory Testing in Psychiatry

      By Royce P Gray, MD; Alexander W Thompson, MD, MBA, MPH
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      Laboratory Testing in Psychiatry

      • ROYCE P GRAY, MDThird-year psychiatry resident, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA
      • ALEXANDER W THOMPSON, MD, MBA, MPHClinical associate professor, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA.

      We review common laboratory testing encountered in psychiatric practice. It seems likely that in areas where the most evidence exists driving laboratory testing (e.g., metabolic monitoring for people on atypical antipsychotics), testing still is not universally done, and we often do not adequately address the results. However, in areas where there is little evidence supporting the practice (extensive laboratory testing on people being admitted to a psychiatric hospitals), we order tests extensively. We cover common tests encountered in the use of antipsychotics, antidepressants, mood stabilizers, antiepileptic drugs, and lithium. We also discuss the role of thyroid, vitamin B12, and folate testing and the special circumstance of caring for those with eating disorders.

      Key words: agranulocytosis, antidepressant, antiepileptic drug, antipsychotic, blood dyscrasia, clozapine, eating disorders, metabolic monitoring, QT interval, urine drug screen 

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    • 2

      Epidemiology of Mental Disorders

      By Stephan Arndt, PhD; Carolyn Turvey, PhD, MS
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      Epidemiology of Mental Disorders

      • STEPHAN ARNDT, PHDDirector, Iowa Consortium for Substance Abuse Research and Evaluation, Professor, Department of Psychiatry, Carver College of Medicine, Professor, Department of Biostatistics, College of Public Health, The University of Iowa, Iowa City, IA
      • CAROLYN TURVEY, PHD, MSProfessor, Department of Psychiatry, Carver College of Medicine, The University of Iowa, Iowa City IA

      This review describes the contribution of psychiatric epidemiology to our understanding of the distribution and determinants of psychiatric disorders. First, it describes basic concepts within epidemiology, such as prevalence, incidence, case definition, bias, and confounding, and their specific meaning within psychiatric research. The two basic study designs in epidemiology, cohort and case-control, are then reviewed. This discussion includes a tutorial on how to calculate key measures of association: risk ratio and odds ratio. Major community-based studies in psychiatric epidemiology are then reviewed, focusing on the Epidemiologic Catchment Area Study, the National Comorbidity Study and the National Comorbidity Study Replication, the National Survey of American Life, the National Latino and Asian American Study of Mental Health, and the National Epidemiologic Survey on Alcohol and Related Conditions. The review concludes with a discussion of pharmacoepidemiology and how it is critical to our understanding of the full impact of psychiatric medications postmarketing. In the future, epidemiology will be revolutionized with “big data” collection in both institutional and community settings. Nonetheless, the basic concepts presented in this review will continue to be relevant and critical to drawing sound, evidence-based conclusions about the true nature, correlates, and causes of psychiatric disorders.  

      This review contains 6 tables, and 63 references.

      Key words: case-control study, cohort study, community-based studies, measures of association, pharmacoepidemiology, psychiatric epidemiology

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    • 3

      The Psychiatric Interview and Mental Status Examination

      By Donald W. Black, MD
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      The Psychiatric Interview and Mental Status Examination

      • DONALD W. BLACK, MD

      The interview and mental status examination are integral to the comprehensive patient assessment and typically follow a standard approach that most medical students and residents learn. The psychiatrist should adjust his or her interview style and information-gathering approach to suit the patient and the situation. For example, inpatients are typically more symptomatic than outpatients, may be in the hospital on an involuntary basis, and may be too ill to participate in even the briefest interview. Note taking is an essential task but should not interfere with patient rapport. The interview should be organized in a systematic fashion that, although covering all essential elements, is relatively stereotyped so that it allows the psychiatrist to commit the format to memory that, once learned, can be varied. The psychiatrist should start by documenting the patient’s identifying characteristics (age, gender, marital status) and then proceed to the chief complaint, history of the present illness, past medical history, family and social history, use of drugs and alcohol, medications, and previous treatments. A formal mental status includes assessment of the patient’s appearance, attitude, and behavior; orientation and sensorium; mood and affect; psychomotor activity; thought process, speech, and thought content; memory and cognition (including attention and abstraction); and judgment and insight. With the data collected, the psychiatrist will construct an accurate history of the symptoms that will serve as the basis for developing a differential diagnosis, followed by the development of a comprehensive treatment plan.

      This review contains 1 figure, 3 tables, and 12 references.

      Key words: assessment, differential diagnosis, interviewing, mental status examination, treatment plan

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    • 4

      Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

      By Sonali P. Desai, MD, MPH; Allen Kachalia, MD, JD
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      Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

      • SONALI P. DESAI, MD, MPHAmbulatory Director, Patient Safety, Center for Clinical Excellence, Associate Director of Quality, Department of Medicine, Division of Rheumatology, Brigham and Women's Hospital, Boston, MA
      • ALLEN KACHALIA, MD, JDAssociate Chief Quality Officer, Co-Director, Center for Clinical Excellence, Brigham and Women's Hospital, Boston, MA

      Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This chapter contains 56 references.

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    • 5

      Classification in Psychiatry

      By Donald W. Black, MD
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      Classification in Psychiatry

      • DONALD W. BLACK, MD

      Classification in psychiatry has ancient roots but mainly took form in the 19th and 20th centuries. European and American psychiatrists brought to the fore careful observation and description of clinical course. Formal attempts to classify patients took root after World War II based on the exigencies of the time. The DSM-I was published in 1952 and summarized all the diagnoses in psychiatry. Diagnostic criteria were introduced in the DSM-III in 1980 to introduce reliability to the diagnostic process, and a multiaxial system was introduced to aid in the comprehensive assessment of patients, later dropped in the DSM-5. Dimensional measures were introduced to aid with patient assessment, although many categories were reformulated based on research findings. In the DSM-5, the diagnoses are listed in order of clinical importance. Residual categories exist for those who do not meet the criteria for a more specific disorder. Although the DSM-5 has been criticized, criteria-based diagnoses will persist until a system can be created based on etiology. 

      This review contains 2 tables, and 23 references.

      Key words: classification in psychiatry, diagnostic criteria, DSM-5, Feighner criteria, International Classification of Diseases, Kraepelin

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    • 6

      Clinical Trial Design and Statistics

      By Julie Ann Sosa, MA, MD, FACS
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      Clinical Trial Design and Statistics

      • JULIE ANN SOSA, MA, MD, FACSAssociate Professor of Surgery, Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT

      A clinical trial is a planned experiment designed to prospectively measure the efficacy or effectiveness of an intervention by comparing outcomes in a group of subjects treated with the test intervention with those observed in one or more comparable group(s) of subjects receiving another intervention.  Historically, the gold standard for a clinical trial has been a prospective, randomized, double-blind study, but it is sometimes impractical or unethical to conduct such in clinical medicine and surgery. Conventional outcomes have traditionally been clinical end points; with the rise of new technologies, however, they are increasingly being supplemented and/or replaced by surrogate end points, such as serum biomarkers. Because patients are involved, safety considerations and ethical principles must be incorporated into all phases of clinical trial design, conduct, data analysis, and presentation. This review covers the history of clinical trials, clinical trial phases, ethical issues, implementing the study, basic biostatistics for data analysis, and other resources. Figures show drug development and clinical trial process, and type I and II error. Tables list Food and Drug Administration new drug application types, and types of missing data in clinical trials.

      This review contains 2 highly rendered figures, 2 tables, and 38 references

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    • 7

      Collaborative Care Models in Psychiatry

      By Danielle M. Gainer, MD; Karley B. Fischer, BS; Parvaneh K. Nouri, MPH
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      Collaborative Care Models in Psychiatry

      • DANIELLE M. GAINER, MDAssistant Professor, Department of Psychiatry, Wright State University Boonshoft School of Medicine, Dayton, OH
      • KARLEY B. FISCHER, BSWright State University, Dayton, OH
      • PARVANEH K. NOURI, MPHWright State University Boonshoft School of Medicine, Dayton, OH

      Integrated care models allow a team of providers to interact in a systematic manner, producing cost-effective and superior outcomes for patients. The collaborative care model (CCoM), one type of integrated care, has emerged as one approach with over 80 randomized controlled trials to support its efficacy. In this model, a behavioral health provider offers evidence-based, brief interventions but also serves as a liaison between the patient, medical providers, and the psychiatric consultant. The team also monitors outcomes through a registry and provides a stepped care approach to adjust interventions collaboratively, as needed. If the barriers to integrated care implementation are surmounted, psychiatrists working as consultants in this model can provide care in an efficient and sustainable manner.

      This review contains 5 figures, 5 tables, and 48 references.

      Key Words: barriers to implementation, behavioral health provider, collaborative care, cost-effective, integrated care, psychiatric consultant, cost-effective, registry, stepped care

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    • 8

      Mood Disorders

      By Hasan A Baloch, MD; Jair C. Soares, MD
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      Mood Disorders

      • HASAN A BALOCH, MDAssistant Professor, Department of Psychiatry, Medical Director, Pediatric Bipolar Program, CERT-BD, UNC School of Medicine, Chapel Hill, NC
      • JAIR C. SOARES, MDDepartment of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX

      Affective disorders are among the most common disorders in psychiatry. They are generally classified according to the persistence and extent of symptoms and by the polarity of these symptoms. The two poles of the affective spectrum are mania and depression. Bipolar disorder is characterized by the presence of the mania or hypomania and often depression. Unipolar depression is defined by depression in the absence of a lifetime history of mania or hypomania. These differences are not merely categorical but have important implications for the prognosis and treatment of these conditions. Bipolar disorder, for example, is better treated using mood-stabilizing medication, whereas unipolar depression responds optimally to antidepressant medications. In addition, prognostically, unipolar depression may sometimes be limited to one episode in a lifetime, whereas bipolar disorder is typically a lifelong condition. The course of both conditions, however, is often chronic, and frequently patients can present with unipolar depression only to later develop manic symptoms. A thorough understanding of both conditions is therefore required to treat patients presenting with affective symptomatology. This chapter discusses the epidemiology, etiology and genetics, pathogenesis, diagnosis, and treatment of unipolar depression and bipolar disorder. Figures illustrate gray matter differences with lithium use and the bipolar spectrum. Tables list the pharmacokinetics of commonly used antidepressants and medications commonly used in the treatment of bipolar disorder.

      This review contains 2 figures, 2 tables, and 136 references.

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    • 9

      Male Sexual Dysfunction

      By Michael Eisenberg, MD; Kathleen Hwang, MD
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      Male Sexual Dysfunction

      • MICHAEL EISENBERG, MDDirector, Male Reproductive Medicine and Surgery, Assistant Professor, Departments of Urology and Obstetrics & Gynecology, Stanford University, Stanford, California
      • KATHLEEN HWANG, MDDepartment of Urology, Brown University, Providence, Rhode Island

      Normal male sexual function requires complex interactions among psychological, neurologic, hormonal, and vascular systems. Under the influence of proper stimulation, the acquisition and maintenance of a penile erection occur. Male sexual dysfunction includes erectile dysfunction (ED), impaired libido, and abnormal ejaculation, which occur due to aberrations in normal male sexual response. Estimates suggest a prevalence of approximately 10 to 20% in the adult male population. Thus, sexual dysfunction is a common problem in this country. This chapter focuses on several key, common components of male sexual dysfunction: namely, ED, premature ejaculation (PE), and Peyronie disease (PD). Figures include management algorithms, a graph depicting distribution of intravaginal ejaculation latency time values in a random cohort of men, and a Sexual Health Inventory for Men (SHIM). Tables list medications associated with ED, oral therapies for the treatment of PD, intralesional therapies for PD, indications for surgical correction of PD, recommended questions to establish the diagnosis of PE, treatment options for PE, and causes of delayed ejaculation, anejaculation, and anorgasmia.
      This chapter contains 5 highly rendered figures, 8 tables, 116 references, 1 teaching slide set, and 5 MCQs.

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  • Psychotherapy
    • 1

      Overview of Psychotherapy in Psychiatry

      By Allison Cowan, MD; Randon Welton, MD
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      Overview of Psychotherapy in Psychiatry

      • ALLISON COWAN, MDAssistant Professor, Department of Psychiatry Wright State University, Dayton, OH
      • RANDON WELTON, MD Associate Professor, Director, Residency Training, Department of Psychiatry Wright State University, Dayton, OH

      Psychotherapy continues to be an integral part of psychiatric practice. The rich, interesting history of psychotherapy in medicine and psychiatry set the background to current practice. Psychoeducation provides patients with necessary information and forms the basic building block for all other psychotherapies. Supportive therapy, cognitive-behavioral therapy, and psychoanalytic/psychodynamic psychotherapies constitute the core of the therapeutic styles, but dialectical behavioral therapy, eye movement desensitization and reprocessing, interpersonal psychotherapy, motivational interviewing, hypnosis, and group psychotherapy are also practiced in current psychiatry. Key therapeutic tenets from each of these disciplines are incorporated into the medical practice of psychiatry. 

      This review contains 5 figures, 4 tables, and 63 references.

      Key words: cognitive-behavioral therapy, current psychiatric practices, dialectical behavioral therapy, psychiatrist as therapist, psychoanalytic psychotherapy, psychodynamic psychotherapy, psychoeducation, psychotherapy, supportive psychotherapy 

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    • 2

      Supportive Psychotherapy

      By Erin Crocker, MD
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      Supportive Psychotherapy

      • ERIN CROCKER, MDUniversity of Iowa Hospitals and Clinics, Iowa City, IA

      Supportive psychotherapy (SPT) is a form of psychological treatment in which a care provider collaborates with a patient to help maximize his or her level of psychosocial functioning and adaptation to his or her current situation. Unfortunately, SPT is often limited to use by psychiatrists within psychiatric settings, even though patients with medical illness also benefit significantly from these interventions. There is arguably a need to incorporate training in brief SPT techniques into general medical education as learning to provide support to patients and help them function to the best of their ability during difficult times is an important part of the role that all physicians should be prepared to provide for their patients.

      This review contains 4 figures, 3 tables, and 45 references.

      Key words: alliance, boundaries, coping, empathy, frame, psychotherapy, relationships, supportive

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    • 3

      Interpersonal Psychotherapy

      By Ceth Ashen, PhD; Ann Back-Price, MSN, APRN, IAAP; Olga Belik-Tuller, PhD; Anna Brandon, Ph.D,, MSCS, ABPP; Scott Fairhurst, PhD; Aimee Grause, PCNS; Jessica Schultz, PhD; Scott Stuart, MD; Kaela Stuart-Parrigon, M.A.
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      Interpersonal Psychotherapy

      • CETH ASHEN, PHDC. Ashen Psychological Consulting, Los Angeles, CA
      • ANN BACK-PRICE, MSN, APRN, IAAPClinical Assistant Professor, Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI
      • OLGA BELIK-TULLER, PHDDirector of Psychology Training, Providence St. John’s Health Center-CFDC, Assistant Clinical Professor, Department of Psychology, University of California Los Angeles, Santa Monica, CA
      • ANNA BRANDON, PH.D,, MSCS, ABPPAdjunct Assistant Professor, University of Iowa, Dallas, TX
      • SCOTT FAIRHURST, PHDProgram Director, Pacific Clinics, Los Angeles, CA
      • AIMEE GRAUSE, PCNSPsychiatric Clinical Nurse Specialist, Brown University, Providence, RI
      • JESSICA SCHULTZ, PHDAssistant Professor of Psychology, Augustana College, Rock Island, IL
      • SCOTT STUART, MDProfessor of Psychiatry and Psychology, University of Iowa
      • KAELA STUART-PARRIGON, M.A.Department of Psychology, Kent State University, Kent, OH

      Interpersonal psychotherapy (IPT) is an empirically validated treatment for affective, anxiety, and eating disorders. IPT rests on attachment theory and posits that individuals become distressed when they have interpersonal problems, conceptualized in IPT as transitions, interpersonal disputes, or grief and loss issues. IPT is short term, with a typical dosing range of six to 20 sessions followed by maintenance treatment to reduce the risk of relapse. Dissemination of IPT has greatly increased over the last decade, with several large-scale efforts in public health settings in the United States and abroad. We review the basics of IPT for depression and anxiety. We also describe its application to groups and adolescents. Recently developed clinical tools that have enhanced the delivery of IPT and have increased fidelity are described. Opportunities for training in IPT are also reviewed.

      This review contains 10 figures, 1 table, and 71 references.

      Key words: adolescents, anxiety, depression, grief and loss, group therapy, interpersonal inventory, interpersonal psychotherapy, interpersonal summary, maintenance psychotherapy, posttraumatic stress disorder

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    • 4

      Cognitive-behavioural Therapy

      By Hassan Majeed, MD; Charles Stanfa, MD ; Donna Sudak, MD
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      Cognitive-behavioural Therapy

      • HASSAN MAJEED, MDAttending Psychiatrist, Department of Psychiatry, Natchaug Hospital, Mansfield Center, CT
      • CHARLES STANFA, MD Community Psychiatry Fellow, University of Pennsylvania
      • DONNA SUDAK, MDProfessor, Department of Psychiatry, Drexel University College of Medicine, Philadelphia, PA

      Cognitive-behavioral therapy (CBT) is an empirically supported psychotherapy shown to be effective and durable for the treatment of a variety of psychiatric illnesses. It is problem focused and conceptually driven. Cognitive restructuring, behavioral activation, exposure, and developing good action plans for out-of-session practice are tools that benefit patients for a lifetime. The purpose of this review is to provide an overview of the literature that supports the use of CBT, introduce the key elements of the therapeutic approach, and illustrate them with case examples. The structure of the session and the CBT approach to the therapeutic alliance are highlighted in the text. The review is enhanced by tables and figures that summarize the features of the therapeutic approach and by worksheets that may be used with patients.

      This review contains 11 tables, and 63 references.

      Key words: cognitive-behavioral therapy, cognitive restructuring, collaboration, behavioral activation, exposure

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    • 5

      Psychodynamic Psychotherapy

      By Adam Brenner, MD; Michael Laney, MD
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      Psychodynamic Psychotherapy

      • ADAM BRENNER, MDProfessor of Psychiatry, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX
      • MICHAEL LANEY, MDResident, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX

      Psychodynamic psychotherapy is an evidence-based treatment that historically had its origins in psychoanalysis. It is based on an appreciation that the past continues to interfere with the present through the persisting existence of relationship templates generated during development. These developmental experiences include ideas, wishes, and fears that are too disturbing for the patient to allow awareness but continue to exert their effects outside of conscious awareness. The psychodynamic therapist fosters an experience that allows for unconscious material to become more available, through free association, examination of resistance, and exploration of transference. As therapy progresses, the growth of the patient’s insight and the resumption of stalled developmental opportunities result in symptomatic improvement and an enhanced quality of life. Psychodynamic psychotherapy has both a long history and an expanding literature that will both reward further study and assist in the care and understanding of those sufferers who are seen by clinicians every day.

      This review contains 5 tables, and 60 references.

      Key words: attachment, autonomy, free association, identity, resistance, separation, therapeutic attitude, transference, triangular relationships, unconscious motivation

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    • 6

      Motivational Interviewing

      By Maurice Bulls, MEd; Sylvie Naar, PhD
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      Motivational Interviewing

      • MAURICE BULLS, MEDMotivational Interviewing Trainer, Behavior Change Consulting, Ferndale, MI
      • SYLVIE NAAR, PHDDirector of Behavioral Sciences, Department of Family Medicine and Publice Health Sciences, Wayne State University, Detroit, MI

      Motivational interviewing (MI) has been established as an efficacious clinical approach for treating a range of emotional and behavioral concerns, both alone and in combination with other interventions. MI is a method of communication designed to increase intrinsic motivation and commitment to change. The MI method is consistent with self-determination theory that suggests that patient’s internalize motivation when he or she feels relatedness, competence, and autonomy support. MI is specified by an underlying perspective or spirit, a flow of processes, and a set of skills. MI spirit is defined by partnership, acceptance, compassion, and evocation. MI processes include engaging, focusing, evoking, planning, and maintaining. The primary MI skills are reflections, open questions, and providing information or advice in an MI style. This review presents an overview of these components with real-world examples. MI is grounded in research and highly applicable across many settings. The practitioner seeking to incorporate MI into practice will better facilitate behavior change and maximize human potential in diverse populations.

      This review contains 5 figures, 6 tables, and 55 references.

      Key words: behavior change adolescents, cognitive-behavioral therapy, medication adherence, mental health, motivational interviewing, obesity, self-determination theory, smoking, substance use

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    • 7

      Couple and Family Therapy

      By Jessica ChenFeng, PhD; Diane Gehart, Ph.D
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      Couple and Family Therapy

      • JESSICA CHENFENG, PHDAssistant Professor, California State University, Northridge
      • DIANE GEHART, PH.DProfessor, California State University, Northridge

      Evidence-based couple and family therapies have a robust and well-established evidence base as a cost-effective treatment for numerous conditions and are the treatment of choice for several childhood and adult mental health issues. This review provides a brief overview of systemic couple and family therapy principles and then reviews the evidence base for using these methods with specific disorders. Family therapy treatments have been identified as a primary intervention for several childhood and adolescent disorders, including conduct, alcohol and substance use, attention-deficit, autism, psychotic, mood, anxiety, and eating disorders, as well as certain physical disorders, including diabetes, enuresis, and asthma. For adults, the current evidence base supports couples therapy for major depressive disorder with couple distress, alcohol and substance use disorders, anxiety disorders, distressed couples, and interpersonal violence with certain batterers. In addition, couple and family therapy is indicated for certain adult chronic health conditions, including stroke, traumatic brain injury, spinal cord injury, cardiovascular diseases, cancer, dementia, and diabetes. The review concludes with a discussion of effective referral for and training in evidence-based family therapy approaches.

      This review contains 6 figures, 5 tables, and 53 references.

      Key words: ADD/ADHD, adolescent, childhood trauma, conduct disorder, couples therapy, depression, eating disorders, family therapy,  marital therapy, mood disorder

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    • 8

      Group Psychotherapy: Development of a Successful Group

      By Wayne A. Bowers, PhD
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      Group Psychotherapy: Development of a Successful Group

      • WAYNE A. BOWERS, PHDClinical Professor, Department of Psychiatry, University of Iowa, Iowa City, IA 52242, United States

      Group psychotherapy is a complex and integrative task that is designed to assist patients to better understand their problems and focus on creating change. Effective group therapy is characterized by the concept that the group functions as the agent of change. Primary among those concepts are curative factors that are used to intentionally facilitate group development and member change. In addition, there is an establishment of group norms that help leader and group members to function efficiently. A fully functioning group develops group cohesion, establishes goals that fit each individual member and the group as a whole, and effectively screens group members to enhance therapeutic productivity.

      This review contains 2 tables and 24 references.

      Key Words: curative factors, instillation of hope, development of socializing techniques, stages of group development, cohesiveness, norms in group therapy, group goals, screening group members

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    • 9

      Group Psychotherapy: Group Therapist Leadership Skills

      By Wayne A. Bowers, PhD
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      Group Psychotherapy: Group Therapist Leadership Skills

      • WAYNE A. BOWERS, PHDClinical Professor, Department of Psychiatry, University of Iowa, Iowa City, IA 52242, United States

      Conducting group psychotherapy is a complex yet fascinating endeavor. To be effective, a group therapist must be intentional in their approach and implementation of interventions. Some basic skills that must be mastered include confrontation of group members and behaviors, emotional stimulation of the group and individual members, and the development and enhancement of group cohesiveness. Practical skills involve the overall structure of the group, providing feedback to members and the group as a whole, modeling effective communication and interpersonal behavior, and self-disclosure in nonjudgmental manner. A group therapist also engages members to be open about themselves and with others and displays effective interpersonal communication by working with a cotherapist to model both interpersonal bonding as well as effective conflict resolution that can be generalized to the outside world.

      This review contains 1 table and 16 references.

      Key Words: cotherapy, emotional expression, executive function, feedback, group leader skills and values, male and female co-therapists, self-disclosure, skills and interventions

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  • Addiction
    • 1

      Neurobiology of Addiction

      By Alex Gogliettino, Program in Neuroscience; Marc Potenza, MD, PhD; Sarah Yip, MSc, PhD; Yasmin Zakiniaeiz, MSc; Zu Wei Zhai, PhD
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      Neurobiology of Addiction

      • ALEX GOGLIETTINO, PROGRAM IN NEUROSCIENCEDepartment of Psychology, Bates College; Department of Psychiatry, Yale University School of Medicine
      • MARC POTENZA, MD, PHDDepartments of Psychiatry and Neuroscience, Child Study Center and the National Center on Addiction and Substance Abuse, Yale University School of Medicine; and the Connecticut Mental Health Center
      • SARAH YIP, MSC, PHDDepartment of Psychiatry and the National Center on Addiction and Substance Abuse, Yale University School of Medicine
      • YASMIN ZAKINIAEIZ, MSCInterdepartmental Neuroscience Program, Yale University School of Medicine
      • ZU WEI ZHAI, PHDDepartment of Psychiatry, Yale University School of Medicine

      Addiction is a disorder characterized by poorly controlled substance use despite negative health and social consequences. Additionally, the only behavioral addiction recognized in the main text of the DSM-5, gambling disorder, presents similarly to many substance addictions with respect to the underlying neurobiology and poorly controlled gambling despite negative consequences (e.g., financial, familial problems). This review first provides an overview of the diagnostic criteria for addictive disorders—both substance and nonsubstance—and subsequently reviews the extant literature examining epidemiology, including global prevalence and co-occurring disorders, as well as differences in addicted and nonaddicted groups with respect to genotype, brain function, and neurochemical systems. Last, the prognosis, quality of life, and current treatment strategies for addictions are discussed. The review also includes tables and figures to supplement the text, summarizes important points, and provides visual representations of tasks used to study cognitive aspects of addictions and addiction pathophysiology.

      This review contains 5 figures, 5 tables, and 80 references.

      Key words: brain function, cognitive function, epidemiology, functional magnetic resonance imaging, genetics, neurochemistry, positron emission tomography, treatment

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    • 2

      Kleptomania, Pyromania, and Disruptive Disorders

      By Eric W Leppink, BA; Jon E Grant, JD, MD, MPH
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      Kleptomania, Pyromania, and Disruptive Disorders

      • ERIC W LEPPINK, BA, Research Coordinator, Department of Psychiatry & Behavioral Neuroscience, University of Chicago Hospital, Chicago, IL
      • JON E GRANT, JD, MD, MPHProfessor, Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, Chicago, IL

      Chronic disruptive and impulsive behaviors, such as kleptomania, pyromania, and intermittent explosive disorder, are significant concerns for clinicians treating psychiatric disorders due to their persistence and potential legal ramifications. To date, only a few studies have assessed treatment options for pyromania, oppositional defiant disorder, intermittent explosive disorder, kleptomania, disruptive mood dysregulation disorder, and conduct disorder. This review discusses the clinical presentation of these disorders and the available literature on their treatment, focusing primarily on randomized controlled studies. Due to the paucity of available clinical studies for these disorders, however, case studies and open trials are mentioned for reference. Summaries of supported pharmaceutical and psychological interventions are provided for each disorder.

      Key words: adolescents, aggression, crime, fire setting, impulsivity, stealing, theft, treatment 

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    • 3

      Feeding and Eating Disorders

      By Patricia Westmoreland, MD; Phillip S Mehler, MD
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      Feeding and Eating Disorders

      • PATRICIA WESTMORELAND, MDAttending Psychiatrist, Eating Recovery Center, Denver, CO Consultant, ACUTE, Denver Health, Denver CO Adjunct Assistant Professor, University of Colorado, Denver, CO Forensic Psychiatrist, Denver, CO
      • PHILLIP S MEHLER, MD

      Feeding and eating disorders are defined by persistent disturbance of eating (or behaviors related to eating) with subsequent changes in consumption or absorption of nutrition that are detrimental to physical health and social functioning. The following eating disorders are described in the DSM-5: anorexia nervosa, bulimia nervosa, binge eating disorder, pica, rumination disorder, avoidant/restrictive food intake disorder (ARFID), other specified feeding or eating disorder (OSFED), and unspecified feeding or eating disorder (USFED). ARFID, OSFED, USFED, rumination disorder, and binge eating disorder are new additions to the manual and are first described in the DSM-5. The DSM-5 also provides severity specifiers—mild, moderate, severe, and extreme—for the diagnoses of bulimia nervosa and anorexia nervosa. This review describes the eating disorders enumerated in the DSM-5 and provides information regarding their genesis and course.

