A PubMed search revealed 14 cases of ziprasidone associated mania, which carried primary diagnoses of mood disorders, generalized anxiety disorders (GAD), panic disorder, and psychotic disorders. To our knowledge, we report the first case of mania associated with ziprasidone augmentation of a selective serotonin reuptake inhibitor in a 60-year-old man (at time of ziprasidone-induced mania) with obssessive-compulsive disorder (OCD).

In May 2002, after partial response to citalopram 80 mg and low-dose clonazepam 1.5 mg/day in three divided doses, ziprasidone was initiated as an augmenting agent at a dose of 20 mg/day and increased to 20 mg BID. Within 7 days of starting ziprasidone family members noted a decreased need for sleep, impulsivity, grandiosity, and increased energy. He was brought to the emergency room after 17 days with florid manic symptoms. Physical and neurological exams were unremarkable. Routine laboratory work, including a drug screen, was non-contributory. His non-psychiatric medications included fexofenadine, hydroxyzine, and sodium nitroprusside. He was hospitalized and ziprasidone was stopped with reduction in the dose of citalopram to 20 mg. Manic symptoms promptly resolved within 3 days.

A case of pure mutism without pseudobulbar palsy and other neurological findings resulting from simultaneous bilateral lenticulostriate artery territory infarction is presented. A 45-year-old woman suffered a transient ischemic attack with nonfluent aphasia and right hemiparesis. Six months later, she developed pure mutism without oral apraxia, pseudobulbar signs, and motor deficits. Magnetic resonance imaging revealed bilateral infarction in the lentiform nucleus regions. In the available data, there is only one report of simultaneous bilateral lenticulostriate infarction.To date, in all reported cases of mutism of subcortical vascular origin there are also various degrees of pseudobulbar signs and motor deficits and the responsible lesions are mostly consecutive.The case presented here is the first to show pure vascular mutism without other neurological findings.

Animal models of obsessive-compulsive disorder may be derived naturally or generated experimentally. Either may be considered a full or partial model, depending on the extent of resemblance to human OCD. Although many models appear to be valid at first glance, complete models should demonstrate “compelling similarities” in all areas examined. Partial models may have only one or two OCD-like features; however, they still provide some opportunities for research. Criteria to consider when evaluating potential models are etiology, symptomatology, and use in indicating methods of therapy and prevention. Demonstration of common underlying physiological mechanisms, patterns of development and expression, and familial associations are some specific elements to consider when assessing the relevance of more complete models.

Cognitive aspects of OCD are difficult, if not impossible, to explore in animals at present and may be quite different from what is found in humans. It is hard to imagine that animals experience ego-dystonicity; however, dogs with acral lick dermatitis (ALD) that have been scolded by their owners will resort to licking themselves when out of sight, implying that they know it is wrong. Because of the difficulty in evaluating an animal's internal state, some adopt the position that there is no complete animal model of OCD and that animal models are at best partial models. However, children who exhibit compulsive behaviors frequently do not experience accompanying obsessions. Even the expression of OCD in children—for example, licking and walking in geometric designs—resembles what is seen in animals.

In the descriptions that follow, only directly comparable aspects of compulsive behavior in animals will be discussed. Naturally occurring models that appear to correspond most closely to full models may be useful in understanding the fundamental mechanisms underlying OCD and the OC spectrum, including genetics and neurobiology. Experimental models, which may be either full or partial models, could contribute similarly or provide limited but specific information in a targeted area of study, depending on the extent of their similarity to OCD.

Beginning this month, CNS Spectrums will publish this column, “Trends in Psychopharmacology,” on a bi-monthly basis. Developments in psychopharmacology are proceeding at a fast pace, and this column will cover important and emerging areas from the field in a format that will be brief, and hopefully understandable. Topics will include what is new, “hot,” controversial, or informative in the field, and, of course, suggestions for future columns are always welcome.

Although the precise etiological nature of autism—the most common development disorder—remains elusive, two main biological factors have been suggested. One is related to a possible neurochemical dysfunction at the level of the serotonergic system; the other underlines the presence of neuroanatomical abnormalities in different areas, in particular, in the cerebellum.

The authors propose a unifying hypothesis linking serotonin (5-hydroxytryptamine, or 5-HT) to the cerebellum on the basis of the observation of a specific 5-HT receptor subtype, 5-HT5A, in this area. The 5-HT5A receptors may be involved in the pathophysiology of autism, and perhaps, in autism-related disorders, since they are mainly expressed in Purkinje's cells. Future studies with specific drugs that interact with 5-HT5A receptors should permit the testing of this hypothesis through the evaluation of the receptors themselves in autopsied brain samples or in vivo by positron emission tomography. Theoretically, such compounds might prove effective in the treatment of autism.

Medical presentations can be designed as a data dump or as a story. One effective communication strategy is to organize a lecture as a three act play, starting with previews as the first act and ending with reviews as the third act. Previews facilitate learner achievement and may help learners view a medical instructor more positively. Reviews also help consolidate audience learning and ensure that messages have been clearly delivered and received. The main act is in the middle and is the content itself. Delivering this content in small multiples gives learners manageable packets of information and can help them to see the differences and similarities between conditions, deepening their understanding of what was presented.

Applying principles of adult learning can enhance the effectiveness of a medical presentation. A previous “Trends in Psychopharmacology” presented an overview of these principles and discussed targeting the learner rather than the content or the lecturer as the focus for a medical presentation. Here we cover the concept of presenting content to a learner as a story and show how to organize or “storyboard” it as a three act play.

