Evelyn is a 35-year-old woman who presented to a psychiatrist with complaints of marriage difficulties. As she described some of these difficulties, she leaned forward, and her psychiatrist responded by changing her body posture and unfolding her arms. Evelyn explained that she had been brought up to be stoic in the face of difficulties. When she described some of the family's early circumstances, her expression became sad and her psychiatrist responded by furrowing her brow. Evelyn's parents had encouraged the kids to be self-reliant and independent; problems were not complained about, they were simply dealt with. At present, however, her situation felt overwhelming. She felt embarrassed to have to talk with a stranger about her marriage. Her psychiatrist reflected back, saying that her early family had obviously given her many strengths, and that it must be difficult to have to ask for help. At that point in the conversation, Evelyn's eyes misted over with tears.

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

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

Abnormal light-related behaviors have been described for patients with panic disorder (PD). The present study was undertaken to investigate the retinal light response in PD using electroretinography (ERG). The authors conducted bwave ERG measurements with a bright light (after dark adaptation) in 28 patients with PD and 28 control subjects. There were no significant differences in the mean b-wave amplitude between the two groups, but the retinal response to light in PD patients was generally lower than in healthy subjects. A large interindividual variability was found; also noted was a significant difference in the mean b-wave amplitude between the right and left eyes in the control group. The data indicate subtle variation of retinal photosensitivity in a subgroup of patients with PD. Because dopaminergic retinal activity affects b-ERG amplitude, the authors hypothesize that the dopaminergic system is involved in the response to light in PD patients.

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

The Eleventh Judicial Circuit Criminal Mental Health Project (CMHP), located in Miami-Dade County, FL, was established in 2000 to divert individuals with serious mental illnesses (SMI; eg, schizophrenia, bipolar disorder, and major depression) or co-occurring SMI and substance use disorders away from the criminal justice system and into comprehensive community-based treatment and support services. The program operates two primary components: prebooking jail diversion consisting of Crisis Intervention Team (CIT) training for law enforcement officers and postbooking jail diversion serving individuals booked into the county jail and awaiting adjudication. In addition, the CMHP offers a variety of overlay services intended to: streamline screening and identification of program participants; develop evidence-based community reentry plans to ensure appropriate linkages to community-based treatment and support services; improve outcomes among individuals with histories of noncompliance with treatment; and expedite access to federal and state entitlement benefits. The CMHP provides an effective, cost-efficient solution to a community problem and works by eliminating gaps in services, and by forging productive and innovative relationships among all stakeholders who have an interest in the welfare and safety of one of our community’s most vulnerable populations.

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

Multiple sclerosis (MS) is the most common cause of neurological disability in young and middle-aged adults. Although Charcot noted behavioral changes associated with MS, nearly a century would elapse before researchers began defining their full extent and severity. Broadly speaking, abnormalities may be divided into those of mood and cognition. Many patients are afflicted with both and it is essential that clinicians are not only aware of this but understand how to detect problems and provide treatment.

The lifetime prevalence of major depression in MS patients approaches 50%. As Scott B. Patten, MD, and colleagues note, these data came from specialist clinics with the potential for ascertainment bias. Shifting their inquiry into a large community-based sample, they report that the rates of mood disorder remain elevated largely in younger MS patients. While it is partly reassuring to find that aging comes with at least one benefit, the gist of this study is to reinforce the message that clinically significant depression is a problem for MS patients. Not only does it adversely affect quality of life and lead to increased suicidal thinking, it exerts more subtle deleterious effects as Peter A. Arnett, PhD, reveals. In a longitudinal study exploring the relationship between depression and cognition, Arnett reports that MS patients with prominent evaluative symptoms of depression (ie, feelings of inferiority, failure) have greater difficulty with cognitive tasks that encompass information processing speed and executive function linked to working memory. A preoccupation with negative thoughts may reduce the cognitive capacity necessary for aspects of attention and working memory.

These data complement the review article of Ralph H.B. Benedict, PhD, ABPP-CN, that focuses on methods of detecting cognitive dysfunction in MS. As with mood disorders, impaired cognition has been linked to difficulties with work, relationships, and, in more extreme cases, basic activities of daily living. Usually, the more subtle pattern of deficits associated with demyelination differ from those seen in cortical-type dementias and will be missed should clinicians rely on screening instruments like the Mini-Mental State Examination. At the same time, the method of choice for eliciting deficits, namely neuropsychological testing is expensive and frequently not readily available. This has meant that alternative instruments, like the Multiple Sclerosis Neuropsychological Screening Questionnaire, assume an added prominence. With good sensitivity, specificity, and ease of administration this informant based scale makes a useful addendum to the neurological examination. It is in the same light that the magnetic resonance imaging (MRI) rating scale by Laury Chamelian, MD, FRCPC, and colleagues should be viewed.

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

The increasing evidence for a neurobiologic basis for alcoholism has spurred the search for pharmacologic agents to treat alcohol abuse. The complex set of symptoms and behaviors that characterizes alcoholism has been linked to dopaminergic and opioid neurotransmitter systems, suggesting that opioid antagonists, such as naltrexone, may alter the positive reinforcement effects and craving involved in alcoholism. Laboratory and clinical investigations of naltrexone have demonstrated the potential for this agent to reduce craving, increase the aversive effects of alcohol, decrease drinking days, and increase abstinence. While naltrexone and other opioid antagonists, such as nalmefene, may be effective components of an alcohol-treatment program, they should only be used in combination with psychosocial interventions, such as support groups and psychotherapy.

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

Aripiprazole lauroxil (AL) is a long-acting atypical antipsychotic approved for the treatment of schizophrenia in adults. AL has five regimen options that offer three different injection intervals using four different dosage strengths. The relationship between dosage strength (milligram injected), injection interval (time between injection visits), and expected steady-state plasma aripiprazole concentrations may not be readily apparent. This article illustrates the relationship by providing visual scenarios of steady-state plasma aripiprazole concentrations for the five AL regimens. The efficacy of AL was originally demonstrated in a pivotal study of two AL regimens (approved as 441 mg monthly and 882 mg monthly). The three additional regimens (662 mg monthly, 882 mg every 6 weeks, and 1064 mg every 2 months) were approved based on pharmacokinetic bridging studies and population pharmacokinetic models. For this paper, expected steady-state concentrations for each AL regimen were derived from the published population pharmacokinetic models and compared using median values and ranges. The five labeled AL regimens differ in dosage strength and injection interval; however, model-simulated concentrations illustrate that each regimen produces steady-state plasma aripiprazole concentrations within the upper and lower bounds associated with known efficacy for AL 441 mg and 882 mg administered monthly. This visual presentation of the relationship between dosage strength of the AL injection, the interval between successive injections, and steady-state aripiprazole plasma concentrations may demonstrate for clinicians how dosage strength and injection interval can be considered in selecting the AL regimen option that best fits the clinical circumstances of the individual patient.

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

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

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