      This review contains 8 tables and 79 references

      Key words: avoidant/restrictive eating disorder, binge eating disorder, DSM-5, eating disorder, other specified feeding or eating disorder, pharmacotherapy, pica rumination, psychotherapy, unspecified feeding or eating disorder

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    • 4

      Clinical Management of Feeding and Eating Disorders

      By Anne Marie O’Melia , MD; Patricia Westmoreland, MD
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      Clinical Management of Feeding and Eating Disorders

      • ANNE MARIE O’MELIA , MD
      • PATRICIA WESTMORELAND, MDAttending Psychiatrist, Eating Recovery Center, Denver, CO Consultant, ACUTE, Denver Health, Denver CO Adjunct Assistant Professor, University of Colorado, Denver, CO Forensic Psychiatrist, Denver, CO

      Eating disorders are diverse in etiology and presentation and are best treated by a multidisciplinary treatment team (physicians, nurses, dietitians, and psychotherapists). Effective treatment includes combinations of behavioral management, psychotherapy, and psychiatric medication. Pica and rumination disorder are typically treated with behavioral management. Treatment of avoidant/restrictive food intake disorder and restricting or binge/purge anorexia nervosa usually requires nutritional and medical management before patients are able to benefit from psychotherapy or psychiatric medication management. There are currently only two medications FDA approved for treatment in eating disorders. Fluoxetine is FDA approved for the treatment of bulimia. Lisdexamfetamine was recently approved for the treatment of binge eating disorder. Novel therapies, such as deep brain stimulation, repetitive transcranial magnetic stimulation, and transcranial direct current stimulation, are being studied for the treatment of severe and enduring forms of anorexia nervosa.


      This review contains 5 tables and 58 references

      Key words: behavioral management, diversity, FDA approval, fluoxetine, lisdexamfetamine, multidisciplinary team, novel therapies, psychotherapy, psychotropics

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    • 5

      Gambling Disorder and Related Behavioural Addictions

      By Jon E Grant, JD, MD, MPH; Eric W Leppink, BA
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      Gambling Disorder and Related Behavioural Addictions

      • JON E GRANT, JD, MD, MPH
      • ERIC W LEPPINK, BA, Research Coordinator, Department of Psychiatry & Behavioral Neuroscience, University of Chicago Hospital, Chicago, IL

      Behavioral addictions are defined as behaviors characterized by the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others. These disorders share many similarities with substance addictions but may have unique treatment considerations. This category of disorders includes many separate behaviors, but some of the most common are gambling disorder, Internet addiction, compulsive buying, and compulsive sexual behavior. Although research remains limited on the neurobiology and treatment of these disorders, some limited evidence to date can help guide initial treatment recommendations. Additional research will be necessary to clarify the optimal treatment approach for these disorders, however. This review provides a general discussion of available research related to these four disorders, including neurobiological, epidemiologic, and treatment considerations.

      Key words: behavioral addiction, gambling, Internet, neurobiology, phenomenology, sex, shopping, treatment

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    • 6

      Overview of Substance Use Disorders

      By Alexander W Thompson, MD, MBA, MPH; Timothy Ando, MD; Emily Morse, DO
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      Overview of Substance Use Disorders

      • ALEXANDER W THOMPSON, MD, MBA, MPHClinical associate professor, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA.
      • TIMOTHY ANDO, MDPsychiatry Resident, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA
      • EMILY MORSE, DOChief Resident in Psychiatry, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA

      Substance use disorders are a major source of morbidity and mortality, contributing to a significant proportion of deaths in the United States and worldwide each year. A substantial rise in deaths related to drug overdoses in recent decades has drawn increasing public attention to this issue. However, the majority of individuals struggling with substance use disorders remain untreated. The financial costs and health burden are substantial. This review provides a broad overview of substance-related and addictive disorders. The evolution of the classification system is described, and the diagnostic criteria for the various substance use disorders are reviewed. Epidemiology and etiologic considerations, including neurobiological pathways, genetics, environmental influences, and dimensional risk factors, are examined. Finally, individual substances and their related disorders are reviewed, including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics, stimulants, tobacco, and other or unknown substances. Intoxication and withdrawal syndromes are described where applicable, and clinical management concepts are discussed. 

      This review contains 6 figures, 5 tables, and 71 references.

      Key words: abuse, addiction, alcohol, caffeine, cannabis, dependence, diagnosis, DSM-5, epidemiology, hallucinogen, hypnotic, inhalant, intoxication, methamphetamine, nicotine, opioid, sedative, stimulant, substance use disorders, tobacco, tolerance, withdrawal

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    • 7

      Alcohol Use Disorders and Clinical Management

      By Alexander Thompson, MD, MBA, MPH; Daniel Rohlf, MD; Joseph Cocozzella, MD
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      Alcohol Use Disorders and Clinical Management

      • ALEXANDER THOMPSON, MD, MBA, MPH
      • DANIEL ROHLF, MD
      • JOSEPH COCOZZELLA, MD

      Alcohol use disorder (AUD) is the current DSM-5 designation for problematic and pathologic alcohol use. AUDs have a high prevalence in the United States and are commonly treated in psychiatric practice. They are associated with a wide variety of medical and psychiatric comorbidities. Effective treatment depends on tailoring treatment setting, behavioral psychotherapies, and psychotropic interventions to the individual patients. Three medications are Food and Drug Administration approved for the treatment of AUDs: naltrexone, acamprosate, and disulfiram. Several other medications (anticonvulsants and baclofen) have been studied, but their role in treating AUDs is uncertain. Naltrexone and/or acamprosate should be considered first-line medications for patients without contraindications. Disulfiram can be considered a second-line or first-line treatment in patients with appropriate support or those who prefer it. All patients who are diagnosed with AUDs should be referred to mutual support groups (i.e., Alcoholics Anonymous).

      This review contains 3 figures, 5 tables, and 35 references.

      Key words: acamprosate, Alcoholics Anonymous, AUDIT, brief interventions, disulfiram, gabapentin, naltrexone, topiramate, 12 step 

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    • 8

      Clinical Management of Drug Use Disorders

      By Alexander Thompson, MD, MBA, MPH; Timothy Ando, MD; James Jackson, MD
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      Clinical Management of Drug Use Disorders

      • ALEXANDER THOMPSON, MD, MBA, MPH
      • TIMOTHY ANDO, MDPsychiatry Resident, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA
      • JAMES JACKSON, MD

      Despite mammoth efforts toward the treatment and prevention of substance use disorders in the United States over the past 30 years, they remain a significant public health concern and an all-too-common comorbidity among people with other forms of mental illness. Continued research into genetics, pharmacotherapies, psychotherapies, and epidemiology for substance use disorders results in huge amounts of new information for clinicians to assimilate each year. This review summarizes current diagnostic and categorical standards in substance use disorders, epidemiology, genetic and physiologic factors in addiction for each class, clinically relevant laboratory testing, evidence-based treatments, and prognostic considerations in substance use disorders. Specifically, sections cover cannabinoids, hallucinogens, opioids, sedatives, and stimulants.

      Key words: benzodiazepines, cannabis, drug dependence, hallucinogens, MDMA, substance abuse, substance dependence, synthetic cannabinoids 

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    • 9

      Alcohol and Drug Withdrawal Syndromes and Their Clinical Management

      By Alexander Thompson, MD, MBA, MPH; Andrea Weber, MD, MME
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      Alcohol and Drug Withdrawal Syndromes and Their Clinical Management

      • ALEXANDER THOMPSON, MD, MBA, MPH
      • ANDREA WEBER, MD, MMEFifth-Year Medicine-Psychiatry Resident, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA

      Withdrawal syndromes are clusters of signs and symptoms that occur with cessation or decrease in use of a substance. All substance withdrawal syndromes are classified and diagnosed based on criteria published in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). All withdrawal syndromes range in their ability to cause significant medical and/or psychiatric consequences. Alcohol withdrawal remains a medically serious syndrome that can occur within hours to days of decreased use and result in hallucinations, delirium, seizures, and death. Despite increasing research into the type, frequency, dose, and route of administration, benzodiazepines remain the first-line treatment in preventing alcohol withdrawal complications. Although typically not medically severe, opioid withdrawal is often associated with relapse even after successful detoxification. Opioid-agonist therapy, including methadone and buprenorphine, remains the treatment of choice for both opioid withdrawal and relapse prevention. Stimulant withdrawal from cocaine or amphetamines can cause significant psychiatric symptoms within minutes to hours of cessation and may require psychiatric hospitalization for suicidal ideation or attempts. There are no current medications approved by the Food and Drug Administration (FDA) for treatment of stimulant withdrawal. Cannabis withdrawal, although not medically dangerous, has recently been adopted as a discrete syndrome in the DSM-5. Its severity correlates significantly with the amount of cannabis used, functional impairment, and ability to achieve sustained remission. There are no current medications approved by the FDA for treatment of cannabis withdrawal.

      This review contains 6 figures, 12 tables, and 100 references.

      Key words: alcohol, amphetamine, benzodiazepines, buprenorphine, cannabis, clonidine, cocaine, dexmedetomidine, methadone, opioid, phenobarbital, stimulant, withdrawal 

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    • 10

      Treatment of Unhealthy Alcohol Use

      By Stephen R Holt, MD, MSc; David A Fiellin, MD
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      Treatment of Unhealthy Alcohol Use

      • STEPHEN R HOLT, MD, MSCAssistant Professor of Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
      • DAVID A FIELLIN, MDProfessor of Medicine, Investigative Medicine and Public Health, Department of Medicine, Yale University School of Medicine, New Haven, CT

      Unhealthy alcohol use represents the fifth leading cause of morbidity and mortality globally, and the first leading cause among persons 18 to 45 years of age. Despite the global impact of unhealthy alcohol use, the adoption of evidence-based treatments has been sluggish. Behavioral strategies for lower level drinking include the brief motivational interview, designed to be within the scope of any healthcare provider, and more specialist-driven approaches for those with alcohol use disorder (AUD) such as cognitive behavioral therapy and motivational enhancement therapy. Benzodiazepines remain the mainstay treatment for inpatient alcohol withdrawal treatment, whereas other medications have similar efficacy in managing patients in the outpatient setting with milder forms of withdrawal. For maintenance treatment of AUD, four FDA-approved medications exist, with efficacy in treating AUD, as well as several non–FDA-approved medications that have been found to be effective in promoting abstinence and reducing drinking. The use of medication to treat many patients with AUD falls within the scope of primary care providers.

      This review contains 6 tables and 54 references.

      Key Words: addiction, alcohol, counseling, drinking, pharmacotherapy, primary care, psychotherapy, relapse, treatment

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    • 11

      Unhealthy Alcohol Use

      By Stephen R Holt, MD, MSc; Joseph H. Donroe, MD, MPH
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      Unhealthy Alcohol Use

      • STEPHEN R HOLT, MD, MSCAssistant Professor of Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
      • JOSEPH H. DONROE, MD, MPH Assistant Professor of Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT

      Unhealthy alcohol use refers to a spectrum of alcohol consumption ranging from at-risk drinking to alcohol use disorder. It is associated with both a high cost to society and to individuals. Globally, alcohol is a leading cause of death and disability, and despite the high prevalence of unhealthy alcohol use, diagnosis, and treatment of alcohol use disorder remains disproportionately low. Risk for unhealthy alcohol use and alcohol related harms is multifactorial and includes genetic factors, gender, age, socioeconomic status, cultural and societal norms, and policies regulating alcohol consumption among others. Excessive alcohol use is associated with a myriad of poor physical and mental health outcomes, and screening for unhealthy alcohol use is universally recommended and effective.

      This review contains 1 figures, 2 tables, and 76 references. 


      Key Words: addiction, alcohol, cancer, diagnosis, drinking, liver disease, screening, stigma, use disorder
      Important Advances

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  • Child Psychiatry
    • 1

      Attention-deficit/hyperactivity Disorder in Children and Adolescents

      By Sergio Delgado, MD
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      Attention-deficit/hyperactivity Disorder in Children and Adolescents

      • SERGIO DELGADO, MDCincinatti Children's Hospital

      Attention-deficit/hyperactivity disorder (ADHD) is the most common and thoroughly researched neuropsychiatric disorder affecting children and adolescents. The prevalence of ADHD ranges from 8 to 12% in school-age children, and 70% of these individuals continue to meet DSM-5 criteria for the disorder in adolescence. ADHD is more commonly diagnosed in boys compared with girls. ADHD is chronic, with prominent symptoms and impairment in family, social, and academic functioning. ADHD is often associated with comorbid disorders, including disruptive, mood, and anxiety disorders, and can increase the risk of developing substance use disorders. The diagnosis of ADHD requires a comprehensive clinical assessment, including a detailed history, clinical interview, and collateral information, and is clinically established by review of symptoms and impairment and having established a developmental history of the symptoms. The biological underpinning of the disorder is supported by genetic, neuroimaging, neurochemistry, and neuropsychological data. Treatment should attend to developmental milestones of the child and include family and individual psychosocial interventions. Psychosocial interventions in combination with medication are helpful for ADHD and comorbid problems. Pharmacotherapy, including psychostimulants, noradrenergic agents, alpha agonists, and antidepressants, plays a fundamental role in the treatment and management of ADHD.

      This review contains 2 figures, 9 tables, and 114 references.

      Key words: attention, attention-deficit/hyperactivity disorder, comorbidity, hyperactivity, impulsivity, learning, nonstimulants, psychosocial, psychostimulants, treatment

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    • 2

      Overview of Neurodevelopmental Disorders and Assessment of Children

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      Overview of Neurodevelopmental Disorders and Assessment of Children

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    • 3

      Autism Spectrum Disorders and Their Clinical Management

      By Ernest Pedapati, MD, MS, FAAP; Jacob Shaffer, BS, MD Candidate
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      Autism Spectrum Disorders and Their Clinical Management

      • ERNEST PEDAPATI, MD, MS, FAAPAssistant Professor, Divisions of Psychiatry and Neurology, Cincinnati Children’s Hospital Medical Center, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH
      • JACOB SHAFFER, BS, MD CANDIDATEBoonshoft School of Medicine, Wright State University, Dayton, OH

      Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder marked by impairments in social behavior and difficulties with repetitive and restrictive behaviors. In 2012, the prevalence of ASD in the United States was estimated to be one in 68 among children age 8 years. Although the etiology of ASD is poorly understood, many researchers have identified genetic, epigenetic, and environmental factors likely involved in the disorder. In approximately 10% of cases, a definitive association with a specific genetic defect can be identified. A diagnosis of ASD is best performed through an interdisciplinary assessment and is based on diagnostic criteria. The DSM-5 criteria on the clinical features of ASD fall into two core domains: impaired social communication and interaction and restricted, repetitive behaviors, interests, or activities. Today, although no definitive “cure” for ASD exists, state-of-the-art therapies and learning environments, along with medications, have resulted in reducing disease burden and quality of life for individuals affected by ASD.

      This review contains 3 figures, 2 tables, and 86 references.

      Key words: autism spectrum disorders, developmental disorders, language speech delay, social communication

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    • 4

      Oppositional Defiant Disorder and Its Clinical Management

      By Paul Croarkin, MD; Reem Shafi, MBBS
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      Oppositional Defiant Disorder and Its Clinical Management

      • PAUL CROARKIN, MD
      • REEM SHAFI, MBBSResident in Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic Depression Center, Rochester, MN

      Oppositional defiant disorder (ODD) is a psychiatric disorder classified in the DSM-5 among disruptive, impulse control, and conduct disorder. The core features of ODD include a pervasive and impairing pattern of anger, irritability, inflexibility, defiance, malevolence, and aggression. Symptoms of ODD typically present during preschool. ODD can be a harbinger of conduct disorder. Isolated, transient symptoms of ODD are normal during development. Mood disorders, attention-deficit/hyperactivity disorder, and neurodevelopmental disorders are important considerations in differential diagnosis. However, ODD frequently co-occurs with other psychiatric diagnoses. Complex interactions with temperamental emotional dysregulation, family stress, early life stress, inconsistent parenting, and genetic and physiologic factors likely underlie the risk, pathophysiology, and prognosis of ODD. Unfortunately, these interactions and the neurobiological underpinnings of ODD are still poorly characterized. Although first-line treatments for ODD involve behavioral and psychosocial interventions, a thoughtful consideration of pharmacotherapy for co-occurring disorders and severe symptoms is an important component of treatment planning. Herein we review the epidemiology, etiology, pathophysiology, diagnostic evaluation, and treatment planning of ODD. Recent applicable controversies such as dimensional conceptualization of psychiatric disorders and the potential intersection of ODD and disruptive mood dysregulation disorder are also summarized. 

      This review contains 5 figures, 4 tables, and 44 references.

      Key words: aggression, attention-deficit/hyperactivity disorder, conduct disorder, defiance, disruptive behaviors, disruptive mood dysregulation disorder, DSM-5,irritability, oppositional defiant disorder, parent management training

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    • 5

      Intellectual Disability

      By Kelly Vinquist, PhD; Jodi Tate, MD
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      Intellectual Disability

      • KELLY VINQUIST, PHDClinical Assistant Professor, Psychiatry, Co-Director, ID-MI program, Department of Psychiatry, University of Iowa Hospitals and Clinics
      • JODI TATE, MDClinical Professor, Psychiatry, Vice Chair of Clinical Services, Co-Director, ID-MI program, Department of Psychiatry, University of Iowa Hospitals and Clinics and

      Individuals with an intellectual disability are one of the most underserved populations in the United States. They have higher rates of medical and psychiatric comorbidity when compared to the general population and face considerable healthcare disparity. Challenging behavior such as physical or verbal aggression is the most common reason why this population interfaces with the mental healthcare system. Understanding and correctly diagnosing the underlying etiology of challenging behaviors requires comprehensive evaluations along with awareness of the key variables that contribute to the occurrence of these behaviors. The differential diagnosis of challenging behavior is wide and includes mental illness, medical illness, pain, side effects from medications, behavioral phenotype of underlying syndrome, behavioral/functional, deficit of skills, and/or developmentally appropriate behavior.

       This review contains 1 figure, 6 tables and 83 references

      Key words: behavioral phenotype, challenging behaviors, etiology, intellectual disability, mental retardation, mental illness, psychiatric disorders

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    • 6

      Conduct Disorder and Its Clinical Management

      By Drew Barzman, MD; Bianca Patel, BA
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      Conduct Disorder and Its Clinical Management

      • DREW BARZMAN, MDDirector of Child and Adolescent Forensic Psychiatry Service, Cincinnati Children’s Hospital
      • BIANCA PATEL, BAThe Netter School of Medicine at Quinnipiac University

      Conduct disorder (CD), a psychiatric condition that is prevalent in some child and adolescent populations, is defined by the DSM-5 as a repetitive and persistent pattern of behavior in which the rights of others and age-appropriate cultural norms are violated. DSM-5 subtypes include childhood-onset, adolescent-onset, and callous-unemotional presentations. The development of CD is affected by gender, age at onset, environmental factors, and genetic factors. Overall, it has been difficult to identify causative factors because there is such a diverse variety of factors and comorbidities involved, although studies to define specific genetic, physiologic, and neurologic links to CD are ongoing. Common comorbidities in CD include oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), major depressive disorder, bipolar disorder, dysthymia, and substance abuse. The most successful treatment involves a multisystemic approach involving medication, family therapy, educational therapy, and parenting skills. Overall, early prevention of CD through treatment is key because the prognosis is poor and can be associated with the development of more severe comorbidities.

      This review contains 3 tables, and 58 references.

      Key words: antisocial behavior behavioral issues, ADHD comorbidities, child mental disorders, conduct disorder

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  • Cognitive Disorders
    • 1

      Successful Aging

      By Dilip Jeste, MD; Jeanne Maglione, MD, PhD
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      Successful Aging

      • DILIP JESTE, MDSenior Associate Dean for Healthy Aging and Senior Care, Distinguished Professor of Psychiatry and Neurosciences, Director, Center for Healthy Aging, University of California, San Diego, San Diego, CA
      • JEANNE MAGLIONE, MD, PHDAssistant Clinical Professor of Psychiatry, University of California, San Diego, San Diego, CA

      The number of older adults in our society is increasing rapidly. Aging is complex and may occur at varying rates across multiple domains, including biological aging, cognitive aging, and emotional aging. Age-related medical conditions are now among the leading causes of morbidity and mortality among older adults, making healthy aging a major public health priority. Successful aging encompasses more than longevity, medical health, or freedom from disability. It can be viewed as a multidimensional construct including minimization of disability and medical illness combined with maximization of physical, cognitive, emotional, and social functioning. We review the current literature regarding successful aging. We also discuss strategies to improve the likelihood of successful aging and several key advances, such as definitions of successful aging in different populations, neuroplasticity of aging, wisdom as an empirical construct, the concept of a good (or successful) death, and the development of age-friendly communities. 

      This review contains 3 figures, 5 tables, and 53 references.

      Key words: aging, elderly, older adult, successful aging, successful aging interventions

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    • 2

      Subjective Cognitive Impairment and Mild Cognitive Impairment (predementias)

      By Shashank Beesam, MD; George Grossberg, MD; Eric Marin, MD
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      Subjective Cognitive Impairment and Mild Cognitive Impairment (predementias)

      • SHASHANK BEESAM, MDGeriatric Track Resident, Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, St. Louis, MO
      • GEORGE GROSSBERG, MDSamuel W. Fordyce Professor, Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, St. Louis, MO
      • ERIC MARIN, MDNeurology Resident, Department of Neurology, Saint Louis University School of Medicine, St. Louis, MO

      Alzheimer disease is thought to have an insidious progression, with asymptomatic brain changes occurring decades prior to formal diagnosis. In recent years, efforts have been made to identify and characterize these changes into a spectrum beginning with subjective cognitive decline through the development of major neurocognitive disorder. Through this process, progress has been made into the predictive factors, prevention, and treatment modalities for the various stages of cognitive decline. In addition to pharmacologic therapies, studies have shown the value in physical, mental, social, and spiritual activity combined with support from physicians, family, and caregivers. Furthermore, individualized care, open and honest physician-patient dialogue, and emphasis on lifestyle modifications have been shown to achieve optimal quality of life and may also decrease the rate of cognitive decline.

      This review contains 5 figures, 5 tables, and 36 references.

      Key words: age-related cognitive decline, Alzheimer disease, major neurocognitive disorder, mild cognitive impairment, mild neurocognitive disorder, senior moment, subjective cognitive impairment

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    • 3

      Major Neurocognitive Disorders

      By Rajesh R Tampi, MD, MS, DFAPA; Deena J Tampi, MSN, MBA-HCA, RN
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      Major Neurocognitive Disorders

      • RAJESH R TAMPI, MD, MS, DFAPAProfessor of psychiatry at Case Western Reserve University School of Medicine and vice chairman for education and faculty development and program director in the Psychiatry Residency, Department of Psychiatry, MetroHealth, Cleveland, OH
      • DEENA J TAMPI, MSN, MBA-HCA, RNExecutive director of Behavioral Health Services, Saint Francis Hospital and Medical Center, Hartford, CT.

      Major neurocognitive disorder is the most common neurodegenerative condition in the world and the leading cause of dependence and disability among older adults worldwide. There are numerous etiologies for major neurocognitive disorder, of which Alzheimer disease (AD) is the most common. Available evidence indicates that the risk factors for major neurocognitive disorder include older age, female sex, lower educational attainment, obesity, and vascular risk factors, including smoking, hypertension, diabetes mellitus, and hyperlipidemia. Certain etiologies for major neurocognitive disorder are heritable, especially those due to AD and frontotemporal lobar degeneration. The pathophysiologic changes associated with the various etiologies of major neurocognitive disorder include neuronal loss, senile plaques, neurofibrillary tangles, vascular pathology, and α-synuclein neuronal inclusions. Major neurocognitive disorder remains a clinical diagnosis with a thorough history, appropriate laboratory tests, and standardized rating scales assisting in determining the etiology and severity of the condition. In older adults, major neurocognitive disorder must be differentiated from depression and delirium as these three conditions may have similar clinical presentations or may coexist. Current data indicate that approximately a third of the cases of major neurocognitive disorder, especially those due to AD, may be prevented by controlling potentially modifiable risk factors, including diabetes, depression, smoking, physical inactivity, midlife hypertension, midlife obesity, and low educational attainment. Currently, the only Food and Drug Administration–approved medications are acetylcholinesterase inhibitors and memantine for use in major neurocognitive disorder due to AD and rivastigmine (an acetylcholinesterase inhibitor) for major neurocognitive disorder due to Parkinson disease.

      Key words: acetylcholinesterase inhibitors, Alzheimer disease, amyloid precursor protein, frontotemporal lobar degeneration, Lewy body disease, major neurocognitive disorder, memantine, Parkinson disease, tau proteins, vascular disease

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    • 4

      Epilepsy and Related Disorders

      By Barbara Dworetzky, MD; Jong Woo Lee, MD, PhD
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      Epilepsy and Related Disorders

      • BARBARA DWORETZKY, MDAssociate Professor of Neurology, Harvard Medical School, Chief, Division of Epilepsy, EEG, and Sleep Neurology, Director, The Edward B. Bromfield Epilepsy Program, Brigham and Women’s Hospital, Boston, MA
      • JONG WOO LEE, MD, PHDAssistant Professor of Neurology, Harvard Medical School, Director, ICU EEG Monitoring, The Edward B. Bromfield Epilepsy Program, Brigham and Women’s Hospital, Boston, MA

      Epilepsy is a chronic disorder of the brain characterized by recurrent unprovoked seizures. A seizure is a sudden change in behavior that is accompanied by electrical discharges in the brain. Many patients presenting with a first-ever seizure are surprised to find that it is a very common event. A reversible or avoidable seizure precipitant, such as alcohol, argues against underlying epilepsy and therefore against treatment with medication. This chapter discusses the epidemiology, etiology, and classification of epilepsy and provides detailed descriptions of neonatal syndromes, syndromes of infancy and early childhood, and syndromes of late childhood and adolescence. The pathophysiology, diagnosis, and differential diagnosis are described, as are syncope, migraine, and psychogenic nonepileptic seizures. Two case histories are provided, as are sections on treatment (polytherapy, brand-name versus generic drugs, surgery, stimulation therapy, dietary treatments), complications of epilepsy and related disorders, prognosis, and quality measures. Special topics discussed are women?s issues and the elderly. Figures illustrate a left midtemporal epileptic discharge, wave activity during drowsiness, cortical dysplasias, convulsive syncope, rhythmic theta activity, right hippocamal sclerosis, and right temporal hypometabolism. Tables describe international classifications of epileptic seizures and of epilepsies, epilepsy syndromes and related seizure disorders, differential diagnosis of seizure, differentiating epileptic versus nonepileptic seizures, antiepileptic drugs, status epilepticus protocol for treatment, when to consider referral to a specialist, and quality measures in epilepsy. This chapter contains 111 references.

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    • 5

      Encephalopathy and Delirium

      By Alliya S. Qazi, MD; Juliana Barr, MD, FCCM
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      Encephalopathy and Delirium

      • ALLIYA S. QAZI, MDSurgical Critical Care Fellow, Department of Surgery, Stanford University School of Medicine, Stanford, CA
      • JULIANA BARR, MD, FCCMAssociate Professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, and Staff Intensivist and Anesthesiologist, Anesthesiology, Perioperative, and Pain Medicine Service, VA Palo Alto Health Care System, Palo Alto, CA.