Lectures can be arranged as a dull recitation of facts or as a story that makes the facts come alive. Generally speaking, a participant is less interested in hearing the facts that a lecturer has to present than in listening to a story the lecturer has to tell. Organizing content into a “three act play” can make a lecture memorable and its lessons practical. Classically, teachers have explained the three parts as: “Say what you are gonna say; say it; then say what you said.” More specifically, the previews are the first part, the presentation itself is the second part, and the reviews are the third part of this structure.

In the past 10 to 15 years, advances in psychopharmacology and research on the neurobiological basis of obsessive-compulsive disorder (OCD) have led to the currently predominant biological model of OCD. Nevertheless, the centrality of complex ideation in OCD supports the usefulness of a psychological approach.

In this article, we propose an integrated psychobiological model that presumes a biological etiology without assuming biological reductionism. We hypothesize that the relationship between biological and psychological organization is best explained in the context of emergent systems theory, and that the psychological meaning of OCD reflects development across phylogeny as opposed to ontogeny. Finally, we propose that OCD reflects disruption of a behavioral inhibition/harm assessment system that incorporates brain structures from different points across human phylogeny. Hence, complex psychological symptoms of a biological etiology are generated.

This supplement to CNS Spectrums focuses on the obsessive-compulsive spectrum of disorders and their relationship to anxiety. Hollander and others pioneered the concept of the obsessive-compulsive spectrum in the early 1990s, and have described its breadth and overlap with other psychiatric disorders. While its place in the psychiatric nomenclature is uncertain, the obsessive-compulsive spectrum is intertwined with the anxiety disorders in both its symptoms and biologic substrates.

Obsessive-compulsive disorder (OCD) has an important place at the center of the spectrum. While currently classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition as an anxiety disorder, OCD is distinct from these conditions in the International Classification of Diseases. There is a strong rationale for its separation from the anxiety disorders. First, OCD often begins in childhood, whereas other anxiety disorders typically have a later age of onset. OCD has a nearly equal gender distribution, unlike the other anxiety disorders, which are more common in women. Studies of psychiatric comorbidity show that, unlike the other anxiety disorders, persons with OCD generally tend not to have elevated rates of substance misuse. Family studies suggest that first-degree relatives of persons with OCD have an elevated prevalence of OCD-related disorders including body dysmorphic disorder, hypochondriasis, and grooming disorders, but not other anxiety disorders except for generalized anxiety disorder. The brain circuitry that mediates OCD appears to be different from that involved in other anxiety disorders. Lastly, OCD is unique with regard to its specific response to selective serotonin reuptake inhibitors, while noradrenergic medications, effective in the anxiety and mood disorders, are largely ineffective. On the other hand, the benzodiazepines, which have little effect on OCD, are often effective for the other anxiety disorders.

Parkinson's disease was first described in 1817 by James Parkinson. Based on his observation of only six individuals, Parkinson accurately described the resting tremor and festinate gait, bradykinesia, and postural instability associated with the disease today. Parkinson's disease primarily affects people >50 years of age and causes progressive neurological degeneration, physical disability, and worsening quality of life.

Consequently, most currently available drugs aim to restore striatal dopamine signaling. This can be best reached by increasing the supply of dopamine with oral levodopa (L-dopa), but also by stimulating dopamine receptors directly using dopamine agonists, or by inhibiting the reuptake of endogenous dopamine. Unfortunately, mainly due to the short half-life of L-dopa and the erratic absorption of oral L-dopa (causing pulsatile dopaminergic stimulation) these treatment strategies become increasingly ineffective in the course of this disease, and motor complications may further reduce the quality of life in these patients.

Fibromyalgia Syndrome (FM) affects 2-4% of the US adult population. It is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, disrupted sleep, memory and mood issues. Researchers believe that FM amplifies painful sensations by affecting the way the brain processes pain signals. In recent years there is converging data favoring the theory of a dysregulation of pain processing in the central nervous system of FM patients, particularly associated with an increase in cerebral glutamate levels. Traditional medications have not proven to be enough. Since 2017, Keays Medical Group has used neuromodulation with Transcranial Magnetic Stimulation to treat FM patients with comorbid major depressive disorder. Preliminary results have shown improvement in all standardized scoring measures including FIQ-R, GAD-7 and PHQ-9 when treated with our FMS Protocol.

Long acting injectable (LAI) antipsychotics are indicated for individuals suffering from schizophrenia, delusional disorder, schizoaffective disorder and bipolar disorder. Even though LAIs have traditionally been used for a subgroup of patients who were not compliant with oral treatments or who were a high risk to others, current trends are changing with increased options and availability of these treatments. A number of factors are implicated in the reversal of this trend including perspectives of patients and perspectives of providers. There is not abundant literature available regarding robust studies to examine these perspectives, but this presentation provides a current summary of available literature.

Some factors that influence perspectives of both patients and providers include knowledge about LAIs, cost of LAIs and the traditional views of these agents as being used under coercive circumstances. Altering perspectives has been a primary barrier to increase the use of these agents. Evidence clearly supports the use of early intervention for individuals with first episode psychosis, and poor medication compliance results in poorer treatment outcomes. With the potential improvement in quality of life and potentially decreasing the cost burden of this illness in society, this avenue for treatment must be a strong consideration for all involved in the treatment of the aforementioned disorders.