      Delirium occurs commonly in critically ill patients. ICU delirium is associated with increased short-term and long-term mortality, increased ICU length of stay, and long-term cognitive deficits in these patients. There are significant health-care costs associated with ICU delirium. Delirium is often overlooked in patients when assessed by clinicians based on clinical judgment alone. The use of a validated delirium assessment tool increases delirium detection rates in patients. ICU delirium is a multifactorial process. Nonmodifiable risk factors include age, dementia, prior coma, emergency surgery or trauma, and a high severity of illness. Modifiable risk factors include benzodiazepine use and blood transfusions. There is no evidence to support the use of any pharmacologic agent for either the prevention or treatment of ICU delirium. Antipsychotics should only be used for symptom management in ICU patients with delirium, and then discontinued when no longer needed. The mainstay of delirium management should be a multi-component, non-pharmacologic strategy aimed at minimizing risk factors. One such multimodal strategy, the ABCDEF Bundle, can significantly decrease the incidence of ICU delirium. Additional research is needed to better understand the pathophysiology and management of ICU delirium.

      This review contains 5 figures, 5 tables, and 50 references.

      Keywords: Delirium, Encephalopathy, Intensive Care, Outcomes, ABCDEF Bundle, ICU Liberation.

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  • Dissociative Disorders
    • 1

      Dissociative Disorders and Their Clinical Management Part One: Dissociative Amnesia (including Its Variant Dissociative Fugue)

      By Hans Markowitsch, PhD; Angelica Staniloiu, MD, PhD
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      Dissociative Disorders and Their Clinical Management Part One: Dissociative Amnesia (including Its Variant Dissociative Fugue)

      • HANS MARKOWITSCH, PHDProfessor of Neuropsychology Emeritus, Department of Physiological Psychology, University of Bielefeld, Germany
      • ANGELICA STANILOIU, MD, PHDAssociate Professor, Department of Psychology, University of Bucharest, Bucharest, Romania, Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada, Assistant Professor Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, Lecturer, Department of Physiological Psychology, University of Bielefeld, Bielefeld, Germany

      Dissociative disorders are heterogeneous with respect to clinical features, course, antecedents and treatment. Among them, dissociative amnesia occupies a special place, at times encroaching on the borders between neurology and psychiatry. Herein we describe dissociative amnesia according to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders and outline data on its epidemiology, neurobiology, neuroimaging, clinical and differential diagnosis, neuropsychology, comorbidities, prognosis, treatment and rehabilitation. To enable a neuroscientific approach to its diagnosis, we outline the memory division into short-term and long-term memory, elaborating on the content-based classification of the long-term memory systems. Dissociative amnesia most commonly manifests itself in its retrograde variants (including dissociative fugue), but anterograde variants can also occur. Dissociative amnesia may be overlooked when it occurs on a background of mixed antecedents and comorbidities. Comprehensive neuropsychological assessment – including tests tapping on all memory systems and symptom validity tests – is still insufficiently integrated in the clinical practice, although it could aid in securing an accurate diagnosis, especially in cases with mixed antecedents or concomitant forensic or litigation backgrounds. Presently there is a paucity of treatment and rehabilitation methods for dissociative amnesia. Developing research evidence-based consensus guidelines for diagnosis and treatment is an essential goal.

      This review contains 6 figures, 7 tables, and 60 references.

      Key Words : consciousness, episodic-autobiographical memory, mnestic block syndrome, neuroimaging, serial-parallel-independent model, personal identity, stressful life events, malingering, trauma, feigning

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    • 2

      Catatonia

      By Donald W. Black, MD; Francisco Appiani, MD; Brendan Carroll, MD; Rebecca Miesle, OMS-III; Jo Ellen Wilson, MD
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      Catatonia

      • DONALD W. BLACK, MD
      • FRANCISCO APPIANI, MDStaff Physician, Program of Clinical Pharmacology. Direction of Teaching and Research. Hospital de Clínicas José de San Martín. Facultad de Medicina. Universidad de Buenos Aires. Director of ACEDEN (Asociacion Civil para el Estudio y Desarrollo de las Neurosciences), Buenos Aires, Argentina
      • BRENDAN CARROLL, MDClinical Assistant Professor, Heritage College of Osteopathic Medicine, Ohio University, Athens, Ohio, USA; Interim Residency Training Director, Grandview Hospital, Kettering health system, Chillicothe VA Medical Center, Chillicothe, Ohio, USA
      • REBECCA MIESLE, OMS-IIIOUHCOM-Central Ohio CORE, Ohio University, Heritage College of Osteopathic Medicine, Athens, Ohio, USA
      • JO ELLEN WILSON, MDAssociate Professor of Psychiatry, Vanderbilt University, Nashville, Tennessee, USA and Attending Physician, Psychiatry Service, Nashville VAMC, Nashville, Tennessee, USA

      Catatonia is a syndrome, not a discrete illness, and was first recognized by Kahlbaum in the 19th century. Catatonia is underdiagnosed and often goes unrecognized despite its clinical significance and treatment implications. The syndrome’s motor symptoms include muteness, rigidity, and stupor. Catatonia has been associated with various psychiatric, medical, and neurologic disorders and is no longer only considered a subtype of schizophrenia. There is no known etiology, but its rapid improvement with benzodiazepines suggests that γ-aminobutyric acid (GABA), an inhibitory neurotransmitter, is involved. Patients displaying catatonic symptoms should have a comprehensive evaluation to rule out medical and neurologic causes and to assess hydration and nutritional status. Patients can have significant nursing care needs, and some might need tube feedings. Benzodiazepines are the first-line treatment, with electroconvulsive therapy reserved for those who fail to respond or have an inadequate response to benzodiazepines. Psychiatrists and other clinicians should understand the diagnosis and treatment of catatonia.

      This review contains 4 tables and 52 references

      Key words: bipolar disorder, catatonia, delirium, GABA, glutamate, major depressive disorder, schizophrenia

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  • Mood and Anxiety Disorders
    • 1

      Neurobiology of Anxiety Disorders

      By Pooja Palkar, MBBS; Eric Hollander, MD
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      Neurobiology of Anxiety Disorders

      • POOJA PALKAR, MBBSFellow - Autism and Obsessive-Compulsive Spectrum and Anxiety and Depression Program, Montefiore Medical Center, Albert Einstein College of Medicine
      • ERIC HOLLANDER, MDDirector - Autism and Obsessive-Compulsive Spectrum Program, and Anxiety and Depression Program, Clinical Professor of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine and Montefiore Medical Center

      In recent years, advances in the fields of neuroimaging and experimental psychology increased our understanding of the basic mechanisms of classical conditioning and learning, contributing to our knowledge of the neurobiology of anxiety disorders. Research has shown that the amygdala is the cornerstone of fear circuitry and that abnormalities in amygdala pathways can affect the acquisition and expression of fear conditioning. Activation of the amygdala in response to disorder-relevant stimuli has been observed in anxiety disorders. The roles of the hippocampus, nucleus accumbens, periaqueductal gray, and insular and medial prefrontal cortices in response to fear have been identified as well. Neurotransmitters such as serotonin, dopamine, γ-aminobutyric acid, glutamate, and some neurosteroids play an important part in the neurobiology of anxiety disorders. Neuropeptides such as oxytocin, neuropeptide Y, galanin, and cholecystokinin have been shown to modulate stress response. Drugs such as N-methyl-d-aspartate (NMDA) antagonists and blockers of voltage-gated calcium channels in the amygdala are anxiolytic. Fear extinction, which entails new learning of fear inhibition, is the mechanism of effective antianxiety treatments such as d-cycloserine, a partial NMDA agonist. Extinction is thought to occur by the medial prefrontal cortex, which inhibits the lateral amygdala under hippocampal modulation. Harnessing extinction to delink neutral stimuli from aversive responses is an important goal of the psychotherapy and pharmacotherapy of anxiety disorders. Discovery of the role of microRNAs in the etiology of anxiety disorders and their possible utility as targets to treat these disorders is fascinating. In this review, we discuss the neurobiology of anxiety disorders, which will help us better manage them clinically.

      Key words: amygdala, anxiety disorders, neurobiology, fear conditioning, neurocircuitry, neurotransmitters, neuropeptides, neurosteroids, endogenous opioids.

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    • 2

      Overview of Anxiety Disorders

      By Jon E Grant, JD, MD, MPH
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      Overview of Anxiety Disorders

      • JON E GRANT, JD, MD, MPH

      Anxiety disorders are the most common psychiatric disorders among adults in the United States. Although anxiety disorders generally result in significant psychosocial impairment, most adults do not seek treatment until many years after the onset of the anxiety disorder. The treatment literature for anxiety disorder has grown tremendously since the 1980s, and both psychotherapy and medications may prove beneficial for people with anxiety disorders. This review presents a general overview of the anxiety disorders.

      This review contains 7 tables, and 33 references.

      Key words: agoraphobia, anxiety disorder, generalized anxiety disorder, panic disorder, separation anxiety disorder, social anxiety disorder, specific phobia, treatment of anxiety

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    • 3

      Clinical Management of Anxiety Disorders

      By Shona Vas, PhD; Pooja N Dave, PhD
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      Clinical Management of Anxiety Disorders

      • SHONA VAS, PHDAssociate Professor, Department of Psychiatry & Behavioral Neuroscience, The University of Chicago
      • POOJA N DAVE, PHDPostdoctoral Fellow, Department of Psychiatry & Behavioral Neuroscience, The University of Chicago, Chicago, IL

      Anxiety disorders are characterized by excessive fear and anxiety accompanied by associated behavioral disturbances that cause significant impairment in social and occupational functioning. Anxiety is a complex mood state that involves physiologic, cognitive, and behavioral components. This review describes the five anxiety disorders most commonly diagnosed in adults: social anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder, and specific phobia. Diagnostic criteria for these disorders are presented along with empirically supported psychological and pharmacologic treatment approaches. Decades of evidence have indicated that for anxiety disorders of mild to moderate severity, cognitive-behavioral therapy (CBT) should be first-line treatment. CBT interventions for anxiety, including psychoeducation, cognitive restructuring, exposure, applied relaxation/breathing retraining, and skills training, are presented with descriptions of how they may be adapted to particular diagnoses, along with data for their efficacy. Data suggest that selective serotonin and norepinephrine reuptake inhibitors are pharmacologic treatments of choice for anxiety and may be used in combination with CBT for moderate to severe symptoms. d-Cycloserine is an emerging treatment that may enhance outcomes in anxiety disorders by optimizing exposure therapy through the facilitation of fear extinction.

      This review contains 7 figures, 12 tables, and 105 references.

      Key words: agoraphobia, anxiety, generalized anxiety disorder, panic disorder, phobias, social anxiety disorder

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    • 4

      Depressive Disorders: Update on Diagnosis, Etiology, and Treatment

      By Jair C. Soares, MD; Isabelle E. Bauer, PhD; Antonio L Teixeira, MD, PhD; Marsal Sanches, MD, PhD
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      Depressive Disorders: Update on Diagnosis, Etiology, and Treatment

      • JAIR C. SOARES, MDDepartment of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
      • ISABELLE E. BAUER, PHDDepartment of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
      • ANTONIO L TEIXEIRA, MD, PHDDepartment of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
      • MARSAL SANCHES, MD, PHDDepartment of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX

      This review discusses the changes in the diagnostic criteria for depressive disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and recent findings exploring the etiology of and treatment strategies for these disorders. Depressive disorders are typically characterized by depression in the absence of a lifetime history of mania or hypomania. New developments in the DSM-5 include the recognition of new types of depressive disorders, such as disruptive mood dysregulation disorder, persistent depressive disorder, premenstrual dysphoric disorder, and the addition of catatonic features as a specifier for persistent depressive disorder. These diagnostic changes have important implications for the prognosis and treatment of this condition. A thorough understanding of both the clinical phenotype and the biosignature of these conditions is essential to provide individualized, long-term, effective treatments to affected individuals. 

      This review contains 1 table and 52 references

      Key words: brain volumes, depressive disorders, DSM-5, hormones, inflammation, neuropeptides, somatic therapy, stress

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    • 5

      Clinical Management of Depressive Disorders

      By Sanjay Gupta, MD; Jon E. Grant, JD, MD, MPH
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      Clinical Management of Depressive Disorders

      • SANJAY GUPTA, MD
      • JON E. GRANT, JD, MD, MPH
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    • 6

      Neurobiology of Mood Disorders

      By Genoveva Uzunova, MD, PhD; Vera Nezgovorova, MD; Danya Schlussel, MS; Eric Hollander, MD
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      Neurobiology of Mood Disorders

      • GENOVEVA UZUNOVA, MD, PHDPsychiatry Fellow, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
      • VERA NEZGOVOROVA, MDPsychiatry Research Fellow, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
      • DANYA SCHLUSSEL, MSResearch Coordinator, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
      • ERIC HOLLANDER, MDProfessor of Psychiatry and Behavioral Sciences, Director, Anxiety and Depression and Autism and OCD Research Program, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY

      Mood disorders (major depressive disorders [MDDs] and bipolar disorders [BDs]) are common psychiatric conditions and major causes of morbidity and mortality worldwide. Their neurobiology is extensively studied, and major advances have been made in understanding the neuroanatomic, neurochemical, synaptic plasticity, and genetic correlates. In this review, we discuss the major neuroanatomic regions in the brain affected in mood disorders and brain structural and functional alterations, the main hypotheses for the neurobiology, the major neurotransmitters and neuromodulators implicated, the synaptic plasticity changes, the role of stress and the hypothalamic-pituitary-adrenal axis, the importance of circadian rhythms, and the role of genetics. We discuss differences in the neurobiology between MDDs and BDs and connect the knowledge of neurobiology to therapeutics. We discuss the main classes of medications, such as antidepressants for treatment of MDD and mood-stabilizing drugs for treatment of BD, and neuromodulation therapies such as transcranial magnetic stimulation. We point to unanswered questions and future directions, such as elucidation of the role of atypical neurotransmitters in mood disorders, the need for better understanding of the genetics and interactions between the immune and central nervous systems, and the development of biomarkers and personalized therapeutics based on the neurobiology. Notably, there are discrepancies in the current scientific knowledge and many unanswered questions in the neurobiology due to the different ages of patients, disease stage, presence of medications, and other comorbidities. It is notable, however, that mood disorders have a clearly established biological basis with alterations in the immune and central nervous systems that affect synaptic plasticity, neural circuits, and larger-scale brain networks and communicate with the autonomic nervous system.

      This review contains 5 figures, 4 tables and 62 references

      Key words: antidepressant, bipolar disorder, epigenetics, hypothalamic-pituitary-adrenal axis, immune system, limbic system, major depressive disorder, mood stabilizer, neurotransmitter, synaptic plasticity, transcranial magnetic stimulation 

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    • 7

      Diagnosis, Etiology, and Treatment of Premenstrual Dysphoric Disorder

      By Marlene P. Freeman, MD; Edwin Raffi, MD, MPH
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      Diagnosis, Etiology, and Treatment of Premenstrual Dysphoric Disorder

      • MARLENE P. FREEMAN, MDAssociate Professor, Department of Psychiatry, Harvard Medical School; Associate Director, Center for Women’s Mental Health, Massachusetts General Hospital, Boston, MA
      • EDWIN RAFFI, MD, MPHInstructor, Department of Psychiatry, Harvard Medical School; Perinatal and Reproductive Psychiatrist, Center for Women’s Mental Health, Massachusetts General Hospital, Boston, MA

      Premenstrual dysphoric disorder (PMDD) was recognized as an official psychiatric diagnosis among depressive disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The exact etiology of PMDD is not yet fully understood, and it is a topic of current research. The hope is that learning more about PMDD can lead to improved treatment modalities for this disorder and better understanding of other related disorders (such as premenstrual mood exacerbation and postpartum- or menopause-related mood disorders). Often misdiagnosed and likely underdiagnosed, PMDD has a 12-month prevalence that ranges from 1.8 to 5.8% for women who menstruate. Mental health providers who treat women of reproductive age should be familiar with the diagnostic criteria, related differential diagnosis, and available treatment modalities for PMDD.

      This review contains 5 figures, 5 tables and 59 references

      Key words: mood disorder, premenstrual dysphoric disorder, premenstrual exacerbation, premenstrual syndrome, reproductive mental health, reproductive psychiatry, women’s mental health

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    • 8

      Obsessive-compulsive Disorder (introduction)

      By Christine Lochner, PhD; Dan Stein, MD, PhD; Eileen Thomas, MD
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      Obsessive-compulsive Disorder (introduction)

      • CHRISTINE LOCHNER, PHDAssociate Professor, SU/UCT MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
      • DAN STEIN, MD, PHDProfessor, Department of Psychiatry & Mental Health and SU/UCT MRC Unit on Anxiety & Stress Disorders, University of Cape Town, Cape Town, South Africa
      • EILEEN THOMAS, MDPsychiatrist, Division of Consultation Liaison, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa

      A hallmark feature of OCD is the presence of obsessions and/or compulsions. The subtyping of OCD has been expanded to allow for a detailed assessment of individuals and their disorder, including insight and tic-related specifiers. Although some individuals with OCD rationalize their behaviors as useful, they are time consuming and cause marked distress and/or functional impairment.  

      This review contains 1 table, and 31 references.

      Key words: diagnostic and statistical manual, obsessive-compulsive disorder

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    • 9

      Hoarding Disorder

      By Christine Lochner, PhD; Dan Stein, MD, PhD; Eileen Thomas, MD
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      Hoarding Disorder

      • CHRISTINE LOCHNER, PHDAssociate Professor, SU/UCT MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
      • DAN STEIN, MD, PHDProfessor, Department of Psychiatry & Mental Health and SU/UCT MRC Unit on Anxiety & Stress Disorders, University of Cape Town, Cape Town, South Africa
      • EILEEN THOMAS, MDPsychiatrist, Division of Consultation Liaison, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa

      Hoarding disorder is characterized by an obsessive need to acquire, collect, or keep possessions and difficulty in organizing and discarding, resulting in accumulation of clutter, which elicits great concern from family and friends. Functioning is usually impaired in a variety of domains. Obsessive-compulsive disorder is the disorder most closely associated with hoarding. Overvalued ideation regarding the value or usefulness of possessions may make it impossible for individuals to discard items.

      This review contains 1 table, and 22 references.

      Key words: clutter, diagnostic and statistical manual, etiology, hoarding, obsessive-compulsive and related disorder

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    • 10

      Body Dysmorphic Disorder

      By Christine Lochner, PhD; Dan Stein, MD, PhD; Eileen Thomas, MD
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      Body Dysmorphic Disorder

      • CHRISTINE LOCHNER, PHDAssociate Professor, SU/UCT MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
      • DAN STEIN, MD, PHDProfessor, Department of Psychiatry & Mental Health and SU/UCT MRC Unit on Anxiety & Stress Disorders, University of Cape Town, Cape Town, South Africa
      • EILEEN THOMAS, MDPsychiatrist, Division of Consultation Liaison, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa

      Body dysmorphic disorder requires obsessional thoughts regarding a perceived defect in appearance and/or compulsive behavior that develop in response to those thoughts. Individuals experience clinically significant impairment because of their appearance concerns. Body dysmorphic disorder and obsessive-compulsive disorder have many similarities, including phenomenologic features, comorbidities, and underlying pathophysiology. Insight into the excessiveness or irrationality of their beliefs varies from good to delusional. Many individuals with body dysmorphic disorder present with comorbid suicidal ideation and substance use disorders.

      This review contains 1 table, and 30 references.

      Key words: body dysmorphic disorder, diagnostic and statistical manual, obsessive-compulsive and related disorder

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    • 11

      Excoriation

      By Christine Lochner, PhD; Dan Stein, MD, PhD; Eileen Thomas, MD
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      Excoriation

      • CHRISTINE LOCHNER, PHDAssociate Professor, SU/UCT MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
      • DAN STEIN, MD, PHDProfessor, Department of Psychiatry & Mental Health and SU/UCT MRC Unit on Anxiety & Stress Disorders, University of Cape Town, Cape Town, South Africa
      • EILEEN THOMAS, MDPsychiatrist, Division of Consultation Liaison, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa

      Excoriation disorder is characterized by the recurrent, compulsive picking of skin, leading to skin lesions. A growing body of evidence emphasizes its prevalence and possible disabling nature, including medical complications such as localized infections and septicemia. Neurocognitive data support the idea that individuals with this disorder have difficulty inhibiting motor behaviors. Excoriation disorder is often considered a chronic disorder, fluctuating in intensity and severity. Important differentials include the use of stimulant drugs and dermatologic conditions, such as scabies.

      This review contains 1 table, and 16 references.

      Key words: diagnostic and statistical manual, excoriation, obsessive-compulsive and related disorder, skin picking

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    • 12

      Trichotillomania

      By Christine Lochner, PhD; Dan Stein, MD, PhD; Eileen Thomas, MD
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      Trichotillomania

      • CHRISTINE LOCHNER, PHDAssociate Professor, SU/UCT MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
      • DAN STEIN, MD, PHDProfessor, Department of Psychiatry & Mental Health and SU/UCT MRC Unit on Anxiety & Stress Disorders, University of Cape Town, Cape Town, South Africa
      • EILEEN THOMAS, MDPsychiatrist, Division of Consultation Liaison, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa

      Trichotillomania (hair pulling disorder [HPD]) is a common disorder affecting mostly women that is often underreported and underrecognized. This condition involves repetitive hair pulling resulting in hair loss with repeated unsuccessful attempts to control or stop the pulling behavior. Individuals usually attempt to conceal or camouflage the hair loss. Clinical phenomenology, neurobiology, and genetic underpinning suggest associations between obsessive-compulsive disorder and HPD.

      This review contains 1 table, and 19 references.

      Key words: hair loss, hair pulling, obsessive-compulsive and related disorder, trichotillomania

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    • 13

      Clinical Management of Obsessive-compulsive and Related Disorders

      By Samuel R Chamberlain, MB/BChir, PhD, MRCPsych
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      Clinical Management of Obsessive-compulsive and Related Disorders

      • SAMUEL R CHAMBERLAIN, MB/BCHIR, PHD, MRCPSYCHWellcome Trust Clinical Fellow in the Department of Psychiatry, University of Cambridge, and Honorary Consultant Psychiatrist at the Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK.

      Obsessive-compulsive and related disorders (OCRDs) now have their own category in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Disorders currently classified as OCRDs are obsessive-compulsive disorder, trichotillomania (hair pulling disorder), excoriation (skin picking) disorder, hoarding disorder, and body dysmorphic disorder. Collectively, the OCRDs are prevalent, cause considerable functional impairment, and are often overlooked by clinicians. This review surveys current definitions and diagnosis of OCRDs, highlighting recommended assessment tools, differential diagnoses, and medical issues. The heritability of OCRDs is examined, based on available twin data, along with implicated genetic factors. Neurobiological understanding of OCRDs is outlined, focusing on dysregulation of habit generation and top-down response control corticostriatal pathways. The review then highlights evidence-based treatments for OCRDs, which differ considerably between individual disorders. Treatment guidance includes descriptions of target medication doses and therapy content. Lastly, limitations in the current knowledge base for OCRDs are reviewed, with implications for future research directions.

      This review contains 1 figure, 7 tables, and 40 references.

      Key words: compulsivity, dopamine, glutamate, impulsivity, screening for OCD, serotonin 

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    • 14

      Management of Depression, Part 1: Identification and Diagnosis

      By Michael Banov, MD
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      Management of Depression, Part 1: Identification and Diagnosis

      • MICHAEL BANOV, MDClinical Assistant Professor, Department of Psychiatry Medical College of Georgia; Augusta, Georgia; Medical Director Northwest Behavioral Medicine and Research Center Marietta, Alpharetta, Georgia

      Clinical depression is a commonly occurring and profoundly disabling condition that affects approximately 4%, or nearly 350 million people, worldwide. Depression has been identified as the world’s leading cause of disability and a major contributor to overall global burden of disease. In the United States alone, estimates of economic burden are greater than 200 billion dollars, including costs of direct medical care, suicide-related mortality, and lost work productivity. Managing depression is challenging due to the marked variability in biological contributors, the heterogeneity of the illness, psychosocial history, current stresses exacerbating the condition, medical and psychiatric co-occurring conditions, lifestyle, and motivation and willingness to accept and engage in treatment recommendations. This review discusses diagnosis, depression screening and workup, neuroimaging, differentiation among depression types, patient safety, and treatment initiation in patients with depression. Tables list DSM-5 versus ICD-10 classification of depression and DSM-5 updates with respect to depression.

      This review contains 5 tables and 60 references

      Key words: bipolar depression, clinical depression, depression, depression screening, psychiatric neuroimaging, unipolar depression 

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    • 15

      Management of Depression, Part 2: Treatment Options

      By Michael Banov, MD
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      Management of Depression, Part 2: Treatment Options

      • MICHAEL BANOV, MDClinical Assistant Professor, Department of Psychiatry Medical College of Georgia; Augusta, Georgia; Medical Director Northwest Behavioral Medicine and Research Center Marietta, Alpharetta, Georgia

      Clinical depression is a commonly occurring and profoundly disabling condition that affects approximately 4%, or nearly 350 million people, worldwide according to the World Health Organization. Managing depression is challenging due to the marked variability in biological contributors, the heterogeneity of the illness, psychosocial history, current stresses exacerbating the condition, medical and psychiatric co-occurring conditions, lifestyle, and motivation and willingness to accept and engage in treatment recommendations. Mental health professionals such as master-level counselors, psychologists, or psychiatrists are specially trained to identify and treat depression; however, a significant amount of depression presents in primary care medical settings. This review covers treatment of depression with psychotherapy, complementary and alternative medicine (CAM), and antidepressant medication, as well as treatment course and long-term depression treatment. Tables list CAM depression treatments, nonnutraceutical CAM therapies, managing antidepressant side effects, tricyclic antidepressants, serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, norepinephrine dopamine reuptake inhibitor, alpha2 antagonists, serotonin-2 antagonist/reuptake inhibitors, monoamine oxidase inhibitors, food restrictions with monoamine oxidase inhibitors, managing partial response/treatment-resistant depression, and serotonin receptor modulators.

      This review contains 15 tables and 98 references

      Key words: antidepressant medication, clinical depression, depression, monoamine oxidase inhibitors, nonpharmacologic depression treatment, omega-3 fatty acids, S-adenosylmethionine, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, St. John’s wort, tricyclic antidepressants

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    • 16

      Bipolar Disorders and Their Clinical Management, Part I: Epidemiology, Etiology, Genetics, and Neurobiology

      By Vladimir Maletic, MD; Bernadette DeMuri-Maletic, MD
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      Bipolar Disorders and Their Clinical Management, Part I: Epidemiology, Etiology, Genetics, and Neurobiology

      • VLADIMIR MALETIC, MD
      • BERNADETTE DEMURI-MALETIC, MDClinical Assistant Professor of Psychiatry and Mental Health Sciences, Medical College of Wisconsin, Milwaukee, WI

      The concept of bipolar disorders has undergone a substantial evolution over the course of the past two decades. Emerging scientific research no longer supports the notion of bipolar disorder as a discrete neurobiologic entity. Most likely, there are a number of different biotypes with similar phenotypical manifestations. Advancements in genetic research suggest that bipolar disorders have a polygenetic pattern of inheritance, sharing common genetic underpinnings with a number of other psychiatric disorders, including schizophrenia, autistic spectrum disorder, and major depressive disorder. Contemporary etiological theories are discussed in some detail, inclusive of the role of immune disturbances, oxidative stress, and changes in neuroplasticity and neurotransmission, which underpin functional and structural brain changes associated with bipolar disorders. Contemporary epidemiologic research and understanding of disease evolution are discussed from the perspective of its clinical relevance. Our review provides a succinct summary of relevant literature.

      This review contains 4 figures, 2 tables, and 80 references.

      Key Words: bipolar disorders, endocrine disturbances, epidemiology, genetics, glia, immunity, neurobiology, neuroplasticity, neurotransmitters

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    • 17

      Bipolar Disorders and Their Clinical Management, Part II: Diagnosis, Differential Diagnosis, and Treatment

      By Bernadette DeMuri-Maletic, MD; Vladimir Maletic, MD, MS
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      Bipolar Disorders and Their Clinical Management, Part II: Diagnosis, Differential Diagnosis, and Treatment

      • BERNADETTE DEMURI-MALETIC, MDClinical Assistant Professor of Psychiatry and Mental Health Sciences, Medical College of Wisconsin, Milwaukee, WI
      • VLADIMIR MALETIC, MD, MSClinical Professor of Psychiatry and Behavioral Sciences, University of South Carolina School of Medicine, Greenville, SC

      Bipolar disorder is a biologically and phenotypically diverse disorder and its diagnosis and treatment provides a significant challenge to even the most seasoned clinician. We provide an update on the diagnosis and differential diagnosis of bipolar disorder, reflecting recent changes in DSM-5. Our review provides a succinct summary of the treatment literature, encompassing pharmacologic and psychosocial interventions for bipolar depression, mania/hypomania, mixed states, and prevention of disease recurrence. We provide a brief critical review of emerging treatment modalities, including those used in treatment resistance. Challenges involved in maintaining adherence are further discussed. Additionally, we review common treatment adverse effects and provide recommendations for proper side effect monitoring. There is evidence of significant functional impairment in patients with bipolar disorder and we conclude with a discussion of the impact of impairment on prognosis and quality of life.

      This review contains 7 tables and 45 references.

      Key Words: bipolar disorders, differential diagnosis, maintenance pharmacotherapy, prognosis, psychosocial interventions, treatment, quality of life

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  • Neurostimulation
    • 1

      ECT: Physiology, Indications, and Treatment

      By Max Fink, MD
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      ECT: Physiology, Indications, and Treatment

      • MAX FINK, MDProfessor of Psychiatry and Neurology, Emeritus, Departments of Psychiatry and Neurology, Stony Brook University, Long Island, NY

      Inducing grand mal seizures (electroshock, electroconvulsive therapy) developed as an effective treatment to alleviate the psychosis of dementia praecox. Clinicians quickly recognized that seizures also relieved depressed moods, suicide risk, catatonia, manic excitement, and delirium. It is an unheralded, often stigmatized, medical achievement. Seizures may be induced chemically or with electric or magnetic currents. Grand mal seizures must be repeated for persistent benefits. Not all seizures are equally effective. Effective seizures are marked by bilateral electroencephalographic brain wave changes and neuroendocrine discharges from hypothalamic-pituitary glands. Treatments are remarkably safe, with zero mortality. Immediate effects on memory are common but are almost always transient. They are not a practical deterrent to the treatments, although they are widely cited to reject its use. The stigmatization of induced seizures that places it as a “last resort” therapy is wasteful and unethical. It offers a remarkable opportunity for advancement in neuroscience. 

      This review contains 4 figures, 3 tables, and 90 references.

      Key words: anesthesia, bipolar disorder, catatonia, delirium, electroconvulsive therapy, electroencephalography, major depression, melancholia, neuroendocrine, seizures

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    • 2

      Neurostimulation

      By Scott Aaronson, MD; Paul Croarkin, DO, MS
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      Neurostimulation

      • SCOTT AARONSON, MD
      • PAUL CROARKIN, DO, MSAssociate Professor of Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic Depression Center, Rochester, MN

      Neurostimulation modalities in psychiatric practice and research efforts use magnetic and electric fields to modulate neuronal functioning. Physicians have used these modalities since ancient history, but most modern brain stimulation treatments developed after the inception electroconvulsive therapy in 1937. Noninvasive brain stimulation generally refers to treatments that do not require surgery, such as electroconvulsive therapy, repetitive transcranial magnetic stimulation, and transcranial current stimulation. Conversely, deep brain stimulation and vagal nerve stimulation are the two most researched invasive brain stimulation modalities for psychiatric disorders. Treatment with repetitive transcranial magnetic stimulation has been shown to be effective for the treatment of resistant major depressive disorders but is less rapid acting and may be optimal for a different patient population as compared to electroconvulsive therapy. Research focused on transcranial direct current stimulation continues to expand, but its role in clinical psychiatric practice is currently not well defined. Despite mixed and, in some cases, disappointing results, invasive brain stimulation techniques such as deep brain stimulation and vagal nerve stimulation will likely continue to have an important role for certain treatment-resistant populations in psychiatric practice. This review examines the development, basic physiologic mechanisms, and evidence base of neurostimulation modalities in psychiatry.

      This review contains 4 figures, 6 tables and 38 references

      Key Words: deep brain stimulation, invasive, neurostimulation, noninvasive, transcranial direct current stimulation, transcranial electrical stimulation, transcranial magnetic stimulation, treatment-resistant depression, vagal nerve stimulation

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  • Personality Disorders
    • 1

      Overview of the Personality Disorders

      By Donald W. Black, MD
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      Overview of the Personality Disorders

      • DONALD W. BLACK, MD
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    • 2

      Part 1: Borderline Personality Disorder and Its Clinical Features

      By Robert Biskin, MDCM, MSc.; Joel Paris, MD
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      Part 1: Borderline Personality Disorder and Its Clinical Features

      • ROBERT BISKIN, MDCM, MSC.Psychiatrist, Institute of Community and Family Psychiatry, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Assistant Professor, Department of Psychiatry, McGill University, Montreal, Quebec
      • JOEL PARIS, MDPsychiatrist, Institute of Community and Family Psychiatry, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Professor, Department of Psychiatry, McGill University, Montreal, Quebec

      Borderline personality disorder (BPD) is routinely encountered in all clinical settings and has been stigmatized and perceived as a difficult disorder to manage. Over the past 25 years, significant gains in our understanding of the diagnosis, treatment, and outcomes of the disorder have helped improve the lives of these patients. BPD is now understood to begin in adolescence and early adulthood, with a generally positive course and reductions in symptoms of self-harm and suicidality within several years of diagnosis. BPD is best understood as developing through an interaction between genetic and environmental factors. No clear biological features have been consistently identified yet, and similarly, no clear psychosocial factor, including childhood adversity or sexual abuse, is causative for BPD. Clearly separating BPD from other disorders, particularly bipolar disorder, is an important consideration and required to ensure proper care. Comorbid disorders, including other personality disorder, are frequent problems that partially reflect a challenge with the current diagnostic system that has not yet been resolved. Although the symptomatic outcome of patients with BPD is very good, functional outcomes, such as holding work and relationships, is more challenging for many patients, and suicide remains a risk in patients with this disorder.

      This review contains 2 figures, 4 tables, and 102 references.

      Key words: borderline personality disorder, outcome, personality disorder, self-harm, suicide

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    • 3

      Part 2: Borderline Personality Disorder and Its Clinical Management

      By Robert Biskin, MDCM, MSc.; Joel Paris, MD
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      Part 2: Borderline Personality Disorder and Its Clinical Management

      • ROBERT BISKIN, MDCM, MSC.Psychiatrist, Institute of Community and Family Psychiatry, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Assistant Professor, Department of Psychiatry, McGill University, Montreal, Quebec
      • JOEL PARIS, MDPsychiatrist, Institute of Community and Family Psychiatry, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Professor, Department of Psychiatry, McGill University, Montreal, Quebec

      The treatment of patients with borderline personality disorder (BPD) has changed significantly over the past 25 years. The previous therapeutic pessimism about BPD treatment outcomes has become more optimistic with the development of a variety of specialized psychotherapies that have been shown to reduce self-harm, suicidality, and health service use as well as improve overall psychopathology. Dialectical behavior therapy was the first evidence-supported treatment, but it has been joined by mentalization-based psychotherapy and a variety of other treatments. Several common factors, including structured treatment approach, are likely important in the effectiveness of these treatments compared with unstructured comparators. Pharmacotherapy serves a more limited role in the treatment of BPD due to many methodological issues in the research and a lack of replication of studies. Judicious and rational use of pharmacotherapy is discussed, as well as suggestions for improving accessibility to specialized psychotherapies through the development of stepped care models. Improving access to care for patients with BPD, throughout all age groups, remains an important next step.

      This review contains 2 figures, 1 table, and 47 references.

      Key words: borderline personality disorder, dialectical behavior therapy, mentalization-based treatment, personality disorder, pharmacotherapy, psychotherapy, self-harm

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    • 4

      Antisocial Personality Disorder and Its Clinical Management

      By Donald W. Black, MD
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      Antisocial Personality Disorder and Its Clinical Management

      • DONALD W. BLACK, MD

      Antisocial personality disorder (ASPD) is characterized by irresponsibility, aggression, criminality, and, in some, a lack of conscience. Recognized for over 200 years, ASPD is associated with domestic violence, psychiatric comorbidity, substance abuse, and excess health care use. ASPD is highly prevalent, and most affected individuals are men. ASPD has its onset in childhood or adolescence, when it may be diagnosed as a disruptive behavior disorder or conduct disorder. Not diagnosed until age 18, ASPD peaks in severity in the late teens or early 20s. It is lifelong for most persons, although the trend is toward improvement in those individuals with an adolescent onset and a prominent antisocial lifestyle. Those who do best have milder syndromes, are married/partnered, have stable jobs, and are older. ASPD is thought to result from a combination of genetic and environmental factors. Some antisocial persons have shown functional abnormalities in limbic structures and the frontotemporal cortex, portions of the brain that control judgment and regulate impulses. There are no effective pharmacologic treatments, but some antisocial persons receive off-label medication to dampen aggressive tendencies and curb impulsivity. Psychotropic medication is also used to treat comorbid syndromes (e.g., major depression). Cognitive-behavioral therapy may be helpful in mild cases. Family and couples therapies may be important for antisocial persons who are partnered or have offspring.

      This review contains 1 figure, 2 tables, and 99 references.

      Key words: aggression, antisocial personality disorder, conduct disorder, impulsivity, juvenile delinquency, lack of remorse, psychopathy, sociopathy 

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    • 5

      Neurobiology of Personality Disorders

      By Theresa Costales, MD; Marianne Goodman, MD; Kalpana Kapil-Pair, PhD; Lea Marin, MD, MPH; Katherine Pier, MD; Jaime Wilsnack, MA
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      Neurobiology of Personality Disorders

      • THERESA COSTALES, MDDepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, The Mental Health Patient Care Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY
      • MARIANNE GOODMAN, MDDepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, Mental Illness Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY
      • KALPANA KAPIL-PAIR, PHDDepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, Mental Illness Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY
      • LEA MARIN, MD, MPHDepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, The Mental Health Patient Care Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY
      • KATHERINE PIER, MDDepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, The Mental Health Patient Care Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY
      • JAIME WILSNACK, MADepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, Mental Illness Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY

      Personality disorders affect an estimated 9.1% of the general population, including 25 to 50% of psychiatric outpatients and up to 80% of inpatients. They constitute heterogeneous clinical presentations characterized by interpersonal deficits owing to disturbances in self and interpersonal functioning. Personality disorders frequently co-occur with other psychiatric conditions and tend to be refractory to traditional pharmacologic treatments, and patients with these disorders have a reduced quality of life and carry significant risk of death by suicide. Research over the last 25 years has advanced our understanding of the neurobiology, neurochemistry, physiology, genetics, and epigenetics that contribute to these complex presentations. A review of the neurobiological basis of personality disorders demonstrates that, in most cases, personality pathology represents a confluence of traits that are on a spectrum with normal personality functioning and other mental disorders. Schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, avoidant personality disorder, and obsessive-compulsive personality disorder are among the disorders with sufficient evidence to support their conceptualization as discrete nosologic entities. Functional neuroimaging and connectivity studies, as well as genetic and epigenetic research, have highlighted structural, neurochemical, environmental, and behavioral targets that hold promise for treatment.

      This review contains 6 figures, 6 tables, and 116 references.

      Key words: antisocial, avoidant, borderline, connectivity, functional magnetic resonance imaging, heritability, obsessive-compulsive, personality, personality disorder, schizotypal 

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  • Schizophrenia
    • 1

      Overview of Schizophrenia and Other Psychotic Disorders

      By James A. Wilcox, MD, PhD; Donald W. Black, MD
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      Overview of Schizophrenia and Other Psychotic Disorders

      • JAMES A. WILCOX, MD, PHD
      • DONALD W. BLACK, MD

      Psychotic disorders are among the most disabling conditions and constitute a major public health problem. Described throughout recorded time, they affect as many as 5% of the population and cause a disproportionate amount of suffering and loss to society. In the chapter on schizophrenia spectrum and other psychotic disorders, the DSM-5 lists delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, and schizoaffective disorder, as well as categories for substance- or medically induced psychotic disorders. The term psychosis indicates that the individual has a severe inability to interpret the surrounding environment in a realistic way. Symptoms include hallucinations, delusions, and bizarre behavior. Psychotic disorders are associated with premature death, mostly attributable to suicide. The pathophysiology and etiology of psychotic disorders are only now beginning to be understood, and treatment for these conditions remains suboptimal. Researchers are currently refining the cause of these symptoms and developing more effective treatments.  

      This review contains 2 tables, and 33 references.

      Key words: brief psychotic disorder, delusions, hallucinations, psychosis, schizoaffective disorder, schizophrenia, schizophreniform disorder 

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    • 2

      Clinical Management of Psychotic Disorders

      By Eric Epping, MD, PhD, MME
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      Clinical Management of Psychotic Disorders

      • ERIC EPPING, MD, PHD, MMEDepartment of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA

      Psychotic disorders constitute a spectrum of mental illnesses that include symptoms of hallucinations, delusions, and/or disorganized thinking and behavior. Although some psychoses are short-term and reversible conditions, schizophrenia is the prototypical illness, which often develops in young adulthood and is typically chronic in its course. A complete medical and psychiatric evaluation is necessary to evaluate patients presenting with psychotic symptoms and to differentiate primary from secondary causes. Treatment of psychosis includes treatment of identifiable causal conditions, acute management of potentially harmful behaviors, prescribing antipsychotic medication, and psychotherapeutic and psychosocial interventions. A variety of antipsychotic medications are available for treatment, which must be individualized to maximize symptom reduction and to minimize short-term and long-term side effects. Long-acting injectable medications are available to improve medication adherence. In some cases, medications to counteract side effects may need to be prescribed. In more severe cases, electroconvulsive therapy may be indicated. Psychotherapy such as cognitive-behavioral therapy can reduce the severity of hallucinations and delusions. Integrated care that also includes family psychoeducation, skills training, and/or assertive community treatment is an essential part of a comprehensive multidisciplinary treatment program for the management of patients with psychotic disorders.  

      Key words: antipsychotic, dopamine, psychosis, psychosocial treatment, schizophrenia serotonin 

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    • 3

      Genetics of Psychosis

      By Matcheri Keshavan, MD; William Stone, PhD; Ming Tsuang, MD, PhD, DSc
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      Genetics of Psychosis

      • MATCHERI KESHAVAN, MDStanley Cobb Professor and Vice-Chair for Public Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Harvard Medical School
      • WILLIAM STONE, PHDAssistant Professor of Psychology, Department of Psychiatry, Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Harvard Medical School
      • MING TSUANG, MD, PHD, DSCBehavioral Genomics Endowed Chair and University Professor, University of California; Distinguished Professor of Psychiatry and Director, Center for Behavioral Genomics, Department of Psychiatry, University of California, San Diego

      Psychotic disorders such as schizophrenia are among the most disabling human illnesses. The causes of these illnesses have remained unknown, leading to much misunderstanding, stigmatization, and suffering. These illnesses are highly heritable, as evidenced by family association studies. Twin and adoption studies have pointed to the possibility of considerable environmental contributions to their causation. The identification of the chromosome locations and the specific genes is aided by linkage and association studies. Recent large-scale genome-wide association studies have pointed to a large number of genes that may together confer risk to this group of illnesses. These genes include those that have been previously implicated in the pathogenesis of psychotic disorders, such as glutamatergic neurotransmission, brain development and synapse plasticity, ion channels, and immune function. These genes may offer new ways to treat these serious illnesses, which are currently only treated with medications that target one system, namely dopamine.

      This review contains 6 figures, 4 tables, and 58 references.

      Key words: brain development, complement, dopamine, familial, genome, glutamate, immune function, psychosis, schizophrenia

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    • 4

      Neurobiology of Psychotic Disorders

      By Kristin Cadenhead, MD; Jamie Joseph, PhD; Skylar Kelsven, BS; Amedeo Minichino, MD; Heline Mirzakhanian, PhD
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      Neurobiology of Psychotic Disorders

      • KRISTIN CADENHEAD, MDDepartment of Psychiatry, University of California San Diego
      • JAMIE JOSEPH, PHDDepartment of Psychiatry, University of California San Diego
      • SKYLAR KELSVEN, BSSan Diego State University/ University of California San Diego Joint Doctoral Program in Clinical Psychology, Department of Psychiatry, University of California San Diego
      • AMEDEO MINICHINO, MDDipartimento di Neurologia e Psichiatria, Sapienza, Università di Roma
      • HELINE MIRZAKHANIAN, PHDDepartment of Psychiatry, University of California San Diego

      Efforts to prevent or lessen the functional impact of psychosis can be informed by a better understanding of the neurobiological underpinnings at the earliest stages of the disorder. Understanding these processes early in the psychosis spectrum will in turn allow more targeted efforts to prevent or minimize functional limitations among patients with psychosis. Advances in technology have enabled the study of a host of biomarkers implicated in the neurobiology of psychosis offering unique avenues to investigate mechanisms of disease while at the same time shedding some light on more patient-tailored treatments and setting the foundation for personalized medicine in psychosis. Insights into the neurobiology of psychosis are reviewed, including findings from neuroimaging, neurocognitive, and electrophysiologic studies and findings related to the role of hypothalamic-pituitary axis activity and neuroinflammation in the emergence of psychosis. Biomarker-informed treatments are discussed, and potential promising biomarkers and related treatments are proposed.

      This review contains 6 figures, 5 tables, and 89 references. 

      Key words: attenuated risk syndrome, biomarkers, prodrome, psychosis, schizophrenia, treatment 

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  • Sleep and Sexual Disorders
    • 1

      Sexual Dysfunctions

      By Waguih William IsHak, MD, FAPA; Atef Bakhoum, MD, PhD
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      Sexual Dysfunctions

      • WAGUIH WILLIAM ISHAK, MD, FAPADepartment of Psychiatry and Behavioral Sciences, Cedars-Sinai Medical Center; Clinical Professor of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA
      • ATEF BAKHOUM, MD, PHDDepartment of Scientific Research, Freedom Drugs and HIV Program, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt; Overseas Collaborator, George Washington University, Washington, DC

      Sexuality and sexual medicine is an important and often understudied aspect of medicine and psychiatry. Often, patients and physicians avoid conversations having to do with sex. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) defines sexual dysfunctions as “a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure”. This review addresses the diagnostic criteria, epidemiology, etiology, phenomenology, diagnostic work-up, treatment modalities, guidelines, and prognosis for sexual dysfunctions including male hypoactive sexual desire disorder, erectile disorder, premature and delayed ejaculation, female sexual interest/arousal disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorder. The table lists sexual dysfunctions listed in DSM-5 with associated prevalence.

      This review contains 1 figure, 1 table and 20 references

      Key Words: DSM-5, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, painful intercourse, premature ejaculation, sexual dysfunction

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    • 2

      Gender Dysphoria

      By Waguih William IsHak, MD, FAPA; Atef Bakhoum, MD, PhD
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      Gender Dysphoria

      • WAGUIH WILLIAM ISHAK, MD, FAPADepartment of Psychiatry and Behavioral Sciences, Cedars-Sinai Medical Center; Clinical Professor of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA
      • ATEF BAKHOUM, MD, PHDDepartment of Scientific Research, Freedom Drugs and HIV Program, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt; Overseas Collaborator, George Washington University, Washington, DC

      In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), gender dysphoria (GD), previously known as gender identity disorder, is defined as distress or impairment in psychosocial, occupational, educational, or other areas of life due to a perceived disagreement between a person’s assigned gender, natal gender, and the gender currently experienced or expressed for at least 6 months. The DSM-5 mentions that one’s experienced gender may be outside of binary gender stereotypes. Diagnostic criteria are different for GD in children and in adolescents/adults. This review covers the definition, epidemiology, etiology/genetics, clinical manifestations, and studies/tests/treatments related to GD. Tables list the diagnostic criteria for GD and definitions of common terms.

      This review contains 2 tables and 30 references

      Key words: DSM-5, gender dysphoria, sexual reassignment surgery

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    • 3

      Sleep Disorders

      By Sudhansu Chokroverty, MD, FRCP, FACP
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      Sleep Disorders

      • SUDHANSU CHOKROVERTY, MD, FRCP, FACPProfessor and Director of Sleep Research, Medical Director of Devry Technology Training Program, Co-Chair Emeritus of Neurology, Department of Neurology, JFK Neuroscience Institute, Edison, NJ, Professor of Neuroscience, Seton Hall University, South Orange, NJ, Clinical Professor of Neurology, Robert Wood Johnson Medical School, New Brunswick, NJ

      Recent research has generated an enormous fund of knowledge about the neurobiology of sleep and wakefulness. Sleeping and waking brain circuits can now be studied by sophisticated neuroimaging techniques that map different areas of the brain during different sleep states and stages. Although the exact biologic functions of sleep are not known, sleep is essential, and sleep deprivation leads to impaired attention and decreased performance. Sleep is also believed to have restorative, conservative, adaptive, thermoregulatory, and consolidative functions. This review discusses the physiology of sleep, including its two independent states, rapid eye movement (REM) and non–rapid eye movement (NREM) sleep, as well as functional neuroanatomy, physiologic changes during sleep, and circadian rhythms. The classification and diagnosis of sleep disorders are discussed generally. The diagnosis and treatment of the following disorders are described: obstructive sleep apnea syndrome, narcolepsy-cataplexy sydrome, idiopathic hypersomnia, restless legs syndrome (RLS) and periodic limb movements in sleep, circadian rhythm sleep disorders, insomnias, nocturnal frontal lobe epilepsy, and parasomnias. Sleep-related movement disorders and the relationship between sleep and psychiatric disorders are also discussed. Tables describe behavioral and physiologic characteristics of states of awareness, the international classification of sleep disorders, common sleep complaints, comorbid insomnia disorders, causes of excessive daytime somnolence, laboratory tests to assess sleep disorders, essential diagnostic criteria for RLS and Willis-Ekbom disease, and drug therapy for insomnia. Figures include polysomnographic recording showing wakefulness in an adult; stage 1, 2, and 3 NREM sleep in an adult; REM sleep in an adult; a patient with sleep apnea syndrome; a patient with Cheyne-Stokes breathing; a patient with RLS; and a patient with dream-enacting behavior; schematic sagittal section of the brainstem of the cat; schematic diagram of the McCarley-Hobson model of REM sleep mechanism; the Lu-Saper “flip-flop” model; the Luppi model to explain REM sleep mechanism; and a wrist actigraph from a man with bipolar disorder.

      This review contains 14 highly rendered figures, 8 tables, 115 references, and 5 MCQs.

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    • 4

      Clinical Management of Insomnia

      By Timothy Roehrs , PhD; Thomas Roth, PhD
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      Clinical Management of Insomnia

      • TIMOTHY ROEHRS , PHD
      • THOMAS ROTH, PHD

      Insomnia is the most common sleep disorder, with a prevalence of around 20%. The clearest risk factors are female gender and the presence of a psychiatric or medical disorder. The most important conceptual change in our understanding of insomnia, defined in the National Institutes of Health 2005 consensus conference, is that insomnia is a disorder itself rather than a symptom of another disorder. Specifically, insomnia is a disorder of hyperarousal. Insomniacs do not have an abnormal sleep homeostat or circadian system but rather an overactivated wake system. Cognitively, patients often complain they cannot “shut [their] brain down.” Physiologic correlates include elevated brain metabolism, increased fast electroencephalographic activity, and increased autonomic, metabolic, and hypothalamic-pituitary-adrenal axis activity. Treatment for insomnia can be divided into two categories, behavioral and pharmacologic. Another important categorization relates to self-treatment (sleep hygiene and over-the-counter drugs) versus clinician-directed therapy (cognitive-behavioral therapy for insomnia [CBT-I] and prescribed hypnotics). Among behavioral treatments are sleep restriction, stimulus control, relaxation training, and cognitive therapy. The most widely used behavioral therapy is a combination of the four treatment components referred to collectively as CBT-I. The majority of Food and Drug Administration (FDA)-approved hypnotics are drugs that occupy the benzodiazepine receptor site, which is part of the GABAA receptor complex. The hypnotic efficacy of the FDA-approved benzodiazepine receptor agonists (BzRAs) has been well documented using objective polysomnography and subjective measures of sleep induction and duration. Many BzRA side effects are associated with the desired sedative effects of the drug and relate to the pharmacokinetics, receptor subtype affinities, and dose of the drug.

      Key words: behavioral therapy, GABA, histamine, insomnia disorder, melatonin, orexin, pathophysiology, pharmacotherapy

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    • 5

      Paraphilic Disorders

      By Waguih William IsHak, MD, FAPA; Atef Bakhoum, MD, PhD; Lancer Naghdechi, MS, DO
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      Paraphilic Disorders

      • WAGUIH WILLIAM ISHAK, MD, FAPADepartment of Psychiatry and Behavioral Sciences, Cedars-Sinai Medical Center; Clinical Professor of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA
      • ATEF BAKHOUM, MD, PHDDepartment of Scientific Research, Freedom Drugs and HIV Program, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt; Overseas Collaborator, George Washington University, Washington, DC
      • LANCER NAGHDECHI, MS, DOWestern University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA, United States

      Sexuality and sexual medicine are important and often understudied aspects of medicine and psychiatry. Often, patients and physicians avoid conversations regarding sex. A paraphilic disorder is diagnosed when a paraphilia, defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners”, results in distress or impairment to the individual, personal harm, or risk of harm, to others. This review covers the definition, diagnostic criteria, epidemiology, etiology, phenomenology, diagnostic work-up, treatment modalities, guidelines, and prognosis of paraphilias including voyeurism, exhibitionism, frotteurism, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, and transvestic disorder. The table and figure list paraphilic disorders listed in the DSM-5 and paraphilias in the Other specified paraphilic disorders section of the DSM-5.

      This review contains 1 figure, 1 table, and 15 references.

      Key Words: DSM-5, exhibitionism, fetish, frotteurism, paraphilia, paraphilic disorder, pedophilic disorder, sexual masochism disorder, sexual sadism disorder, transvestic disorder, voyeurism

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    • 6

      Parasomnias

      By KyoungBin Im, MD, MS
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      Parasomnias

      • KYOUNGBIN IM, MD, MSCarver College of Medicine, The University of Iowa, Director of Sleep Laboratory of Iowa City VA Mecial Center, Iowa City, IA

      Parasomnias have long been recognized as part of sleep-related disorders or diseases in the mental disorders classification system such as Diagnostic and Statistical Manual of Mental Disorders. Nevertheless, many parasomnia symptoms are considered as a transient deviation from the norm in otherwise normal subjects due to disrupted status of consciousness. Sleep states are classified as rapid eye movement (REM) sleep and non-REM (NREM) sleep; similarly, parasomnias are classified as NREM-related parasomnias and REM-related parasomnias. NREM-related parasomnias share common pathophysiology of arousal-related phenomenon out of slow-wave sleep. Although listed as REM parasomnia disorders, nightmares and sleep paralysis are still considered comorbid symptoms or signs of other sleep disorders or mental disorders. Only REM sleep behavior disorder (RBD) is considered a relatively homogenous disease entity among all parasomnia diagnoses. Although RBD is the most newly added disorder entity in parasomnias, it is the most rigorously studied parasomnia such as RBD is strongly and clearly associated with concomitant or future developing neurodegenerative disease.

      This review contains 1 figure, 4 tables, and 18 references.

      Key Words: confusional arousals, dream enactment, pseudo-RBD, REM sleep behavior disorder, sleep-related eating, sleep terror, sleepwalking

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    • 7

      Gay, Lesbian, and Transgender Issues in Psychiatry

      By Jonathan R. Hester, MD, PGY-2; Julie M. Praus, MD
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      Gay, Lesbian, and Transgender Issues in Psychiatry

      • JONATHAN R. HESTER, MD, PGY-2Department of Psychiatry, Wright State University School of Medicine, Dayton, OH
      • JULIE M. PRAUS, MDAssistant Professor, Department of Psychiatry, Wright State University School of Medicine, Dayton, OH, Dayton Veterans Affairs Medical Center, Dayton, OH

      This review is intended to give an overview of psychiatric considerations for the lesbian, gay, bisexual, and transgender (LGBT) population. The history of LGBT-related diagnoses in the DSM is discussed along with the epidemiology of various mental disorders in the LGBT population, with several diagnoses having a higher incidence including depression, anxiety, substance use disorders, self-harm, and suicidal ideation or attempt. To explain these discrepancies, several theories and models are explored, specifically the minority stress model and adverse childhood events. Additionally, recommendations for clinical psychiatric practice are explored including affirmative therapy and transgender-affirming cognitive behavioral therapy, two interventions specifically studied in the LGBT population as well as overall goals of treatment when treating patients struggling with their gender identity.

      This review contains 5 tables, and 35 references. 

      Key Words: adverse childhood events, affirmative therapy, bisexual, gay, lesbian, LGBT, minority stress, transgender, transgender-affirming cognitive behavioral therapy

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  • Somatic Symptom Disorders
    • 1

      Factitious Disorders

      By Donald W. Black, MD; James Amos, MD; Michael Strong, MD, PGY-2
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      Factitious Disorders

      • DONALD W. BLACK, MD
      • JAMES AMOS, MDClinical Professor of Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, Iowa
      • MICHAEL STRONG, MD, PGY-2 Psychiatry Resident, University of Iowa Hospitals and Clinics, Iowa City, Iowa

      Factitious disorder (FD) is a psychiatric disorder in which patients deliberately perpetrate or lie about medical and/or psychiatric illness in themselves or others. Although it has been thought to be driven by the need to take the patient role, no body of research has clearly identified the underlying motivation, cause, or treatment for it. Illness deception, along with the similarity to other diagnostic categories, such as somatic symptom disorder, personality disorder, and malingering (which is not considered a mental illness but can be a focus of clinical attention), has hindered basic and clinical research into the nature and treatment of FD. Still, moving psychiatric treatment of FD forward can take advantage of tools already available to clinicians, including motivational interviewing techniques to facilitate empathic confrontation in the general hospital. Despite the lack of treatment studies, employing therapies known to be effective for borderline personality disorder, which is similar in many ways to FD, for FD patients willing to participate might be helpful.

      This review contains 4 figures, 5 tables and 26 references

      Key words: factitious disorder imposed on another, factitious disorder imposed on self, malingering, medically unexplained symptoms, Munchausen by proxy, Munchausen syndrome, pseudologia fantastica, somatic symptom disorders 

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    • 2

      Malingering Disorders

      By Christopher Sharp, MD; Scott Simpson, MD, MPH
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      Malingering Disorders

      • CHRISTOPHER SHARP, MDPsychiatric Emergency Services, Denver Health Medical Center, Instructor, University of Colorado School of Medicine, Denver, CO
      • SCOTT SIMPSON, MD, MPHMedical Director, Psychiatric Emergency Services, Denver Health Medical Center, Assistant Professor, University of Colorado School of Medicine, Denver, CO

      Malingering is the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.” Malingering is difficult to identify and a challenge for physicians to manage. There are innumerable incentives for malingering, including financial gain, housing, and controlled substances. Although there is no definitive way to identify malingering, clues that suggest malingering include inconsistencies in the history and examination, discrepancies among collateral informants, and the results of neuropsychological testing. By recognizing how malingering may be a rational, adaptive choice for patients to address their needs, psychiatrists can preserve the doctor-patient relationship and build an alliance to achieve the patient’s goals in a more productive manner. Pitfalls for clinicians treating malingering patients include burnout, aversive countertransference reactions, and inadequate treatment of comorbid medical or psychiatric conditions. Psychiatrists must also be attentive to appropriate documentation and personal safety. The long-term prognosis of malingering patients is not well understood.

      This review contains 5 figures, 7 tables, and 81 references.

      Key words: antisocial personality disorder, confrontation, countertransference, external incentive, factitious disorder, forensic psychiatry, malingering 

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    • 3

      Somatic Symptom Disorder and Related Conditions

      By Stephen Thielke, MD, MS
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      Somatic Symptom Disorder and Related Conditions

      • STEPHEN THIELKE, MD, MSAssociate Professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Investigator, Research, Education, and Clinical Center, Puget Sound Veterans Affairs Medical Center, Seattle, WA

      Somatic symptom disorder (SSD) is a novel construct, first presented in the DSM-5. It has two criteria: distressing or impairing bodily symptoms and excessive or disproportionate thoughts, feelings, or behaviors directed toward those symptoms. The criteria must be applied critically to make sense logically and clinically. The framework does not suggest any causal relationship between the elements. SSD uses a different formulation than in previous constructs, with no requirement that symptoms be medically unexplained. Little research has been conducted about SSD, and it is inappropriate to draw conclusions from similar diagnoses. Therefore, almost nothing is known about epidemiology, natural history, and treatment response in SSD. Health anxiety disorder is similar to SSD, but without significant somatic symptoms. Conversion disorder and factitious disorder entail more specific findings than does SSD. Providers should carefully apply diagnostic criteria for SSD, focus on the individual’s distress, and consider how this diagnosis influences the provider-patient relationship. Future research will refine the understanding of the condition and therapeutic approaches to it.

      This review contains 1 figure, 5 tables, and 39 references.

      Key words: behaviors, conversion disorder, disproportionate, excessive, factitious disorder, feelings, health anxiety, somatic symptom disorder, somatization, thoughts

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    • 4

      Conversion Disorder and Its Clinical Management

      By Anna Borisovskaya, MD; William Carspecken, MD, MSc, MBA; Sonali Kothari, MD; Laura Marie LaPlante, MD; Marcella Pascualy, MD
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      Conversion Disorder and Its Clinical Management

      • ANNA BORISOVSKAYA, MDAssistant Professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Staff Psychiatrist, Veterans Affairs Medical Center, Puget Sound Health Care System, Seattle, WA
      • WILLIAM CARSPECKEN, MD, MSC, MBABonica Scholar and Resident Physician, Department of Anesthesiology & Pain Medicine, University of Washington, Resident Physician, Veterans Affairs Medical Center, Puget Sound Health Care System, Seattle, WA
      • SONALI KOTHARI, MDStaff Psychiatrist, Veterans Affairs Medical Center, Puget Sound Health Care System, Seattle, WA
      • LAURA MARIE LAPLANTE, MDActing Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Staff Psychiatrist, Veterans Affairs Medical Center, Puget Sound Health Care System, Seattle, WA
      • MARCELLA PASCUALY, MDAssociate Professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Consult-Liaison Psychiatry Director, Veterans Affairs Medical Center, Puget Sound Health Care System, Seattle, WA

      This review discusses the complex path to the current definition of conversion disorder (CD), from ancient Egypt to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the way that our understanding of the disorder’s etiology and pathophysiology shaped both its name and its diagnostic criteria. We describe emergence of a comprehensive theory of CD’s pathophysiology, in which an overly sensitive limbic system, shaped by traumatic experiences, changes neural networks responsible for perceptual experiences and movement plans, ultimately producing CD symptoms. We also discuss the importance of early diagnosis of CD as a delayed diagnosis is associated with worse outcomes and precludes appropriate treatment. A variety of diagnostic techniques exist to help distinguish between functional neurologic symptoms and organic disease. Among treatments, we highly recommend therapeutic disclosure of the diagnosis and cognitive-behavioral therapy, which has a small but high-quality evidence base to support its use in the treatment of CD. Collaboration between psychiatrists and neurologists may ensure appropriate diagnosis and treatment of this challenging condition. Prognosis of CD is generally poor, with comorbid personality disorder and delayed diagnosis correlating with worse outcomes.

      This review contains 4 figures, 6 tables, and 87 references.

      Key words: conversion disorder, functional neurologic disorder, hysteria, medically unexplained symptoms, psychogenic movement disorder, psychogenic nonepileptic seizures

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    • 5

      Fibromyalgia as a Biopsychosocial Model for the Intersections of Physical and Emotional Pain

      By Ronne J Proch, DO, MA; Babar Hasan, MD
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      Fibromyalgia as a Biopsychosocial Model for the Intersections of Physical and Emotional Pain

      • RONNE J PROCH, DO, MAWright State University Boonshoft School of Medicine, United States Air Force
      • BABAR HASAN, MDWright State University Boonshoft School of Medicine, Premier Health Systems

      The evaluation and treatment of pain and chronic pain conditions has been a dynamic and perpetually evolving area of focus as we strive towards a more standardized and comprehensive approach informed by ongoing research. The recent emergence of disorders focused on the recognition of the pain experience outside of a definitive physical lesion, specifically Fibromyalgia, has continued to challenge previously held beliefs about pain and our approach to its treatment. This article reviews the history of pain management through review of past and present guidelines and the unintended consequences of the interpretation of these guidelines. The biologic cause and function of pain, types of pain, and the neurologic basis of pain are presented with illustrative figures. Fibromyalgia as a syndrome, its evolving diagnostic criteria according to the American College of Rheumatology, and the insight this disorder gives us into the pharmacologic treatment of chronic pain are discussed.  Psychosocial considerations are also presented as they do play a significant role in both diagnosis and treatment of this order.  Overall the purpose of this article is to better inform treatment plans, recommendations, provider communication, and expectations for pain relief through the understanding that not all pain is the same and thus should not be treated as such. 

      This review contains 6 figures, and 30 references.

      Key Words: Dorsal Horn Neurons, Sensory/Discriminatory Pathways, Emotional/Motivation Pathways, Serotonin, Norepinephrine, Opioids, Endorphins, Peripheral Sensitization, Central Segmental Sensitization, Central Suprasegmental Sensitization, Fibromyalgia

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  • Psychopharmacology
    • 1

      General Psychopharmacology

      By Shadi Doroudgar, PharMD, BCPS, CGP, BCPP; Paul Perry, BPharm, PhD
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      General Psychopharmacology

      • SHADI DOROUDGAR, PHARMD, BCPS, CGP, BCPPAssistant Professor, Clinical Sciences Department, Touro University California College of Pharmacy, Vallejo, California
      • PAUL PERRY, BPHARM, PHDProfessor of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, California, Emeritus Professor of Psychiatry and Pharmacy, University of Iowa, Iowa City, Iowa

      Initial development of neuropsychiatric medications relied heavily on serendipitous discovery rather than targeted drug designs. Nowadays, drug discovery targets include receptors, enzymes, and transporters. The human brain comprises many neurons, each being connected to other neurons via synapses. Neurotransmission occurs when a presynaptic neuron projects its terminal segment to form a connection or synapse with an adjacent postsynaptic neuron. When stimulated, neurotransmitters that are stored in small vesicles in the presynaptic neuron are released into an interneuronal gap called the synaptic cleft. Serotonin, dopamine, norepinephrine, γ-amino butyric acid, glutamate, and acetylcholine are among the primary neurotransmitters and chemicals that play important roles in neuropsychiatric functions. As such, they are often common targets of drug development. Grasping the basics of neurotransmission, enzyme degradation, and receptor and transporter pharmacology is essential in understanding today’s FDA-approved pharmaceuticals. This neuropharmacology primer will allow the rational and appropriate clinical selection of pharmacotherapy and accurate anticipation of clinical effects following use.

      This review contains 1 figure and 45 references

      Key Words: acetylcholine, dopamine, γ-amino butyric acid, glutamate, neurotransmission, norepinephrine, pharmacology, psychiatric medications, psychopharmacology, receptor, serotonin

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    • 2

      Antidepressants

      By Shadi Doroudgar, PharMD, BCPS, CGP, BCPP; Baovy Dang, MS
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      Antidepressants

      • SHADI DOROUDGAR, PHARMD, BCPS, CGP, BCPPAssistant Professor, Clinical Sciences Department, Touro University California College of Pharmacy, Vallejo, California
      • BAOVY DANG, MSPharm D Candidate, Touro University California College of Pharmacy

      Antidepressant medications have numerous clinical uses in the field of psychiatry. There are many antidepressant classes, with the selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors being commonly used in clinical practice for depression and anxiety. Although these medications are effective, complete clinical effect is not rapid and full relief of symptoms can take more than a month. However, side effects with antidepressants can be expected to occur upon initiation of treatment and may lead to patient nonadherence. Education and appropriate patient counseling are necessary to assure that the therapeutic effects of medications are maximized. Treatment with antidepressants should be tailored to patient-specific criteria.

      This review contains 1 figure, 4 tables and 43 references

      Key Words: antidepressants, FDA-approved, obsessive-compulsive disorder, monoamine oxidase, MAOIs, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants.

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    • 3

      Antipsychotics

      By Shadi Doroudgar, PharMD, BCPS, CGP, BCPP; Elham Eftekhari, Pharm D Candidate
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      Antipsychotics

      • SHADI DOROUDGAR, PHARMD, BCPS, CGP, BCPPAssistant Professor, Clinical Sciences Department, Touro University California College of Pharmacy, Vallejo, California
      • ELHAM EFTEKHARI, PHARM D CANDIDATETouro University California College of Pharmacy

      Antipsychotics are used to treat a variety of disorders. They are commonly used in the management of psychiatric symptoms of schizophrenia and bipolar disorder. However, among other uses, they also have shown efficacy in treating symptoms of autism, nausea/vomiting, and hiccups. In the case of psychiatric uses, long-term maintenance treatment is typically needed to avoid relapse of symptoms. Antipsychotic choice based on the efficacy is difficult; therefore, in many cases side-effect profile of an agent becomes relevant when deciding on a treatment regimen. Side effects of antipsychotics include extrapyramidal symptoms, metabolic adverse effects, hematologic changes, anticholinergic effects, and QTc prolongation. As clinicians, it is important to be aware of these side effects and their monitoring parameters. These can be managed by discontinuing a drug, decreasing dosage, changing the drug to a different antipsychotic, and using another drug for their treatment.

      This review contains 5 tables and 97 references

      Key Words: antipsychotics, atypical antipsychotics, clozapine, D2 receptor, extrapyramidal symptoms, FDA-approved, REMS, typical antipsychotics

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    • 4

      Anxiolytics

      By Shadi Doroudgar, PharMD, BCPS, CGP, BCPP; Gurjit Bains, PharmD Candidate
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      Anxiolytics

      • SHADI DOROUDGAR, PHARMD, BCPS, CGP, BCPPAssistant Professor, Clinical Sciences Department, Touro University California College of Pharmacy, Vallejo, California
      • GURJIT BAINS, PHARMD CANDIDATETouro University California College of Pharmacy

      The underlying pathophysiology of anxiety disorders revolve around neurotransmitter transmission, the pharmacologic target of common medication treatments. Pharmacologic treatment of anxiety disorders generally consists of benzodiazepines for short-term relief of anxiety symptoms and antidepressants as a long-term therapy. Benzodiazepines use should be limited because of habit-forming properties, dependence, and risk of adverse effects. Antidepressants are the typically preferred initial agents for long-term use due to efficacy and lack of dependence. Anxiety disorders may occur as comorbidities with other psychiatric disorders. Other pharmacologic agents are utilized as alternative therapy for patients who do not respond to mainstay therapy or are not candidates for the treatment with antidepressants.

      This review contains 1 figure, 6 table and 77 references

      Key Points: anxiety disorders, benzodiazepines, generalized anxiety disorder, norepinephrine, panic disorder, social anxiety disorder, selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors

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    • 5

      Mood Stabilizers: Implementing Combined Treatment Regimens in Bipolar Disorder

      By Charles Bowden, MD; Melissa Martinez, MD
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      Mood Stabilizers: Implementing Combined Treatment Regimens in Bipolar Disorder

      • CHARLES BOWDEN, MDNancy U. Karren Endowed Chair of Psychiatry, Clinical Professor of Psychiatry and Pharmacology, Departments of Psychiatry and Pharmacology University of Texas Health Science Center, San Antonio, TX
      • MELISSA MARTINEZ, MDAssociate Professor of Psychiatry University of Texas Health Science Center, San Antonio, TX

      Patients with bipolar disorders spend a greater proportion of their illness in a depressed or mixed state rather than experiencing either mania or hypomania. Over the past 20 years, most major pharmaceutical companies have either reduced or abandoned the research and development of novel psychiatric drugs, exiting the development of new, safe, efficacious, and tolerable treatment regimens for bipolar disorder. Therefore, optimizing the current treatments available is critical. We review studies of the last 15 years that provide guidance relevant to managing the maintenance phase of bipolar disorders. Based on these data, we provide recommendations for effective treatment planning and implementation, principally for the maintenance phase care of persons with bipolar disorder. We also discuss strategies for implementing medication regimens, differentiating strategies for maintenance phase treatment from those of acute phase treatment. Assessing key symptoms that are sensitive to change is critical for longitudinal assessments and treatment planning for patients with bipolar disorders. In most studies, only a subset of rating scale items differentiate patients with good responses from those without. Identified symptoms include racing thoughts, less need for sleep, hyperactivity, increased activity, and increased energy. We developed a procedure for using Multistate Outcome Analysis of Treatment (MOAT) in bipolar disorders. MOAT integrates efficacy and tolerability data during studies to provide information about the quantity and quality of time spent in distinct mood states. The protocol developed will be useful for assessing treatment strategies in bipolar disorder.


      This review contains 4 figures, 7 tables and 32 references

      Key words: bipolar, depression, lithium, mania, mixed, mood stabilizer, survival analysis, symptom domains, valproate

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    • 6

      Neuroleptic Malignant Syndrome and Serotonin Syndrome

      By Richard Sanders, MD; Richard Krysiak, MD
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      Neuroleptic Malignant Syndrome and Serotonin Syndrome

      • RICHARD SANDERS, MDBoonshoft School of Medicine, Wright State University, Dept. of Psychiatry
      • RICHARD KRYSIAK, MDBoonshoft School of Medicine, Wright State University, Dept. of Psychiatry

      Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) are iatrogenic life-threatening conditions with similar clinical symptoms. Altered mental status, rigidity, and autonomic instability are common in both serotonin overload and toxic dopamine antagonism. It is paramount that providers understand the key differences between these two pathologies, as pharmacologic treatments can exacerbate the condition if SS is mistaken for NMS or vice versa. Hyperreflexia, clonus, diarrhea, and vomiting suggest the excessive activity of serotonin circuits in SS, whereas prominent rigidity and hyporeflexia suggest the underactivity of dopamine circuits in NMS. Supportive care and discontinuing the offending agent(s) are keys to treating both syndromes, but serotonin antagonists (eg, cyproheptadine) could be helpful in SS, whereas NMS may sometimes benefit from muscle relaxants (eg, dantrolene) and dopamine agonists (eg, bromocriptine). Following recovery, decisions about further use of an inciting agent (or similar agents) require reconsideration of risks, benefits, and alternatives, based on newly realized hazards. It is usually important to wait at least 2 weeks before rechallenge with any drugs resembling the inciting agents.

      This review contains 1 figure, 5 tables, and 29 references.

      Key Words: bromocriptine, cyproheptadine, dantrolene, Hunter criteria, neuroleptic malignant syndrome, parkinsonism, serotonin syndrome

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    • 7

      Psychopharmacology for Substance Use Disorders

      By Olapeju Simoyan, MD, MPH, BDS, FAAFP, FASAM; Krista Ulisse, DO
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      Psychopharmacology for Substance Use Disorders

      • OLAPEJU SIMOYAN, MD, MPH, BDS, FAAFP, FASAMProgram Director, Geisinger Marworth Addiction Medicine Fellowship, Waverly, PA Associate Professor, Geisinger Commonwealth School of Medicine, Scranton, PA
      • KRISTA ULISSE, DOResident in Psychiatry Geisinger Medical Center, Danville, PA

      The illicit use of opioids is the fastest growing substance use problem in the United States. There are three FDA- approved medications for maintenance treatment for opioid use disorder: methadone, buprenorphine and naltrexone. Stimulants include cocaine and methamphetamines. 3,4-methylenedioxymethamphetamine (MDMA or “ecstasy”) is an amphetamine derivative that also has hallucinogenic properties. Treatment of stimulant withdrawal is primarily supportive. Psychosocial interventions for stimulant use disorder may improve adherence, but they have not been shown to improve abstinence at the end of treatment. Benzodiazepines have been shown to reduce the severity and duration of symptoms related to alcohol withdrawal, in addition to reducing the risk of seizures. The Food and Drug Administration has approved disulfiram, acamprosate and naltrexone for the treatment of alcohol use disorder.

      This review contains 2 tables, and 30 references.

      Keywords: Opioid use disorder, maintenance treatment for opioid use disorder, stimulant use disorder, stimulant withdrawal, benzodiazepine overdose, benzodiazepine withdrawal, alcohol use disorder, alcohol withdrawal

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  • Other
    • 1

      Consult-liaison (psychosomatic) Psychiatry

      By Tracy D. Gunter, MD
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      Consult-liaison (psychosomatic) Psychiatry

      • TRACY D. GUNTER, MD
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    • 2

      Overview of Forensic Psychiatry

      By Tracy D. Gunter, MD
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      Overview of Forensic Psychiatry

      • TRACY D. GUNTER, MD
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    • 3

      Overview of Ethics in Psychiatry

      By Cheryl Erwin, JD, PhD; Janeta Tansey, MD, PhD
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      Overview of Ethics in Psychiatry

      • CHERYL ERWIN, JD, PHDAssociate Professor, Director, Center for Ethics, Humanities & Spirituality, Texas Tech University Health Sciences Center, School of Medicine, Graduate School of Biomedical Sciences, Lubbock, TX
      • JANETA TANSEY, MD, PHDPrincipal, Virtue Medicine, Iowa City, IA

      This review of psychiatry ethics is intended for residents, fellows, and practicing psychiatrists. We provide an overview of the historical sources of ethical reasoning and give practitioners a structured method for analysis of ethical dilemmas typically encountered in the practice of medicine. Through the use of case examples, we explain how difficult situations often challenge received knowledge and superficial opinion about the ethical options present and justifiable in real-life situations. This review will appeal to the higher callings and traditions of medicine and encourage the physician who is faced with ethical decisions about which reasonable practitioners may disagree. Tools of ethical reasoning provide a means for making ethical decisions that are grounded in history and tradition.

      This review contains 1 figure, 6 tables, and 30 references.

      Key words: confidentiality, decision making, doctor-patient relationship, ethics, informed consent, narrative, principles, professionalism, respect, virtue

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    • 4

      Cultural Diversity in Psychiatry

      By Joanna Chambers, MD; Mary Guerriero Austrom, PhD; Ryan Harris, MD; Danielle Patterson, MD
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      Cultural Diversity in Psychiatry

      • JOANNA CHAMBERS, MDDepartment of Psychiatry and Office of Diversity Affairs, Indiana University School of Medicine, Indianapolis, IN
      • MARY GUERRIERO AUSTROM, PHDDepartment of Psychiatry and Office of Diversity Affairs, Indiana University School of Medicine, Indianapolis, IN
      • RYAN HARRIS, MDDepartment of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
      • DANIELLE PATTERSON, MDDepartment of Psychiatry, Indiana University School of Medicine, Indianapolis, IN

      This purpose of this review is to provide general guidelines to practicing psychiatrists and psychologists on cultural diversity in the discipline. Diversity and mental health is a complex topic in a complex discipline, and our goal is to contribute to an understanding of how cultural identity affects our work. This review does not explicitly state how to treat any one cultural group. Rather, it is a tool for psychiatrists and other mental health providers to begin a sensitive and helpful conversation with patients of all backgrounds and a way to explore their own cultural identities. As our nation becomes increasingly diverse, providers are expected to understand how a patient’s cultural identity impacts the presenting problem and, ultimately, treatment. In addition, an ever-present opportunity remains for mental health professionals to explore their own cultural identity and how it may be involved in conscious and unconscious biases, which, in turn, also impact how they interpret, treat, and manage care. We explore key aspects of diversity with the goal of cultivating a deeper level of insight and awareness among psychiatrists in training and those currently in practice when caring for patients with diverse backgrounds. The guidelines offer a starting point toward delivering culturally competent care and, coupled with a commitment to lifelong learning from psychiatrists and other mental health professionals, can help minimize the stigma of traditionally marginalized groups. 

      This review contains 7 tables, and 67 references. 

      Key words: aging, diversity, LGBTQ, psychiatry, race, religion 

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    • 5

      Overview of Legal Issues in Psychiatry

      By Tracy D. Gunter, MD
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      Overview of Legal Issues in Psychiatry

      • TRACY D. GUNTER, MD

      Psychiatrists routinely encounter legal and regulatory issues in the practice of psychiatry. This review provides an overview of the psychiatrist’s duties and responsibilities in the doctor-patient relationship and common legal issues arising in clinical practice, with reference to US statutory and regulatory practices. The field of forensic psychiatry is described, and the roles of the forensic evaluator and the treatment provider are compared.

      This review contains 2 figures, 5 tables, and 64 references.

      Key words: civil commitment, confidentiality, duty to third parties, forensic psychiatry, guardianship, gun ownership, medical decision making, medical marijuana, risk assessment 

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    • 6

      Mistreatment of Elders

      By Emily I Gorman, MD; Judith Linden, MD
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      Mistreatment of Elders

      • EMILY I GORMAN, MDDepartment of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA
      • JUDITH LINDEN, MDAssociate Professor and Vice Chair for Education, Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA

      Elder mistreatment affects a considerable proportion of individuals older than 60 to 65 years of age and may include intentional abuse (physical, sexual, emotional, or financial) and neglect. As the proportion of the population that is older than 65 years of age increases, elder mistreatment will become an increasingly common issue. Only a minority of cases of elder abuse are reported; thus, an interview with the patient should be conducted in private if elder mistreatment is suspected. Patient risk factors for elder mistreatment include cognitive or behavioral impairment, poor physical health, and poor social supports. This review examines the approach to the patient, as well as definitive treatment, disposition, and outcomes for victims of elder abuse. The figure shows an algorithm for elder abuse assessment and intervention. Tables list types of elder abuse, factors predisposing to elder mistreatment, indicators of abuse, and the Elder Abuse Suspicion Index.

      This review contains 1 highly rendered figure, 4 tables, and 42 references.

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    • 7

      Headache and Facial Pain

      By Elizabeth W. Loder, MD, MPH
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      Headache and Facial Pain

      • ELIZABETH W. LODER, MD, MPHAssociate Professor of Neurology, Harvard Medical School, Chief, Division of Headache and Pain, Department of Neurology, Brigham and Women’s Hospital, Boston, MA

      Headaches are a near-universal experience, with a 1-year prevalence of 90% and a lifetime prevalence of 99%. Headaches and pain to the head account for roughly 3% of visits to US emergency departments annually, making them the fourth most common reason for seeking emergency care. There are numerous types of headaches, and although the majority are benign, types exist that may result from serious and potentially life-threatening causes. As such, it is important for the physician to consider a broad differential diagnosis for every headache patient. This review discusses the classification of headaches, identifies pain-sensitive structures in the head, discusses the history and examination in patients with headache, and describes many of the primary and secondary headaches. Figures show the areas of the brain sensitive to pain; 1-year prevalence of migraine in men, women, and children; frequency of attacks in migraineurs; prevalence of headaches by age group and in patients with cerebrovascular disorders; and symptoms of idiopathic intracranial hypertension. Tables list the major categories of headache disorders, key elements of the headache history, helpful questions to ask, features of selected primary and secondary headaches, reasons to consider neuroimaging, efficacy of selected over-the-counter medications, triptans available in the United States, medication options for urgent or emergency treatment of migraine, selected preventive medications for migraine, generally accepted indications for preventive treatment, general principles for the use of preventive medications, titration schedules for preventive medication, interval or short-term preventive treatment of menstrual migraine, strategies for managing increase in migraines in patients starting estrogen replacement therapy, transition medications for rapid, temporary suppression of headaches, medications possibly effective for cluster and hypnic headaches, differential diagnosis of the acute, severe, new-onset headache, and etiologies of papilledema and headache.

      This review contains 6 highly rendered figures, 20 tables, and 112 references.

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    • 8

      Delirium

      By Sarah Wagner, DO; Robert Gerstman, DO
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      Delirium

      • SARAH WAGNER, DOResident Psychiatrist, Geisinger Medical Center, Danville, PA
      • ROBERT GERSTMAN, DOStaff Psychiatrist, Geisinger Medical Center, Danville, PA

      Delirium is a disturbance of attention and awareness, which develops over a short period of time. It is a change in a person’s baseline and fluctuates throughout the course of the day.1 Delirium can accompany almost any serious medical illness. It is an independent risk factor for increasing a person’s morbidity and mortality. Delirium is associated with an increased length of hospital stay and an increase in health care cost.2 There is growing literature to assist in the diagnosing and treatment of patients with delirium. This article dives into the recent research addressing the pharmacologic and nonpharmacologic methods to treat delirium. Various pharmacologic interventions have been studied over the past several years including the use of melatonin, ramelteon, dexmedetomidine, and antipsychotics.

      This review contains 2 tables and 17 references.

      Key Words: acute brain failure, altered mental status, Confusion Assessment Method, critical care, delirium, encephalopathy, ICU, RASS, Richmond Agitation-Sedation Scale

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    • 9

      Women’s Health: Treating Survivors of Sexual Assault

      By Elizabeth Schindler, DO; Allison Cowan, MD
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      Women’s Health: Treating Survivors of Sexual Assault

      • ELIZABETH SCHINDLER, DOPsychiatry Resident, Wright State University, Dayton, OH,
      • ALLISON COWAN, MDAssistant Professor, Department of Psychiatry, Wright State University, Dayton, OH

      Almost half of all women and almost a quarter of all men in the United States have experienced sexual violence in their lifetime. Treating individuals who have survived sexual assault can pose challenges for psychiatric and medical treatment. The rates of posttraumatic stress disorder (PTSD) are higher with sexual assault, and people with sexual trauma often feel stigmatized and have difficulty presenting for care. This chapter reviews epidemiology and neurobiology of sexual assault as well as the physical and psychological sequelae of sexual assault. Here, the authors review and propose practical treatment recommendations to assist in the treatment of individuals with a history of sexual assault.

      This review 5 figures, 5 tables, and 53 references.

      Key Words: posttraumatic stress disorder, rape recovery, sexual assault, treatment recommendations, women’s mental health, rape survivor treatment, rape

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    • 10

      Psychiatry and Interpersonal Communication

      By Brent D Schnipke, MD; Randon S Welton, MD
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      Psychiatry and Interpersonal Communication

      • BRENT D SCHNIPKE, MDResident, PGY-1, Department of Psychiatry, Wright State University, Dayton, OH
      • RANDON S WELTON, MDAssociate Professor of Psychiatry, Director, Residency Training Program, Department of Psychiatry, Wright State University, Dayton, OH

      Interpersonal and communication skills (ICS) are central to the practice of psychiatry. These skills are broad and can be defined in several ways, and several frameworks are presented, using the Accreditation Council for Graduate Medical Education competencies as well as other published guidelines. ICS are essential to good patient care and require special knowledge in psychiatry due to the particular diseases that are encountered. ICS are equally valuable to psychiatrists in communicating with family members, other physicians, and other members of the healthcare team, as well as in education and leadership. Recommendations for adapting ICS to these circumstances are outlined. For psychiatry trainees, regular evaluation of ICS is mandated but is also recommended for practicing psychiatrists. If deficiencies are noted, strategies for addressing them can be pursued, and suggested improvement practices are provided.

      This review contains 2 figures, 4 tables, and 21 references.

      Key Words: communication, communication skills, consultation-liaison psychiatry, doctor-patient communication, interpersonal, psychiatry, psychotherapy, therapeutic alliance, rapport

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    • 11

      Resource Management: Parity and Access to Care

      By Destry L. East, D.O, PGY3; Ryan P. Peirson, MD
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      Resource Management: Parity and Access to Care

      • DESTRY L. EAST, D.O, PGY3Wright State Psychiatry Residency, [email protected]
      • RYAN P. PEIRSON, MDAssistant Professor of Psychiatry, Wright State University Boonshoft School of Medicine, [email protected]

      The current structure of our mental health parity laws are a combination of multiple bills at the national and state levels which have been passed since the original Mental Health Parity and Addiction Act of 2008 (MHPAEA). With the MHPAEA only employer-provided insurance programs that covered 50 or more employees and covered mental health services were required to have parity between mental health and physical health coverage. With the passage of the Affordable Care Act in 2010 and its essential benefit mandate (which required the coverage of mental health services) the MHPAEA broadened its reach to include smaller health plans and some Medicaid plans. Reforms in Medicare, CHIP and Tricare also have included parity between mental health and physical health coverage. Despite these changes there is still work needed in regards to state parity laws and better access to care.

      This review contains 5 figures, and 25 references.

      Key Words: Parity, Mental Health, Access, Coverage, MHPA, MHPAEA, NQTL, Essential Health Benefits

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  • Physician Competencies and Mechanisms
    • 1

      Complementary, Alternative, and Integrative Medicine

      By Helene M. Langevin, MD
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      Complementary, Alternative, and Integrative Medicine

      • HELENE M. LANGEVIN, MDDirector, Osher Center for Integrative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

      Complementary and alternative medicine (CAM) refers to a group of diverse medical and health care systems, practices, and products that are not considered to be part of conventional or allopathic medicine. Common CAM practices (e.g., acupuncture, meditation, and therapeutic massage) are gradually becoming incorporated into conventional care in response to patients looking to alternative sources for information and advice about health matters and increased understanding of various CAM methods through evidence-based testing. However, although the claims of some methods are supported with academic research, well-founded concerns remain in many popularized CAM practices regarding the lack of evidence and placebo effects. It is thus imperative for physicians to be comfortable in discussing CAM-related topics with patients and be able to appropriately and informatively guide them in a way that harnesses potential benefits and avoids potential harm. In this review, the major CAM therapies in the United States are examined, including the settings in which they are being used, evidence base status, and efficacy of some of the most commonly used modalities. 

      This review contains 5 figures, 21 tables, and 123 references.

      Keywords: Alternative medicine, complementary medicine, acupuncture, homeopathy, osteopathy, chiropractic, massage therapy, naturopathy

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  • Neurology
    • 1

      The Neurologic Examination

      By Nicholas J Beimer, MD; Douglas J Gelb, MD, PhD
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      The Neurologic Examination

      • NICHOLAS J BEIMER, MDClinical Instructor, Department of Neurology, University of Michigan, Ann Arbor, MI
      • DOUGLAS J GELB, MD, PHDProfessor, Department of Neurology, University of Michigan, Ann Arbor, MI

      All physicians, regardless of their medical specialty or the setting in which they treat patients, must be able to perform a neurologic examination. In the outpatient office, up to 9 to 10% of all symptoms suggest the possibility of neurologic disease and up to 5% of emergency department visits are due to primary neurologic disease. The neurologic examination is critical in triaging these patients, selecting diagnostic tests, and indicating management. This review covers how to think about the neurologic examination, the screening examination, and diagnosis-focused neurologic examinations with an emphasis on stroke, epilepsy, encephalopathy and coma, neurodegenerative diseases, neuromuscular disease, and functional disorders. The figure shows a conceptual approach to the neurologic examination. The tables list components of the screening neurologic examination, neurologic examination focus points for suspected stroke and suspected epilepsy, lateralization and localization of common seizure semiologies, and neurologic examination focus points for encephalopathy/coma, suspected neurodegenerative disease, suspected neuromuscular disease, and suspected functional neurologic disorders.

      This review contains 1 highly rendered figure, 8 tables, and 14 references.

      Key words: Neurologic examination, neurodegenerative disease, neuromuscular disease, neurologic screening

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    • 2

      Neuroimaging for the Clinician

      By Joshua P Klein, MD, PhD
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      Neuroimaging for the Clinician

      • JOSHUA P KLEIN, MD, PHDChief, Division of Hospital Neurology, Department of Neurology, Brigham and Women’s Hospital, and Assistant Professor of Neurology, Harvard Medical School, Boston, MA

      Modern neuroimaging has revolutionized the practice of neurology by allowing visualization and monitoring of evolving pathophysiologic processes. High-resolution magnetic resonance imaging (MRI) can now resolve structural abnormalities on a near-cellular level. Advances in functional imaging can assess the in vivo metabolic, vascular, and functional states of neuronal and glial populations in real time. Given the high density of data obtained from neuroimaging studies, it is essential for the clinician to take an active role in understanding the nature and significance of imaging abnormalities. This chapter reviews computed tomography and MRI techniques (including angiography and advanced sequences), specialized protocols for investigating specific diagnoses, risks associated with imaging, disease-specific imaging findings with general strategies for interpretation, and incidental findings and artifacts. Figures include computed tomography, T1- and T2-weighted signal intensity, diffusion-weighted magnetic resonance imaging, magnetic resonance spectroscopy, imaging in epilepsy and dementia, extra-axial versus intra-axial lesions, typical lesions of multiple sclerosis, spinal imaging, spinal pathology, vascular pathology, intracranial hemorrhage, and common imaging artifacts. Tables list Hounsfield units, patterns of enhancement from imaging, advanced techniques in imaging, magnetic resonance imaging sequences, and the evolution of cerebral infarction and intraparenchymal hemorrhage on magnetic resonance imaging.

      This chapter contains 213 references.

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    • 3

      Movement Disorders

      By Bradley J. Robottom, MD; Jason S. Hawley, MD; William J. Weiner, MD
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      Movement Disorders

      • BRADLEY J. ROBOTTOM, MDAssistant Professor, Department of Neurology, University of Maryland School of Medicine
      • JASON S. HAWLEY, MDUS Army, Movement Disorders Service, Department of Neurology, Walter Reed Army Medical Center
      • WILLIAM J. WEINER, MDProfessor and Chairman, Department of Neurology, University of Maryland School of Medicine

      The term movement disorders encompasses a wide range of conditions that cause abnormal movements. This review discusses hypokinetic movement disorders, including bradykinesia, akinesia, akinetic rigid syndrome, and Parkinsonism, an akinetic rigid syndrome that is one of the most common of all the movement disorders which is most often a manifestation of Parkinson disease (PD). The review looks at the epidemiology, etiology, pathology, diagnosis, treatment, and management of PD. Other parkinsonian syndromes include progressive supranuclear palsy, corticobasal syndrome, multiple system atrophy, vascular parkinsonism, normal pressure hydrocephalus, drug-induced parkinsonism, and dementia associated with Parkinson disease. Hyperkinetic movement disorders include tremor, dystonia, tics, myoclonus, and chorea. They include Huntington disease, Wilson disease, tardive dyskinesia, Tourette syndrome, and essential tremor. Figures in this review include examples of generalized dystonia, moderate parkinson disease, affected handwriting, Kayser-Fleischer ring, cervical dystonia, head deviation, and writer's cramp. Tables provide clinical definitions, clues to drug-induced parkinsonism, and a list of drugs that can cause parkinsonism.

      This review contains 129 references.

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    • 4

      Pain Syndromes Other Than Headache

      By Edgar L. Ross, MD
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      Pain Syndromes Other Than Headache

      • EDGAR L. ROSS, MD

      Pain is experienced within a complex biologic, emotional, psychological, and social context that may defy physical examination, diagnostic procedures, and laboratory tests. This chapter aims to empower internists to improve their medical practices in pain management. It provides a scientific background that covers nociception and how sensory processing occurs at multiple levels in the body. Clinical assessment is detailed, as well as diagnostic categories that include mixed or uncertain chronic pain syndromes (back pain, fibromyalgia, postamputation pain, pain from cancer and bone) and neuropathic pain syndromes (polyneuropathy, mononeuropathy multiplex, ganglionopathy, genetic disorders, focal and regional syndromes). Treatment of chronic pain can be surgical or interventional. Pharmacologic treatment for acute and chronic nociceptive pain includes special considerations for geriatric and terminal patients. For treatment of neuropathic pain, medications are the major component. One tables lists iatrogenic nerve injuries that can cause posttraumatic neuralgia and complex regional pain syndrome. Other tables detail stepwise pharmacologic management of neuropathic pain and cite recommendations on opioid use from the Centers for Disease Control and Prevention. One figure illustrates how pain transducers monitor and influence tissue conditions. Other figures show sensory processing in the spinal cord dorsal horn, physical findings in the feet of patients with bilateral foot pain from small-fiber polyneuropathy, illustrate how examination can identify specific nerve injuries causing chronic pain, and provide classification of chronic pain syndromes. This chapter contains 82 references.

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    • 5

      Dizziness

      By Kevin A. Kerber, MD, MS; Robert W. Baloh, MD
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      Dizziness

      • KEVIN A. KERBER, MD, MSAssistant Professor, Department of Neurology, University of Michigan, Ann Arbor, MI
      • ROBERT W. BALOH, MDProfessor, Departments of Neurology and Surgery (Head and Neck), UCLA Medical Center, Reed Neurological Research Center, Los Angeles, CA

      Dizziness is the quintessential symptom presentation in all of clinical medicine. It is a common reason that patients present to a physician. This chapter provides background information about the vestibular system, then reviews key aspects of history-taking and examination of the patient, then discusses specific disorders and common presentation types. Throughout the chapter the focus is on neurologic and vestibular disorders. Normal vestibular anatomy and physiology are discussed, followed by recommendations for history-taking and the physical examination. Specific disorders that cause dizziness are explored, along with common causes of non-specific dizziness. Common presentations are discussed, including acute severe dizziness, recurrent attacks, and recurrent positional vertigo. Finally, the chapter looks at laboratory investigations in diagnosis and management. Figures include population prevalence of dizziness symptoms, the anatomy of inner structures, primary afferent vestibular nerve activity, the head thrust test, the Dix-Hallpike maneuver, the supine positional test, the canalith repositioning procedure, and the barbecue roll maneuver. Tables list physiologic properties and clinical features of the components of the peripheral vestibular system, information to be acquired from history of the present illness, common symptoms patients report as dizziness, examination components, distinguishing among common peripheral and central vertigo syndromes, common causes of nonspecific dizziness, types of dizziness presentations, relevant imaging abnormalities on neuroimaging studies, vestibular testing components, and medical therapy for symptomatic dizziness.

      This review contains 8 highly rendered figures, 10 tables, and 68 references.

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    • 6

      Stroke and Other Cerebrovascular Diseases

      By Scott E. Kasner, MD, MSCE, FAHA, FAAN; Christina A Wilson, MD, PhD
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      Stroke and Other Cerebrovascular Diseases

      • SCOTT E. KASNER, MD, MSCE, FAHA, FAANProfessor, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Director, Comprehensive Stroke Center, University of Pennsylvania Health System, Philadelphia, PA
      • CHRISTINA A WILSON, MD, PHDAssistant Professor, Department of Neurology, University of Florida, Gainesville, FL

      Stroke is a leading cause of neurologic morbidity and mortality, and rapid treatment is key for a good outcome. This review addresses the epidemiology, common presenting symptoms, causes, and treatment of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Current recommendations for the emergent evaluation and treatment of an acute ischemic stroke are highlighted, including recently updated indications and contraindications for intravenous recombinant tissue plasminogen activator administration and recent guidelines for the expanded role of endovascular mechanical embolectomy for stroke due to acute large vessel occlusion. An algorithm of diagnostic evaluations to assist with identification of the cause of ischemic stroke is offered. Evidence-based primary and secondary stroke prevention is discussed, including the ideal choice of antithrombotic based on identified stroke mechanism and optimal risk factor management. Best practice supportive measures for the post-stroke patient are highlighted, including recent guidelines for the management of elevated intracranial pressure. Management of uncommon causes of ischemic stroke is also addressed. 

      Key Words: Intracerebral hemorrhage, ischemic stroke, recombinant tissue plasminogen activator, subarachnoid hemorrhage

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    • 7

      Encephalitis

      By Shamik Bhattacharyya, MD; Jennifer L. Lyons, MD
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      Encephalitis

      • SHAMIK BHATTACHARYYA, MDDivision of Neurological Infections, Department of Neurology Brigham and Women’s Hospital and Harvard Medical School Boston, MA
      • JENNIFER L. LYONS, MDDivision of Neurological Infections, Department of Neurology Brigham and Women’s Hospital and Harvard Medical School Boston, MA

      In 2013, the International Encephalitis Consortium proposed clinical criteria for acute encephalitis consisting of 24 hours of altered level of consciousness, lethargy, or personality change and at least three additional supportive features. Although viruses are the most common cause of acute encephalitis, not all encephalitides are acute, viral, or even infectious. Chronic encephalitis can be pathologically similar to acute encephalitis, but the causative agents and clinical manifestations vary. Management of encephalitis is largely supportive; however, for many common encephalitides primary preventive approaches exist. This module reviews the epidemiology, manifestations, diagnosis, management, and prevention of various encephalitides, including herpes family encephalitis (herpes simplex virus, varicella-zoster virus, cytomegalovirus, human herpesvirus 6), arbovirus encephalitis (West Nile virus, eastern equine encephalitis virus, tick-borne encephalitis virus, Japanese encephalitis virus), other encephalitides associated with viruses (influenza virus, human immunodeficiency virus, John Cunningham virus, rabies virus), encephalitides associated with bacteria (Mycoplasma pneumonia, Listeria monocytogenes), and autoimmune encephalitis (acute disseminated encephalomyelitis, paraneoplastic and other autoimmune encephalitides, immune reconstitution inflammatory syndrome). Tables include the International Encephalitis Consortium’s supportive feature of encephalitis, differential diagnosis for magnetic resonance imaging (MRI) findings in the patient with suspected encephalitis, diagnostic considerations for triaging workup of infection-associated encephalitis, differential diagnosis of arboviral infections by location of travel or residence, and preventive strategies for select infectious encephalitis. Figures include MRIs showing patients with herpes simplex encephalitis, varicella-zoster virus, eastern equine encephalitis, HIV, Listeria monocytogenes, acute disseminated encephalomyelitis, acute hemorrhagic leukoencephalitis, and immune reconstitution inflammatory syndrome.

      This module contains 8 highly rendered figures, 5 tables, 78 references, and 5 MCQs.

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    • 8

      Ataxias

      By Hélio A G Teive, MD, PhD; Orlando G P Barsottini, MD, PhD
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      Ataxias

      • HÉLIO A G TEIVE, MD, PHDAssociate Professor of Neurology, Internal Medicine Department, Neurology Service, Ataxia Unit, Universidade Federal do Paraná
      • ORLANDO G P BARSOTTINI, MD, PHDAdjunct Professor of Neurology, Department of Neurology and Neurosurgery, Division of General Neurology and Ataxia Unit, Universidade Federal de São Paulo

      Ataxia is a disorder of balance and coordination. The most common forms are cerebellar ataxia and afferent/sensory ataxia. Ataxias can be classified as primary or secondary, as well as hereditary, nonhereditary degenerative, and sporadic. This review covers the primary (congenital, hereditary, and nonhereditary degenerative ataxias) and secondary cerebellar ataxias and afferent/sensory ataxias. Hereditary ataxias are classified as autosomal recessive cerebellar ataxias (such as Friedreich ataxia and ataxia-telangiectasia), autosomal dominant cerebellar ataxias (currently known as spinocerebellar ataxias, such as spinocerebellar ataxia type 3 or Machado-Joseph disease), episodic ataxias, X-linked cerebellar ataxias, and mitochondrial ataxias. Idiopathic degenerative cerebellar ataxias include the cerebellar form of multiple system atrophy (MSA-C) and idiopathic late-onset cerebellar ataxias. Secondary cerebellar ataxias or acquired ataxias include ataxias due to exogenous or endogenous nongenetic causes, such as toxic, paraneoplastic, immune mediated, nutritional, infectious, and secondary to focal injury to the cerebellum. Afferent/sensory ataxia represents a special group of ataxias with many possible causes and is associated with peripheral neuropathies, dorsal root ganglionopathies, sensory nerve root involvement, and posterior spinal column involvement. Figures show several clinical and radiologic (magnetic resonance imaging) signs of autosomal recessive, autosomal dominant ataxias, and multiple system atrophy (type C). Tables list the most common neurologic signs of cerebellar and afferent/sensory ataxias, the main forms of autosomal recessive and autosomal dominant cerebellar ataxias, and the most common causes of secondary cerebellar and afferent/sensory ataxias.

      Key words: afferent/sensory ataxias, ataxias, autosomal recessive cerebellar ataxias, congenital ataxias, nonhereditary degenerative ataxias, secondary cerebellar ataxias, spinocerebellar ataxias

      This review contains 5 highly rendered figures, 4 tables, and 99 references.

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    • 9

      Headache and Facial Pain

      By Elizabeth W. Loder, MD, MPH
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      Headache and Facial Pain

      • ELIZABETH W. LODER, MD, MPHAssociate Professor of Neurology, Harvard Medical School, Chief, Division of Headache and Pain, Department of Neurology, Brigham and Women’s Hospital, Boston, MA

      Headaches are a near-universal experience, with a 1-year prevalence of 90% and a lifetime prevalence of 99%. Headaches and pain to the head account for roughly 3% of visits to US emergency departments annually, making them the fourth most common reason for seeking emergency care. There are numerous types of headaches, and although the majority are benign, types exist that may result from serious and potentially life-threatening causes. As such, it is important for the physician to consider a broad differential diagnosis for every headache patient. This review discusses the classification of headaches, identifies pain-sensitive structures in the head, discusses the history and examination in patients with headache, and describes many of the primary and secondary headaches. Figures show the areas of the brain sensitive to pain; 1-year prevalence of migraine in men, women, and children; frequency of attacks in migraineurs; prevalence of headaches by age group and in patients with cerebrovascular disorders; and symptoms of idiopathic intracranial hypertension. Tables list the major categories of headache disorders, key elements of the headache history, helpful questions to ask, features of selected primary and secondary headaches, reasons to consider neuroimaging, efficacy of selected over-the-counter medications, triptans available in the United States, medication options for urgent or emergency treatment of migraine, selected preventive medications for migraine, generally accepted indications for preventive treatment, general principles for the use of preventive medications, titration schedules for preventive medication, interval or short-term preventive treatment of menstrual migraine, strategies for managing increase in migraines in patients starting estrogen replacement therapy, transition medications for rapid, temporary suppression of headaches, medications possibly effective for cluster and hypnic headaches, differential diagnosis of the acute, severe, new-onset headache, and etiologies of papilledema and headache.

      This review contains 6 highly rendered figures, 20 tables, and 112 references.

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    • 10

      Tension-type Headache: Epidemiology, Diagnosis, and Pathophysiology

      By Paul Rizzoli, MD, FAAN, FAHS
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      Tension-type Headache: Epidemiology, Diagnosis, and Pathophysiology

      • PAUL RIZZOLI, MD, FAAN, FAHSAssistant Professor of Neurology, Harvard Medical School, Clinical and Fellowship Director John R. Graham Headache Center, Brigham and Women’s Faulkner Hospital, Boston, MA

      Tension-type headache (TTH) is a significant but underappreciated condition that is much more frequent than migraine, 42% versus 11%, and produces significant socioeconomic burden. Why then do research advances in this condition seem to lag?

      One reason is that precise epidemiologic data are lacking, with lifetime prevalence estimates varying from about 13 to 78%. Also, classification is confounded by whether or not to include the occasional but universal headache as TTH. Furthermore, TTH pathophysiology is debated, with some feeling that the pathophysiology of TTH is similar to and on a spectrum with migraine, and some feeling that it is entirely separate and related to peripheral and muscular mechanisms. More recently, central pain mechanisms have also been implicated in the pathophysiology. In addition, a large body of information connects stress and TTH.

      Although TTH varies widely in frequency and severity among and within patients, TTH pain, compared with pain in other headache types, could be characterized generally as more mild in severity and more generalized in location. This review discusses the current epidemiologic data and diagnostic challenges in TTH and the current pathophysiologic mechanisms.

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    • 11

      Approach to the Geriatric Patient

      By Tia Kostas, MD; Mark Simone, MD; James L Rudolph, MD, SM
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      Approach to the Geriatric Patient

      • TIA KOSTAS, MDAssistant Professor of Medicine, Section of Geriatrics & Palliative Medicine, Department of Medicine, University of Chicago, Chicago, IL
      • MARK SIMONE, MDInstructor of Medicine, Harvard Medical School, Associate Program Director-Primary Care, Mount auburn Hospital Internal Medicine Residency, Director, Quality Improvement, Division of Geriatric Medicine, Department of Medicine, Mount Auburn Hospital, Cambridge, MA
      • JAMES L RUDOLPH, MD, SMAssociate Professor of Medicine, Harvard Medical School, Chief (Interim) Geriatrics and Palliative Care, Director, Boston, GRECC, VA Boston Healthcare System, Jamaica Plain, MA, Acting Clinical Chief, Associate Epidemiologist, Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, MA

      As of 2012, over one in eight Americans is over the age of 65, and this number is rising, particularly in the 85+ age group. This segment of the population has a rate of hospitalization three times higher than that for persons of all ages. General internists and family medicine physicians provide a large portion of care for this age group and should therefore be comfortable using a comprehensive approach to geriatric assessment. This review describes general considerations regarding geriatric care, including the process of taking a functional history and clinical implications of geriatric care. The geriatric assessment process is discussed in terms of physical, cognitive, social, and medical domains. The benefits of geriatric assessment in primary care, specialty care, and hospitalized patients are described. Tables outline activities of daily living, sensory changes with aging, major causes of visual impairment in the geriatric population, major neurocognitive disorder diagnostic criteria, medications to avoid or use with caution based on Beers criteria and Screening Tool of Older individuals’ Potentially inappropriate Prescriptions criteria, U.S. Preventive Services Task Force–recommended services relevant to older adults, and vaccinations in older adults. Figures illustrate the key vulnerabilities of older adults; outcomes linked to functional dependence; common disorders associated with cognitive concerns; domains of cognition and examples of impairment in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition; the social and medical domains of geriatric assessment; barriers to medication adherence in older patients; and resources for medication appropriateness in older adults.

      This review contains 8 highly rendered figures, 8 tables, 110 references, and 5 MCQs.

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    • 12

      Severe Traumatic Brain Injury

      By Kiarash Shahlaie, MD, PhD; Marike Zwienenberg, MD; Kee D. Kim, MD; Ryan Martin, MD; Lara Zimmermann, MD
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      Severe Traumatic Brain Injury

      • KIARASH SHAHLAIE, MD, PHDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • MARIKE ZWIENENBERG, MDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • KEE D. KIM, MDAssociate Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • RYAN MARTIN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,
      • LARA ZIMMERMANN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,

      Traumatic brain injury remains a leading cause of death and disability worldwide. Patients with severe traumatic brain injury are best treated with a multidisciplinary, evidence-based, protocol-directed approach, which has been shown to decrease mortality and improve functional outcomes. Therapy is directed at the prevention of secondary brain injury through optimizing cerebral blood flow and the delivery of metabolic fuel (ie, oxygen and glucose). This is accomplished through the measurement and treatment of elevated intracranial pressure (ICP), the strict avoidance of hypotension and hypoxemia, and in some instances, surgical management. The treatment of elevated ICP is approached in a protocolized, tiered manner, with escalation of care occurring in the setting of refractory intracranial hypertension, culminating in either decompressive surgery or barbiturate coma. With such an approach, the rates of mortality secondary to traumatic brain injury are declining despite an increasing incidence of traumatic brain injury.

      This review contains 3 figures, 5 tables and 69 reference

      Key Words: blast traumatic brain injury, brain oxygenation, cerebral perfusion pressure, decompressive craniectomy, hyperosmolar therapy, intracranial pressure, neurocritical care, penetrating traumatic brain injury, severe traumatic brain injury

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    • 13

      Major Neurocognitive Disorders

      By Rajesh R Tampi, MD, MS, DFAPA; Deena J Tampi, MSN, MBA-HCA, RN
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      Major Neurocognitive Disorders

      • RAJESH R TAMPI, MD, MS, DFAPAProfessor of psychiatry at Case Western Reserve University School of Medicine and vice chairman for education and faculty development and program director in the Psychiatry Residency, Department of Psychiatry, MetroHealth, Cleveland, OH
      • DEENA J TAMPI, MSN, MBA-HCA, RNExecutive director of Behavioral Health Services, Saint Francis Hospital and Medical Center, Hartford, CT.

      Major neurocognitive disorder is the most common neurodegenerative condition in the world and the leading cause of dependence and disability among older adults worldwide. There are numerous etiologies for major neurocognitive disorder, of which Alzheimer disease (AD) is the most common. Available evidence indicates that the risk factors for major neurocognitive disorder include older age, female sex, lower educational attainment, obesity, and vascular risk factors, including smoking, hypertension, diabetes mellitus, and hyperlipidemia. Certain etiologies for major neurocognitive disorder are heritable, especially those due to AD and frontotemporal lobar degeneration. The pathophysiologic changes associated with the various etiologies of major neurocognitive disorder include neuronal loss, senile plaques, neurofibrillary tangles, vascular pathology, and α-synuclein neuronal inclusions. Major neurocognitive disorder remains a clinical diagnosis with a thorough history, appropriate laboratory tests, and standardized rating scales assisting in determining the etiology and severity of the condition. In older adults, major neurocognitive disorder must be differentiated from depression and delirium as these three conditions may have similar clinical presentations or may coexist. Current data indicate that approximately a third of the cases of major neurocognitive disorder, especially those due to AD, may be prevented by controlling potentially modifiable risk factors, including diabetes, depression, smoking, physical inactivity, midlife hypertension, midlife obesity, and low educational attainment. Currently, the only Food and Drug Administration–approved medications are acetylcholinesterase inhibitors and memantine for use in major neurocognitive disorder due to AD and rivastigmine (an acetylcholinesterase inhibitor) for major neurocognitive disorder due to Parkinson disease.

      Key words: acetylcholinesterase inhibitors, Alzheimer disease, amyloid precursor protein, frontotemporal lobar degeneration, Lewy body disease, major neurocognitive disorder, memantine, Parkinson disease, tau proteins, vascular disease

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    • 14

      Primary and Metastatic Central Nervous System Malignancies

      By Fabio M. Iwamoto, MD; Howard A. Fine, MD
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      Primary and Metastatic Central Nervous System Malignancies

      • FABIO M. IWAMOTO, MDAssistant Clinical Investigator, Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
      • HOWARD A. FINE, MDSenior Investigator and Chief, Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD

      About 13,000 deaths each year in the United States are attributed to primary central nervous system (CNS) malignancies. An estimated 20% of patients with cancer eventually develop clinically apparent CNS metastases, and an estimated 170,000 cases of brain metastases are diagnosed in the United States yearly. Autopsy studies suggest that as many as 50% of patients dying from advanced cancer may have metastasis to the CNS. This chapter provides an overview of primary and metastatic CNS malignancies with in-depth discussion of gliomas, primary CNS lymphoma, meningioma, brain metastases, leptomeningeal metastases, and metastatic epidural spinal cord compression. Discussions cover epidemiology, etiology, diagnosis, and treatment of gliomas, including surgery, radiotherapy, and chemotherapy for both newly diagnosed gliomas and recurrent gliomas. The epidemiology, diagnosis, treatment and prognosis for primary CNS lymphomas are reviewed, as well as the epidemiology, etiology, diagnosis, treatment, and prognosis for meningiomas. Epidemiology, diagnosis, and prognosis for brain metastases are briefly discussed, and the section on treatment includes surgery, stereotactic radiosurgery, and whole-brain radiotherapy for patients with three or fewer brain metastases. The sections on leptomeningeal metastases and metastatic epidural spinal cord compression cover diagnosis, treatment, and prognosis. This chapter contains 126 references.

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    • 15

      Fatigue and Asthenia

      By Thomas D. Sabin, MD; David M. Dawson, MD
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      Fatigue and Asthenia

      • THOMAS D. SABIN, MDProfessor of Neurology, Tufts University School of Medicine, Boston MA
      • DAVID M. DAWSON, MDProfessor of Neurology, Brigham and Women’s Hospital, Boston MA

      The word fatigue implies a sense of exhaustion, lassitude, or inability to generate drive or energy. In taking a medical history of a patient with fatigue, the examiner should pursue questions of timing and circumstance. A medical or psychiatric diagnosis can be established in two thirds of patients who complain of fatigue, and in many cases, they are remediable. This chapter reviews the history of fatigue, including outbreaks. The clinical picture, diagnostic criteria, special considerations in diagnosis, general medical disorders, prescription drugs, postural orthostatic tachycardia syndrome, neutrally mediated hypotension, Chiari malformation, neurologic causes of fatigue, psychiatric investigation, laboratory investigations, magnetic resonance imaging (MRI) studies, pathophysiology, prognosis, and treatment are detailed. Asthenia is discussed in relation to clinical data, the central nervous system, muscle, and electromyography (EMG). Tables include terms and phrases used for indicating fatigue; definitions, features, and medical causes of chronic fatigue syndrome (CFS); blood tests to evaluate chronic fatigue; symptoms of CFS determined from laboratory studies; MRI studies for detecting CFS; outcomes of MRI studies of CFS; summary of CFS facts; summary of drugs used for fighting fatigue in multiple sclerosis patients; clinical testing for signs of asthenia; considerations when measuring creatine kinase; EMG testing in search of abnormalities; and decisive EMG findings. Figures show maps of sensory loss, an MRI of a relapsing-remitting multiple sclerosis patient, white matter hyperintensities, a diagram of EMG testing, and repetitive stimulation testing for neuromuscular transmission disorder.

      This chapter contains 5 highly rendered figures, 14 tables, 74 references, and 5 MCQs.

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    • 16

      Sleep Disorders

      By Sudhansu Chokroverty, MD, FRCP, FACP
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      Sleep Disorders

      • SUDHANSU CHOKROVERTY, MD, FRCP, FACPProfessor and Director of Sleep Research, Medical Director of Devry Technology Training Program, Co-Chair Emeritus of Neurology, Department of Neurology, JFK Neuroscience Institute, Edison, NJ, Professor of Neuroscience, Seton Hall University, South Orange, NJ, Clinical Professor of Neurology, Robert Wood Johnson Medical School, New Brunswick, NJ

      Recent research has generated an enormous fund of knowledge about the neurobiology of sleep and wakefulness. Sleeping and waking brain circuits can now be studied by sophisticated neuroimaging techniques that map different areas of the brain during different sleep states and stages. Although the exact biologic functions of sleep are not known, sleep is essential, and sleep deprivation leads to impaired attention and decreased performance. Sleep is also believed to have restorative, conservative, adaptive, thermoregulatory, and consolidative functions. This review discusses the physiology of sleep, including its two independent states, rapid eye movement (REM) and non–rapid eye movement (NREM) sleep, as well as functional neuroanatomy, physiologic changes during sleep, and circadian rhythms. The classification and diagnosis of sleep disorders are discussed generally. The diagnosis and treatment of the following disorders are described: obstructive sleep apnea syndrome, narcolepsy-cataplexy sydrome, idiopathic hypersomnia, restless legs syndrome (RLS) and periodic limb movements in sleep, circadian rhythm sleep disorders, insomnias, nocturnal frontal lobe epilepsy, and parasomnias. Sleep-related movement disorders and the relationship between sleep and psychiatric disorders are also discussed. Tables describe behavioral and physiologic characteristics of states of awareness, the international classification of sleep disorders, common sleep complaints, comorbid insomnia disorders, causes of excessive daytime somnolence, laboratory tests to assess sleep disorders, essential diagnostic criteria for RLS and Willis-Ekbom disease, and drug therapy for insomnia. Figures include polysomnographic recording showing wakefulness in an adult; stage 1, 2, and 3 NREM sleep in an adult; REM sleep in an adult; a patient with sleep apnea syndrome; a patient with Cheyne-Stokes breathing; a patient with RLS; and a patient with dream-enacting behavior; schematic sagittal section of the brainstem of the cat; schematic diagram of the McCarley-Hobson model of REM sleep mechanism; the Lu-Saper “flip-flop” model; the Luppi model to explain REM sleep mechanism; and a wrist actigraph from a man with bipolar disorder.

      This review contains 14 highly rendered figures, 8 tables, 115 references, and 5 MCQs.

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    • 17

      Epilepsy and Related Disorders

      By Barbara Dworetzky, MD; Jong Woo Lee, MD, PhD
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      Epilepsy and Related Disorders

      • BARBARA DWORETZKY, MDAssociate Professor of Neurology, Harvard Medical School, Chief, Division of Epilepsy, EEG, and Sleep Neurology, Director, The Edward B. Bromfield Epilepsy Program, Brigham and Women’s Hospital, Boston, MA
      • JONG WOO LEE, MD, PHDAssistant Professor of Neurology, Harvard Medical School, Director, ICU EEG Monitoring, The Edward B. Bromfield Epilepsy Program, Brigham and Women’s Hospital, Boston, MA

      Epilepsy is a chronic disorder of the brain characterized by recurrent unprovoked seizures. A seizure is a sudden change in behavior that is accompanied by electrical discharges in the brain. Many patients presenting with a first-ever seizure are surprised to find that it is a very common event. A reversible or avoidable seizure precipitant, such as alcohol, argues against underlying epilepsy and therefore against treatment with medication. This chapter discusses the epidemiology, etiology, and classification of epilepsy and provides detailed descriptions of neonatal syndromes, syndromes of infancy and early childhood, and syndromes of late childhood and adolescence. The pathophysiology, diagnosis, and differential diagnosis are described, as are syncope, migraine, and psychogenic nonepileptic seizures. Two case histories are provided, as are sections on treatment (polytherapy, brand-name versus generic drugs, surgery, stimulation therapy, dietary treatments), complications of epilepsy and related disorders, prognosis, and quality measures. Special topics discussed are women?s issues and the elderly. Figures illustrate a left midtemporal epileptic discharge, wave activity during drowsiness, cortical dysplasias, convulsive syncope, rhythmic theta activity, right hippocamal sclerosis, and right temporal hypometabolism. Tables describe international classifications of epileptic seizures and of epilepsies, epilepsy syndromes and related seizure disorders, differential diagnosis of seizure, differentiating epileptic versus nonepileptic seizures, antiepileptic drugs, status epilepticus protocol for treatment, when to consider referral to a specialist, and quality measures in epilepsy. This chapter contains 111 references.

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    • 18

      Clinical Aspects of Non-alzheimer Disease Dementias

      By David Knopman, MD
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      Clinical Aspects of Non-alzheimer Disease Dementias

      • DAVID KNOPMAN, MDProfessor of Neurology, Department of Neurology, Mayo Clinic, Rochester, MN

      There are a relatively small number of disorders that account for the majority of dementia in the elderly that is not Alzheimer disease (AD): cerebrovascular disease, Lewy body disease (α-synucleinopathies), and the frontotemporal lobar degenerations. Cerebrovascular disease and Lewy body disease account for most non-AD dementia among persons in the eighth decade of life and beyond. These two frequently co-occur with AD but can occur in their pure forms rarely (in the case of dementia associated with cerebrovascular disease) or more commonly (in the case of Lewy body disease). There is no one cognitive or behavioral syndrome associated with cerebrovascular disease; however, attempts to isolate a common theme suggest that cognitive slowing is typical of cerebrovascular contributions to cognitive impairment. Cerebrovascular pathology relevant to cognitive impairment accumulates subclinically more commonly than it causes acute, strokelike declines in cognition. Dementia with Lewy bodies is a multidimensional disorder that includes a nonamnestic dementia, Parkinson disease or at least some parkinsonian features, a disorder of sleep and wakefulness, autonomic disturbances, and depression. The disorders of sleep prominently include rapid eye movement sleep behavior disorder, excessive daytime sleepiness, visual hallucinations, and marked fluctuations in level of alertness. The frontotemporal lobar degenerations are nearly as common as causes of dementia in persons under age 65 as is AD. The group of disorders includes two cognitive syndromes (primary progressive aphasia and behavior variant frontotemporal dementia) and two neuropathologic subtypes (tauopathy and TDP43 proteinopathy) and is associated with three major autosomal dominant genetic mutations (in MAPT, GRN,and C9ORF72).

      Key words: dementia with Lewy bodies, frontotemporal lobar degenerations, vascular cognitive impairment

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    • 19

      Huntington Disease and Other Genetic Causes of Choreas

      By Ainhi Ha, MBBS, PhD, FRACP; Débora Maia, MD; Victor S C Fung, PhD, FRACP; Francisco Cardoso , MD, PhD, FAAN
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      Huntington Disease and Other Genetic Causes of Choreas

      • AINHI HA, MBBS, PHD, FRACPStaff Specialist Neurologist, Department of Neurology, Westmead Hospital, Westmead, Australia
      • DÉBORA MAIA, MDConsultant, Movement Disorders Unit, Neurology Service, The Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
      • VICTOR S C FUNG, PHD, FRACPClinical Associate Professor, Sydney Medical School, University of Sydney, & Director, Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, Australia
      • FRANCISCO CARDOSO , MD, PHD, FAANProfessor of Neurology, Movement Disorders Unit, Neurology Service, The Federal University of Minas Gerais, Belo Horizonte, MG, Brazil

      The aim of this review is to provide an overview of Huntington disease (HD) and other genetic choreas with an emphasis on clinical presentation, diagnosis, treatment, and expected outcome. Chorea is a syndrome characterized by brief, abrupt, involuntary movements resulting from a continuous flow of random muscle contractions. The first step in approaching a subject with chorea is to define the underlying etiology because the natural history and management vary accordingly. Age at onset, body distribution, other neurologic features, and family history are important in establishing the cause of chorea. HD is the most common etiology of genetic choreas worldwide. It is a progressive neurodegenerative disorder transmitted as an autosomal dominant trait characterized by a combination of movement disorders, cognitive decline, and behavioral abnormalities that causes progressive disability and death. When an HD phenotype test is negative for this condition, other causes, such as neuroacanthocytosis; spinocerebellar ataxia 17; Huntington disease–like syndrome 2, 3, or 4; benign hereditary chorea; and dentatorubral-pallidoluysian atrophy, as well as others, should be investigated. 

      Key words: Huntington, movement disorders, genetic choreas, neurodegenerative disorder

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    • 20

      Difficult to Treat (refractory) Chronic Migraine: Outpatient Approaches

      By Lawrence Robbins, MD, (retired)
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      Difficult to Treat (refractory) Chronic Migraine: Outpatient Approaches

      • LAWRENCE ROBBINS, MD, (RETIRED) Assistant Professor of Neurology, Dept. of Neurology, University of Illinois; (retired) Assistant Professor of Neurology, Dept. of Neurology, Rush Medical College, Chicago, Il

      This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion  blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. 

      This review contains 8 highly rendered figures, 4 tables, and 25 references.

      Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

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    • 21

      Migraine: Psychiatric Comorbidities

      By Todd A Smitherman, PhD; Anna Katherine Black, MA; A Brooke Walters Pellegrino, PhD
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      Migraine: Psychiatric Comorbidities

      • TODD A SMITHERMAN, PHDAssociate Professor of Psychology, Department of Psychology, University of Mississippi, Oxford, MS
      • ANNA KATHERINE BLACK, MAGraduate Student, Clinical Psychology, Department of Psychology, University of Mississippi, Oxford, MS
      • A BROOKE WALTERS PELLEGRINO, PHDDirector of Behavioral Medicine, Hartford Healthcare Headache Center, West Hartford, CT

      Psychiatric disorders often co-occur with migraine, and these comorbid conditions compound disability and are risk factors for medication overuse and migraine progression. For these reasons, attention to psychiatric comorbidities in clinical practice is of paramount importance. Assessment of depression, anxiety, and sleep disorders is recommended, focusing on the core cognitive and emotional symptoms of the comorbidities and using measures validated among medical patients. Pharmacologic treatment of migraine and comorbid psychiatric conditions is challenging owing to a lack of agents with proven efficacy for both conditions, side effect profiles that may exacerbate one condition, and potential drug interactions. Existing data suggest that migraineurs with psychiatric symptomatology can obtain positive outcomes with appropriate preventive medications, behavioral interventions for headache or the comorbid condition, or a combination thereof.

      Keywords: anxiety, comorbidity, depression, insomnia, migraine, pharmacotherapy, relaxation, stress management

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    • 22

      Migraine: Behavioral Treatment

      By Elizabeth K Seng, PhD
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      Migraine: Behavioral Treatment

      • ELIZABETH K SENG, PHDAssistant Professor, Ferkauf Graduate School of Psychology, Yeshiva University, New York, NY

      Behavior change is an essential component of any migraine management plan. Behavioral migraine treatments are interventions designed to change a patient’s behavior with the result of a reduction in migraine symptoms and migraine-related disability. Behavioral treatments commonly target medication adherence, behavioral and psychosocial factors known to precipitate migraine (including stress, sleep, and skipping meals), maladaptive cognitive patterns, and comorbid psychiatric symptoms (most commonly depression and anxiety). Guidelines and evidence from randomized clinical trials indicate that biofeedback, relaxation treatments, and cognitive-behavioral therapy are effective preventive migraine treatments. Patient education and self-monitoring are foundational components to any behavioral intervention for migraine. Portable personal technology is increasingly becoming an essential part of migraine patient care and provides another avenue for supporting adherence to medication and behavioral migraine management.  

      Key words: anxiety; behavior; biofeedback; cognitive-behavioral therapy; depression; migraine; psychology; relaxation; sleep; stress

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    • 23

      Nerve Blocks and Neurostimulation in the Treatment of Migraine

      By Matthew S Robbins, MD
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      Nerve Blocks and Neurostimulation in the Treatment of Migraine

      • MATTHEW S ROBBINS, MDAssociate Professor of Clinical Neurology, Albert Einstein College of Medicine, Chief of Neurology, Jack D. Weiler Hospital, Montefiore Medical Center, Director of Inpatient Services, Montefiore Headache Center, Associate Program Director, Neurology Residency, Bronx, NY

      Peripheral nerve and sphenopalatine ganglion blocks are a safe, effective treatment option for headache disorders, although, despite a wealth of anecdotal experience, the evidence is conflicting for efficacy in chronic migraine prophylaxis. Neurostimulation has emerged as an effective treatment modality for migraine with both noninvasive and minimally invasive options available. Such options include transcutaneous supraorbital nerve stimulation for prophylaxis and single-pulse transcranial magnetic stimulation for the acute treatment of migraine with aura. Although occipital nerve stimulation may be effective for some patients with intractable chronic migraine, the evidence is mixed and procedure-related complications are common. Emerging treatment modalities for acute and preventive treatment of migraine include noninvasive vagus nerve stimulation and implanted sphenopalatine ganglion stimulation.

      This review contains 5 highly rendered figures, 2 tables, and 106 references.

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    • 24

      Cognitive Disorders Other Than Alzheimer Disease

      By Seth A Gale, MD; Kirk R. Daffner, MD, FAAN
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      Cognitive Disorders Other Than Alzheimer Disease

      • SETH A GALE, MDAssociate Neurologist, Division of Cognitive and Behavioral Neurology, Brigham and Women’s Hospital, and Instructor of Neurology, Harvard Medical School, Boston, MA
      • KIRK R. DAFFNER, MD, FAANChief, Division of Cognitive and Behavioral Neurology, Brigham and Women’s Hospital, J. David and Virginia Wimberly Professor of Neurology, Harvard Medical School, Boston, MA

      Higher cognitive functions, such as abstract reasoning, complex decision making, and language, are the mental faculties that separate our species from other animals. When these faculties become impaired as a result of neurologic disease, striking and devastating behavioral changes result. Many neurologic diseases are associated with impaired cognition and behavior, and their etiologies are as varied as their clinical presentations. In this review, the focus is on dementia with Lewy bodies (DLB), the frontotemporal dementias (FTDs), and vascular cognitive impairment (VCI). The review covers the epidemiology and diagnosis of  DBB, FTDs, and VCIs, as well as the etiology and genetics. Figures show neuroimaging in DLB, management of DLB, FTLD clinical syndromes, FTLD clinicopathologic correlations: approximate distribution of pathotypes for behavioral-variant FTD and primary progressive aphasia (PPA) variants, PPA-semantic subtype, PPA-logopenic subtype, post-stroke VCI, and subcortical ischemic vascular disease subtype of VCI. Tables list diagnostic criteria for DLB, FTD genetics: gene/protein relationship, clinical syndrome, salient geatures, VCI: clinical and pathologic features of the main subtypes, summary guidance based on VCI prevention studies, and summary guidance based on VCI treatment studies.

      This review contains 8 highly rendered figures, 5 tables, and 254 references.

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    • 25

      Migraine Epidemiology, Impact, and Pathogenesis

      By Amy A Gelfand, MD; Dawn C Buse, PhD
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      Migraine Epidemiology, Impact, and Pathogenesis

      • AMY A GELFAND, MDDirector, Pediatric Headache, Division of Child Neurology, Department of Neurology, UCSF Benioff Children’s Hospital, San Francisco, CA
      • DAWN C BUSE, PHDAssociate Professor, Department of Neurology, Albert Einstein College of Medicine of Yeshiva University, Assistant Professor, Clinical Health Psychology Doctoral Program, Ferkauf Graduate School of Psychology of Yeshiva University, Director of Behavioral Medicine, Montefiore Headache Center Bronx, NY

      Migraine is a common and often disabling neurologic disorder. No longer thought of as neurovascular in etiology, migraine is now known to be a complex disorder of the brain with strong genetic underpinnings. The impact of migraine may extend beyond the affected individual to also impact partners and children. Although many patients search to identify “triggers” of migraine, teasing out such relationships can be remarkably complex. The premonitory phase of a migraine attacks can include symptoms such as food cravings, photophobia, and increased yawning—symptoms that could, for example, lead a person to mistakenly conclude that the migraine attacks are “triggered” by eating chocolate, bright lights, or being tired. We review current evidence on the epidemiology, impact, and pathophysiology of migraine. 

      Key words: epidemiology, impact, migraine, pathophysiology

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    • 26

      Management and Therapeutic Issues in the Dementias

      By David Knopman, MD
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      Management and Therapeutic Issues in the Dementias

      • DAVID KNOPMAN, MDProfessor of Neurology, Department of Neurology, Mayo Clinic, Rochester, MN

      As of 2016, treatment of Alzheimer disease (AD) dementia and the principal non-AD dementias is entirely palliative. Although there are several drugs approved for the treatment of mild to moderate AD dementia, these drugs—the cholinesterase inhibitors and memantine—have rather modest benefits. In general, nonpharmacologic approaches to the management of patients with dementia emphasize support for the caregiver, attention to safety, and providing a supportive and socially enriched environment for the patient. Depression is common in dementias of diverse etiology; lower doses of later-generation antidepressants are effective in controlling depressive symptoms in patients with dementia. Agitation is not a ubiquitous occurrence in patients with dementia, but physically aggressive behavior, hallucinations, and delusions affect a sizable fraction of patients with dementia. There is much controversy regarding the appropriate medication classes to use in cases of agitation, but the antipsychotic agent quetiapine is often effective and unique among its class in not causing parkinsonism or tardive dyskinesia.

      Key words: antidepressants, antipsychotic agents, caregiver support, cholinesterase inhibitors

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    • 27

      Motor Neuron Diseases

      By Elena Ratti, MD; Merit E. Cudkowicz, MD, MSc; James D Berry, MD, MPH
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      Motor Neuron Diseases

      • ELENA RATTI, MDClinical Research Fellow, Neurological Clinical Research Institute, Massachusetts General Hospital, Boston, MA
      • MERIT E. CUDKOWICZ, MD, MSCChief of Neurology, Massachusetts General Hospital, Julieanne Dorn Professor of Neurology Harvard Medical School, Neurological Clinical Research Institute, Massachusetts General Hospital, Boston, MA
      • JAMES D BERRY, MD, MPHAssistant Professor of Neurology, Neurological Clinical Research Institute, Massachusetts General Hospital, Boston, MA

      The motor neuron diseases (MNDs) are a family of diseases commonly categorized by their propensity to affect upper or lower motor neurons and by their mode of inheritance. The chapter provides some content on infectious MNDs caused by viral infections affecting the motor neurons in the anterior horn of the spinal cord. However, the chapter devotes most of its attention to the inherited and sporadically occurring MNDs. The majority of research into adult MND focuses on amyotrophic lateral sclerosis (ALS) due to its high prevalence, rapid progression, and phenotypical similarities between its inherited form and its sporadic form. As our knowledge of genetic mechanisms underlying ALS pathology has grown, common themes have emerged. These include abnormalities in RNA biology, axonal transport, protein folding, and inflammatory responses. These themes currently drive much of the direction in ALS experimental therapy development. It is clear that MND is complex and involves several different molecular pathways. Given this complexity, ALS might not be a single disease entity, and if this is the case, treatment approaches may need to be targeted to specific pathologies rather than all ALS patients on a broad scale. Chapter content is enhanced by tables outlining the types of MNDs, criteria for supporting a diagnosis, first-line workup, the genes associated with ALS, ALS efficacy outcome measures, symptom management of ALS, and spinal muscular atrophy classification. Mechanisms of ALS are illustrated, and clinical photographs demonstrate symptoms. This chapter contains 252 references. 

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    • 28

      Multiple Sclerosis and Related Disorders

      By J William Lindsey, MD
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      Multiple Sclerosis and Related Disorders

      • J WILLIAM LINDSEY, MDProfessor, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX

      Multiple sclerosis (MS) is a relatively common cause of neurologic symptoms and disability in young adults. The distinguishing pathologic features of MS are loss of myelin and inflammation in the central nervous system (CNS). The myelin sheath is essential for rapid conduction of nerve signals along large-diameter axons. Oligodendrocytes produce and maintain myelin in the CNS, and Schwann cells produce and maintain myelin in the peripheral nerves. In addition to MS, there are a number of related disorders causing demyelination, inflammation, or both in the CNS. This chapter discusses MS and related disorders, including neuromyelitis optica, optic neuritis, acute disseminated encephalomyelitis, transverse myelitis, Behçet syndrome, neurosarcoidosis, inherited demyelinating diseases (leukodystrophies, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy [CADASIL]), and virus-induced demyelination (progressive multifocal leukoencephalopathy, subacute sclerosing panencephalitis). The section on MS covers epidemiology, etiology/genetics, pathogenesis, diagnosis, differential diagnosis, management, and prognosis. Figures include organization of the microenvironment of larger-diameter axons, typical magnetic resonance imaging findings in MS and neuromyelitis optica, postgadolinium images of the cervical spine in MS, and an approach to treatment of relapsing-remitting MS. Tables list MS and related disorders, distribution of neurologic deficits at the onset of MS, differential diagnosis of MS, disease-modifying therapies for relapsing-remitting MS, and selected leukodystrophies, as well as diagnostic criteria and selected symptomatic therapies for MS.

      This chapter contains 3 highly rendered figures, 7 tables, 82 references, 1 teaching slide set, and 5 MCQs.

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    • 29

      Principles and Practice of Palliative Care

      By Kristen G Schaefer, MD; Rachelle E Bernacki, MD, MS
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      Principles and Practice of Palliative Care

      • KRISTEN G SCHAEFER, MDDirector of Medical Student and Resident Education, Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Center for Palliative Care, Harvard Medical School, Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
      • RACHELLE E BERNACKI, MD, MSDirector of Quality Initiatives, Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Center for Palliative Care, Harvard Medical School, Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, MA

      The trajectories of serious illness and dying have changed in the last century; in the past, patients lived shorter lives and often died quickly of infectious disease, whereas patients in the 21st century live longer and often with prolonged debility in the advanced stages of illness. As a result, patients with serious illness can suffer undertreated symptoms and often feel poorly prepared for the final stages of disease. With more options for advanced life support and other aggressive interventions at the end of life, patients and families face increasingly complex medical decisions in the terminal phase of illness, and the treatments they receive do not always align with their goals and values. Emerging evidence suggests that integrating palliative care into the treatment of advanced illness can improve outcomes, decrease costs, and improve both patient and family satisfaction. Consequently, patient access to high-quality specialty-level palliative care is becoming standard of care at most academic cancer centers and more available in the community. This chapter describes the practice and principles of specialty-level palliative care and outlines specific "generalist" palliative care competencies essential for all physicians caring for patients with serious illness, including prognostication, patient-centered communication, and the navigation of ethical dilemmas in the field of palliative care. Tables outline the philosophy of palliative care, domains of suffering, location of death of hospice patients, the palliative performance scale, median survival times for cancer syndromes, indicators associated with a poorer prognosis in congestive heart failure, the NURSE mnemonic for accepting and responding to emotion, palliative care communication competencies in the intensive care unit, and the SPIKES mnemonic for breaking bad news. Figures depict causes of death in 1900 versus 2010, palliative care through the trajectory of serious illness, theoretical trajectories of disease, life expectancies for women and men, mortality at 1 year post discharge, and a model for patient-centered communication. 


      This chapter contains 6 highly rendered figures, 9 tables, 169 references, 1 teaching slide set, and 5 MCQs.

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    • 30

      Time Is on Our Side: Age as a Diagnostic and Pathologic Clue in Pediatric Movement Disorders

      By Marisela E. Dy, MD; Bhooma R. Aravamuthan, MD, DPhil; Jeff L. Waugh, MD, PhD
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      Time Is on Our Side: Age as a Diagnostic and Pathologic Clue in Pediatric Movement Disorders

      • MARISELA E. DY, MDMovement Disorders Fellow, Department of Neurology, Boston Children’s Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA
      • BHOOMA R. ARAVAMUTHAN, MD, DPHILChild Neurology Resident, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
      • JEFF L. WAUGH, MD, PHDMedical Director, Pediatric Movement Disorders and Deep Brain Stimulation Program, Department of Neurology, Boston Children’s Hospital Massachusetts General Hospital Harvard Medical School Boston, MA

      Pediatric movement disorders encompass a heterogeneous array of neurologic symptoms and syndromes and may be acquired or inherited. Movement phenomenology and age at symptom onset provide important clues in identifying the underlying etiology and establishing a diagnosis. Movement disorders are classified as hyperkinetic (increased movement) or hypokinetic (reduced amplitude and/or rate of movement). In children, hyperkinetic movement disorders are substantially more common than hypokinetic disorders; in adults, a mix of hyper- and hypokinetic disorders is the norm. We present a framework for evaluating a child with abnormal movements and describe a broad range of pediatric movement disorders: chorea, neurotransmitter-associated syndromes, tic disorders, stereotypies, primary dystonias, and dystonic cerebral palsy. Recently described genes associated with pediatric movement disorders, such as ADCY5-related dyskinesia, NKX2.1-associated chorea and dystonia, and the primary dystonias (DYT2 and DYT26), are highlighted. The developmental regulation of neurotransmitter metabolism, a dynamic process that leads to dramatic shifts in neurotransmitter availability in childhood and adolescence, is also reviewed. The myelination and maturation of long-range neuronal networks are described, and the timing of these changes is related to the timing of childhood movement disorders. Incorporating age and timing into a framework for assessing abnormal movements in children has the potential to improve both clinical and research approaches to these disorders. Understanding the genetic and pathophysiologic bases of abnormal movements may aid clinicians in rapidly recognizing and distinguishing these disorders. Recognizing the clinical specificity and age dependency of abnormal movements in children may guide researchers in identifying the molecular underpinnings of these disorders. 

      Key words: Movement disorders, gene expression, childhood development, childhood hyperkinetic disorders

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    • 31

      Myopathies

      By Thomas I. Cochrane, MD, MBA; Anthony A Amato, MD
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      Myopathies

      • THOMAS I. COCHRANE, MD, MBAAssociate Neurologist, Division of Neuromuscular Disease, Department of Neurology, Brigham and Women’s Hospital, Assistant Professor of Neurology, Harvard Medical School, Boston, MA
      • ANTHONY A AMATO, MDChief, Division of Neuromuscular Disease, Department of Neurology, Brigham and Women’s Hospital, Professor of Neurology, Harvard Medical School, Boston, MA

      Muscle disease (myopathy) can be acquired or hereditary. Symptoms include skeletal muscle weakness, atrophy, muscle cramps or myalgias, and impaired function of respiratory, pharyngeal, facial, or ocular muscles. Clinicians must identify treatable myopathies and initiate therapy before permanent weakness occurs. For patients with untreatable disorders, proper supportive care, rehabilitation, genetic counseling, and psychological support are critical. This chapter covers common myopathies, including muscular dystrophies; malignant hyperthermia; metabolic myopathies; mitochondrial myopathies and encephalopathies; ion channelopathies, periodic paralyses, and nondystrophic myotonias; and drug-induced myopathies. Clinical presentation, diagnosis, pathogenesis, and therapy are emphasized. Tables describe genetic classification of the limb-girdle and distal muscular dystrophies; proteins involved in myofibrillar myopathy; other distal myopathies; and antirheumatic, antiinflammatory, and immunosuppressive drug-induced myopathy. Figures show the sarcolemmal membrane and enzymatic proteins associated with muscular dystrophies, sarcomeric and nuclear proteins associated with muscular dystrophies, and major metabolic pathways used by muscle.

      This chapter contains 3 highly rendered figures, 4 tables, 107 references, and 5 MCQs.

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    • 32

      Parkinson Disease: Epidemiology, Pathology, and Clinical Diagnosis

      By Maurizio Zibetti, MD, PhD; Aristide Merola, MD, PhD
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      Parkinson Disease: Epidemiology, Pathology, and Clinical Diagnosis

      • MAURIZIO ZIBETTI, MD, PHD
      • ARISTIDE MEROLA, MD, PHD

      Parkinson disease (PD) is the second most common neurodegenerative disorder after Alzheimer disease. PD predominantly affects elderly people, and most countries are now facing a marked demographic change, with a progressively larger proportion of the population reaching old age. Thus, PD is expected to cause an increasing social and economic burden on society in the near future. The causes of PD are still mostly unknown. There has been a substantial progress in our understanding of the genetic basis of PD in the past 15 years; however, these mutations explain only a small fraction of all PD cases and other non-genetic factors may play a role. This review covers the epidemiology, pathology, and clinical diagnosis of PD. Figures show age-specific incidence of PD, age-specific prevalence of PD, PD risks for exposures reported in high-quality studies, PD and atypical parkinsonism clinical features, and neuroimaging alterations in PD and atypical parkinsonism. Tables list factors associated with increased or decreased risk of PD, Braak staging scheme of α-synuclein pathology in PD, United Kingdom Parkinson’s Disease Society Brain Bank clinical diagnostic for PD, National Institute of Neurological Disorders and Stroke diagnostic criteria for PD, differential diagnosis of parkinsonian syndromes, and “atypical” atypical parkinsonism.

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    • 33

      Traumatic Brain and Spinal Cord Injuries

      By Geoffrey S.F. Ling, MD, PhD, FAAN; Mohit Datta, MD
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      Traumatic Brain and Spinal Cord Injuries

      • GEOFFREY S.F. LING, MD, PHD, FAANUniformed Services University of the Health Sciences, Bethesda, MD
      • MOHIT DATTA, MD

      Traumatic brain injury (TBI), the most common cause of death and disability in young adults in the United States, is classified by severity (mild, moderate, or severe). This chapter reviews the pathogenesis of TBI, the types and severity of injuries, and management of TBI. Figures include computed tomography (CT) images of brains showing bi-frontal hemorrhagic contusions with associated peri-hematomal edema, a right-sided hyperdense lenticular-shaped space-occupying lesion with minimal midline shift, and evolution of the CT appearance of a subdural hematoma (from a hyperdense lesion, through to an isodense lesion, to a hypodense space-occupying lesion). Tables present the Glasgow Coma Scale, indications for CT scan in mild TBI (based on the Canadian head rule), guidelines for the management of moderate to severe TBI, and return to play or work criteria for patients suffering from concussion. This chapter contains 61 references.

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    • 34

      Brain and Spinal Abscesses

      By Allan R Tunkel, MD, PhD; W Michael Scheld, MD
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      Brain and Spinal Abscesses

      • ALLAN R TUNKEL, MD, PHDProfessor of Medicine, Drexel University College of Medicine, Philadelphia, PA, Chair, Department of Medicine, Monmouth Medical Center, Long Branch, NJ
      • W MICHAEL SCHELD, MDProfessor of Medicine and Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA

      Brain and spinal abscesses are focal infections of the central nervous system that are often associated with significant morbidity and mortality if not recognized early and managed in a timely manner. In patients with brain abscess, the clinical manifestations run the gamut from indolent to fulminant; most are related to the size and location of the space-occupying lesion within the brain and the virulence of the infecting organism. Untreated spinal epidural abscess usually progresses through four stages: backache and focal vertebral pain, nerve root pain, spinal cord dysfunction, and complete paralysis. Magnetic resonance imaging is the diagnostic neuroimaging procedure of choice in patients with brain and spinal abscesses; on diffusion-weighted images, restricted diffusion may be seen and may help distinguish abscesses from necrotic neoplasms. Aspiration of the abscess is important to facilitate microbiologic diagnosis; after aspiration and submission of specimens for special stains, histopathologic examination, and culture, empirical antimicrobial therapy should be initiated based on stains of the aspirated specimen and the probable pathogenesis of infection. Once the infecting pathogen is isolated, antimicrobial therapy can be modified for optimal treatment. Surgical therapy is often required for the optimal approach to patients with brain and spinal abscesses.

      This review contains 6 figures, 5 tables, and 72 references.

      Key words: antimicrobial therapy for central nervous system infections, brain abscess, epidural abscess, focal intracranial infections, head trauma, infections in immunocompromised hosts, spine infections, subdural empyema, toxoplasmosis 

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    • 35

      Chorea: Classification, Differential Diagnosis, and Treatment

      By James P Battista, MD; Ruth H Walker, MB, ChB, PhD
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      Chorea: Classification, Differential Diagnosis, and Treatment

      • JAMES P BATTISTA, MDMovement Disorders Division, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
      • RUTH H WALKER, MB, CHB, PHDMovement Disorders Clinic, Department of Neurology, James J. Peters VAMC, Bronx, NY; Movement Disorders Division, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY

      Chorea is a common hyperkinetic movement disorder that can have a large differential diagnosis. Causes can include genetic and sporadic etiologies, including metabolic abnormalities, autoimmune, structural, paraneoplastic, psychogenic, and iatrogenic causes. The workup can be challenging due to this large number of possible causes, and can include basic metabolic and specialized blood analysis such as genetic testing, in addition to imaging studies and cerebrospinal fluid analysis. Treatment of symptoms outside the realm of reversible causes can be challenging, and is a major focus of current research. This review covers sporadic causes, genetic causes, and management. Figures show a flowchart for evaluation of patients with chorea, a computed tomography scan of a Huntington disease patient showing caudate head atrophy, brain computed tomography scan showing calcification, and acanthocytosis. Videos show mild and moderate Huntington disease, Huntington disease-like 2,  and chorea-acanthocytosis. Tables list metabolic abnormalities that can manifest as chorea, paraneoplastic and nonparaneoplastic syndromes associated with chorea, and reported successful therapies for chorea.

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    • 36

      Tension-type Headache: Acute and Preventive Therapies

      By Melissa Rayhill, MD
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      Tension-type Headache: Acute and Preventive Therapies

      • MELISSA RAYHILL, MDAssistant Professor, Department of Neurology, University at Buffalo School of Medicine, the State University of New York at Buffalo

      Tension-type headache (TTH) is an incredibly common condition. The clinician should be careful to distinguish TTH from migraine and from causes of secondary headache. The importance of regular sleep, nutrition, hydration, and appropriate management of life stressors cannot be overemphasized. The mainstays of abortive pharmacologic therapy for TTH are the nonsteroidal antiinflammatory drugs. Most of these drugs are thought to have roughly equivalent efficacies based on many older clinical trials and more recent meta-analyses. The side effects of this drug class can be severe and include renal toxicity and gastrointestinal bleeding; these drugs may also increase cardiovascular risk. Tricyclic antidepressants are thought to be the most effective preventive therapy for TTH, particularly amitriptyline. Other antidepressant medications as well as muscle relaxants may also be beneficial in some patients. A number of other nonpharmacologic and procedural therapies exist, although the evidence supporting the use of these treatments is variable. However, in many patients, these other modalities can be helpful therapeutic adjuncts. In this review, we also discuss the evidence base for physical therapy, acupuncture, trigger-point injections, massage therapy, and psychological therapy. 

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    • 37

      Tremors

      By Alfonso Fasano, MD, PhD; Günther Deuschl, MD, PhD
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      Tremors

      • ALFONSO FASANO, MD, PHDAssociate Professor of Medicine, Division of Neurology, University of Toronto, Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital, Toronto, ON, Canada
      • GÜNTHER DEUSCHL, MD, PHDProfessor of Neurology, Department of Neurology, Christian-Albrechts-University, University-Hospital Schleswig-Holstein, Kiel, Germany

      Tremor is the most common movement disorder and denotes a rhythmic and involuntary movement of one or several regions of the body. This review covers disease definition, essential tremor, enhanced physiologic tremor, parkinsonian tremor, dystonic tremor, orthostatic tremor, cerebellar tremor, Holmes tremor, neuropathic tremor, palatal tremor, drug-induced and toxic tremors, functional tremor, rare tremor syndromes, tremorlike conditions, and treatment of tremor. Figures show action tremor assessment, the central nervous system circuits of tremor, magnetic resonance imaging findings in specific tremor conditions, general management of tremor patients, an algorithm for the treatment of parkinsonian tremor, and an algorithm for the treatment of dystonic tremor and primary writing tremor. Tables list types of tremor according to the condition of activation, tremor conditions in newborns and during childhood, clinical features of the most common tremor syndromes, motor signs other than tremor and nonmotor features of essential tremor patients, Movement Disorder Society consensus criteria for the diagnosis of essential tremor, genetic and environmental causes of essential tremor, causes of enhanced physiologic tremor, drugs and toxins known to cause tremor, paroxysmal tremors, pseudorhythmic myoclonus in the differential diagnosis of tremor, and pharmacologic management of essential tremor.

       

      Key words: essential tremor, movement disorder, pathologic tremor, physiologic tremor, tremor

       

      This review contains 6 highly rendered figures, 7 videos, 11 tables, and 163 references.

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    • 38

      Seizure

      By Robert Silbergleit, MD
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      Seizure

      • ROBERT SILBERGLEIT, MDProfessor, Neurological Emergencies Research, Department of Emergency Medicine, Ann Arbor, MI

      A seizure is a sudden change in behavior that is accompanied by electrical discharges in the brain. Many patients presenting with a first-ever seizure are surprised to find that it is a very common event in both children and adults. Epilepsy, a chronic disorder of the brain characterized by recurrent unprovoked seizures, is far less common. Patients who present to the emergency department with seizures vary considerably in underlying etiology, symptoms, and prognosis. Optimal care of the seizure patient in the emergency department requires differentiating those who need little intervention from those requiring intensive resuscitation. This review presents the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of seizure. Figures show the progression of selected neuronal pathophysiologic mechanisms involved over time during and after status epilepticus, tongue bite from seizure, a general emergency department management strategy for patients with seizure presentations, an electroencephalogram of a patient who experienced convulsive syncope after placement of an intravenous line, and staged treatment of status epilepticus. Tables list key elements of the initial emergency department management of status epilepticus, third-line medications for treatment of seizures, and the Status Epilepticus Severity Score (STESS).

      Key words: acute seizure, convulsion, epilepsy, seizure, status epilepticus

      This review contains 5 highly rendered figures, 3 tables, and 54 references.

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    • 39

      Delirium in the Emergency Department: Diagnosis, Evaluation, and Management

      By Maura Kennedy, MD, MPH
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      Delirium in the Emergency Department: Diagnosis, Evaluation, and Management

      • MAURA KENNEDY, MD, MPHDivision Chief, Geriatric Emergency Medicine, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Emergency Medicine, Harvard Medical School, Boston, MA

      Delirium, an acute confusional state characterized by disturbances in attention, cognition, and arousal, is present in 7 to 10% of older emergency department (ED) patients, underdiagnosed in the ED setting, and associated with increased short-term mortality. Delirium is typically precipitated by a physiologic stressor, such as an acute medical illness, a new medication, or a change in environment. The keys to the care and management of delirious patients are timely diagnosis of delirium and identification and treatment of the precipitating cause. The medical evaluation should include a formal delirium assessment that includes tests of attention and targeted diagnostic tests to identify the underlying etiology, such as infection, metabolic derangement, neurologic emergencies, new medications, and/or toxidromes. Pharmacologic treatment of delirium should be limited to patients who are severely agitated and at risk for substantial harm to self and/or others and patients with delirium secondary to alcohol withdrawal. Typical and atypical psychotics at low doses are first line for use in severely agitated patients. Benzodiazepines may worsen delirium and should be reserved for treatment of patients with delirium secondary to alcohol withdrawal or if sedation is required for critical imaging and/or procedures. ED physicians should also be conscious of and strive to minimize iatrogenic precipitants of delirium.

       

      This review contains 2 figures, 10 tables and 53 references

      Key words: aged, agitation, arousal attention, confusion, delirium, delirium/diagnosis, delirium/etiology, delirium/therapy, dementia complications, geriatrics, risk factors

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    • 40

      Traumatic Spinal Cord Injury

      By Kiarash Shahlaie, MD, PhD; Marike Zwienenberg, MD; Kee D. Kim, MD; Ryan Martin, MD; Lara Zimmermann, MD
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      Traumatic Spinal Cord Injury

      • KIARASH SHAHLAIE, MD, PHDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • MARIKE ZWIENENBERG, MDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • KEE D. KIM, MDAssociate Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • RYAN MARTIN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,
      • LARA ZIMMERMANN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,

      Traumatic spinal cord injury currently affects approximately 285,000 persons in the United States and carries with it significant morbidity and cost. Early management focuses on adequate ventilation and hemodynamic resuscitation of the patient and limiting motion of the spine to prevent a second injury. Medical management targets maintenance of adequate blood flow to the spinal cord, whereas surgical management focuses on decompression, realignment, and stabilization of the vertebral column. In this chapter, we discuss the approach to the patient with traumatic spinal cord injury, injury types, and medical and surgical management.

      This review contains 9 figures, 4 tables and 30 references

      Key Words: American Spinal Injury Association score, burst fracture, Chance fracture, compression fracture, hangman, mean arterial pressure therapy, odontoid fracture, spinal cord injury, traction

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  • Wellness in Training
    • 1

      A Wellness Roadmap for Medical Trainees: What a Program Director Should Know

      By Richard Joseph, MD MBA; Lori Berkowitz, MD
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      A Wellness Roadmap for Medical Trainees: What a Program Director Should Know

      • RICHARD JOSEPH, MD MBABrigham and Women’s Hospital, Division of General Internal Medicine and Primary Care, Boston, MA
      • LORI BERKOWITZ, MDObstetrics & Gynecology, Massachusetts General Hospital, Boston, MA

      This review contains 2 figures, and 25 references.

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    • 2

      Self-compassion During GME Training

      By Rebecca M. Reimers, MD, MPH
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      Self-compassion During GME Training

      • REBECCA M. REIMERS, MD, MPHDepartment of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts

      Self-compassion is a positive psychology concept that is related to resilience, improved coping, and reduced stress. The three key components are self-kindness, mindfulness, and understanding that we are all part of a common humanity. Self-compassion is in opposition of harsh self-judgment or self-criticism, which have been linked to stress, emotional dysregularion, and avoidance of negative feedback.  Self-compassion can be useful during individual times of crisis and on a daily basis for improved resilience and coping. Exercises for acute events, suggestions for daily living, and a review of self-compassion research in healthcare settings are reviewed and explained in the following article.

      This review contains 1 table and 16 references.

      Keywords: mindfulness; resilience; self-compassion; well-being; residency; burnout; graduate medical education

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    • 3

      Sleep Well to Be Well: Importance of Healthy Sleep During Medical Training

      By Ilia Kritikou, MD
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      Sleep Well to Be Well: Importance of Healthy Sleep During Medical Training

      • ILIA KRITIKOU, MDDivision of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

      Sleep is vital for our survival and wellness; lack of sleep is associated with significant cognitive, behavioral and physical health consequences, including increased mortality. In resident physicians and other health care providers, scheduled in-house calls, frequent pager/phone calls, and work required during nights are the norm. These phenomena along with the normal pull for work/life balance lead to acute and chronic partial sleep restriction, sleep disruption and circadian misalignment. As is true for the general population, residents are not immune to sleepiness and performance deficits associated with curtailed sleep. Residents are also at risk for metabolic dysregulation, including increased risk of obesity, cardiovascular disease, and mood disturbances that accompany disrupted sleep and circadian misalignment. Initial data suggesting worse patient outcomes when residents work >80 hours weekly, pushed Accreditation Council for Graduate Medical Education (ACGME) to limit resident duty-hours to 80 weekly, 30 per shift; newer data fail to show improved patient outcomes under the new limited work schedule. Nevertheless, recent studies suggest extended work schedules and circadian misalignment negatively affect well-being of resident physicians, increase risk of motor vehicle accidents. Long-term effects are yet to be determined.Implementing educational programs that foster programmatic, individual responsibility for fatigue management, GME programs and their leadership may mitigate negative consequences on safety and wellness.

      This review contains 2 figures, 3 tables, and 36 references.

      Keywords: sleep, sleep deprivation, sleepiness, circadian rhythms, residency, health care, patient outcomes, ACGME, wellness

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    • 4

      Creating a Culture of Wellness - No Jerks Allowed

      By Hope A Ricciotti, MD
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      Creating a Culture of Wellness - No Jerks Allowed

      • HOPE A RICCIOTTI, MDChair, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

      The culture of a health care system influences physician wellness; in turn, physician wellness is an indicator of the health care system quality. A career as a physician was traditionally viewed as a calling where patients came first, even to the personal detriment of the physician. Organizational cultures that support work-life integration allow flexibility and cooperative scheduling for the activities of work, home, family, community and self. Today’s health care challenges require collaboration, teamwork and the collective intelligence to get to the solutions that our complex environment requires. Open workspace is one method that can transform culture; academic medicine is following the model of the business world with spaces that flatten hierarchy, enhance communication among faculty and trainees, and foster a culture of civility and greater attachment to the organization. Top-down hierarchical leadership is outdated and counterproductive. Organizations with a flat structure are nimble, innovative and tend to outperform those with more traditional hierarchies. Adopting the humble attitude of a servant leader is essential to building positive department and organizational culture. Effective leaders have self-awareness, self-regulation, motivation, empathy and social skills, qualities collectively known as emotional intelligence. We need to move away from a physician centric culture and replace it with a new brand of department or health care organization that is just and collaborative, that promotes innovation and teamwork, iterates quickly and nurtures individuals at all levels to voice ideas and demonstrate leadership. These same ingredients promote joy in work and align with safe care models.

      This review contains 27 references.

      Keywords: Culture change, emotional intelligence, flattened hierarchy, innovation, leadership, servant leader, work-life integration

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    • 5

      Mindfulness

      By Alice D. Domar, Ph.D
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      Mindfulness

      • ALICE D. DOMAR, PH.DExecutive Director, Domar Centers for Mind/Body Health, Director of Integrative Care, Boston IVF, Senior Staff Psychologist, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Associate Professor of Obstetrics, Gynecology and Reproductive Biology, part-time, Harvard Medical School

      Most if not all physicians in training report feelings of exhaustion, burnout and inadequacy. Although many of these are normal reactions to an intense and rigorous period in their lives, it is possible to learn behaviors which can counter some of the physical and psychological impact. Mindfulness has been shown to be an effective antidote, and it is possible to incorporate mindfulness into one’s daily routine in a practical and efficient manner. Practicing mindfulness can ease the consequences of stress while simultaneously improving patient care. The key is the amount of practice one engages in; the more times one can practice mindfulness on a daily basis, the more benefits one receives. Physicians are encouraged to learn basic mindfulness skills and incorporate them into their personal and professional lives.

      This review contains 11 references.

      Keywords: mindfulness, meditation, residents, medical training, stress, depression, anxiety, symptom reduction

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    • 6

      Embracing Uncertainty

      By Arabella L. Simpkin, MD, MMSc
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      Embracing Uncertainty

      • ARABELLA L. SIMPKIN, MD, MMSCMassachusetts General Hospital Department of Medicine 100 Cambridge Street, 16th Floor, Boston, MA 02114

      We are constantly faced with uncertainty, which can instill a sense of vulnerability and fear. Prior studies link intolerance of uncertainty to burnout, ineffective communication strategies, cognitive biases and inappropriate resource use. Paradoxically, uncertainty is the driver of curiosity and progress, and is an important part of the practice of medicine. Indeed, the only certainty is in uncertainty. Unfortunately, we Western culture too often equates uncertainty with ignorance or failure, viewing it as a threat rather than a surmountable challenge, thus encouraging denial of this fundamental state for both physicians and patients. The time is ripe for a renewed perspective. Changing our culture to acknowledge, celebrate and embrace uncertainty could have positive downstream ramifications: decreasing physician burnout by reducing stress from uncertainty and altering our perspective on this state; and lightening physician’s burdens by absolving responsibility for implicitly having promised more than a physician or even medicine can deliver. Indeed, understanding and embracing uncertainty could be the most significant contribution of 21st century science to the human intellect.

      This review contains 29 references. 

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    • 7

      Perfectionism

      By Alice D. Domar, PhD
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      Perfectionism

      • ALICE D. DOMAR, PHDExecutive Director, Domar Centers for Mind/Body Health, Director of Integrative Care, Boston IVF, Senior Staff Psychologist, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Associate Professor of Obstetrics, Gynecology and Reproductive Biology, part-time, Harvard Medical School

      Perfectionism is common and even encouraged in medicine. Acceptance to medical school is predicated on academic excellence; those who commence being schooled in medicine and their perfectionistic tendencies may be rewarded. Residency and fellowship years are a time where teamwork, appropriate social behavior and flexibility may be as important as academic knowledge.  This can be threatening to the physician who has succeeded through perfectionistic academic self-induced pressure. Committing a mistake, although expected by all in this field, can feel overwhelming and unacceptable to a perfectionist: it can lead to symptoms of stress, depression and even suicide. Solutions to maladaptive perfectionism include cognitive-behavior therapy and coaching.

      This review contains 14 references.

      Key words: perfectionism, adaptive, maladaptive, physician burnout, suicide, CBT, coaching

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    • 8

      Substance Use Disorders

      By Erik A. Levinsohn, MD; Kevin P. Hill, MD, MHS
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      Substance Use Disorders

      • ERIK A. LEVINSOHN, MDBeth Israel Deaconess Medical Center
      • KEVIN P. HILL, MD, MHSDirector of Addiction Psychiatry, Beth Israel Deaconess Medical Center, Assistant Professor of Psychiatry, Harvard Medical School

      Given the incredible scope of substance use disorders, this chapter will primarily focus on alcohol and opioid use disorders, while also discussing substance use broadly. Furthermore, this chapter does not provide detailed guidelines for managing patients with a substance use disorder. Instead, this review aims to provide the reader with conceptual background of the biology of addiction as well as a general framework for its diagnosis and management. While this chapter primarily focuses on physicians in the role of caregiver, it is important to note that physicians also struggle with SUDs, at a rate near that of the general population.25

      This review contains 3 tables and 25 references.

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