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The treatment of tremor is challenging, and therapeutic options are often limited and non-specific. Treatment always has to be individualized, and apart from the objective severity of tremor, significant importance should be given to subjective severity and impact of the tremor on the patient. Supportive non-pharmacologic and non-surgical methods should be incorporated into the treatment regimen. Finally, surgical therapy is proven and effective in several tremor syndromes and should be offered to eligible patients.
Autism spectrum disorder (ASD) is defined by the American Psychiatric Association as persistent deficits in social communication and interactions and restricted, repetitive patterns of behavior, interests, or activities. There are many potential etiological causes for ASD. In the United States, the combined prevalence of ASD per 1,000 children was 23 in 2018. The American Academy of Pediatrics (AAP) recommends screening specifically for ASD during regular doctor visits at 18 and 24 months to ensure systematic monitoring for early signs of ASD. Most reported concerns from parents relate to abnormal childhood developmental trajectory and history of unusual behaviors, with variability in ages when features suggestive of ASD are most noticeable. Behavioral interventions for ASD focus on minimizing the effects of developmental delays and maximizing speech/language, motor, social-emotional, and cognitive skills. Medications can be used to target comorbid conditions or problematic behaviors that interfere with progress or pose safety concerns. The financial burden on families of children with ASD is correlated with the existing societal financial safety net. Poorer outcomes are expected when the family carries a substantial share of the cost to support the development of children with ASD, especially in lower-income households.
Child and adolescent psychiatry (CAP) is a complex and challenging subspecialty in psychiatry that developed immensely in the last century. In this chapter, we present a brief overview of development and specific aspects of the assessment, diagnosis, and treatment of children and adolescents.
Psychiatric disorders are complex and multifaceted conditions that profoundly impact various aspects of an individual’s life. Although the neurobiology of these disorders is not fully understood, extensive research suggests intricate interactions between genetic factors, changes in brain structure, disruptions in neurotransmitter pathways, as well as environmental influence.
In the case of psychotic disorders, such as schizophrenia, strong genetic components have been identified as a key feature in the development of psychosis. Moreover, alterations in dopamine function and structural brain changes that result in volume loss seem to be pervasive in people affected by these disorders. Meanwhile, mood disorders, including major depressive disorder and bipolar disorder, are characterized by disruptions in neurotransmitter systems responsible for mood regulation, such as serotonin, norepinephrine, and dopamine. Anxiety and personality disorders also exhibit neurotransmitter dysfunction and neuroanatomical changes, in addition to showing a genetic overlap with mood and psychotic disorders.
Understanding the underlying mechanisms in the pathophysiology of these conditions is of paramount importance and involves integrating findings from various research areas, including at the molecular and cellular levels. This brief overview aims to highlight some of the important developments in our current understanding of psychiatric disorders. Future research should aim to incorporate a comprehensive approach to further unravel the complexity of these disorders and pave the way for targeted therapeutic strategies and effective treatments to improve the lives of individuals afflicted by them.
Bipolar disorder (BD) is one of the most important and potentially incapacitating mental disorders, typically characterized by the alternation of depressive symptoms with periods of elevated mood, called manic or hypomanic episodes. The present chapter provides an overview of the main aspect of this psychiatric condition, including its clinical presentation, diagnosis, pathophysiology, and therapeutic aspects. While the diagnosis and management of BD can be challenging, ongoing research has led to considerable advances in its understanding. It is expected that those advances will bring about improvements in the identification and treatment of this mental illness.
Personality disorders play a major role in psychiatric clinical practice. Usually evident by adolescence, they arise when emotions, thoughts, impulsivity, and especially interpersonal behavior deviate markedly from the expectations of the individual’s culture. These disorders comprise a group of diverse and complex conditions that still warrant better understanding across multiple dimensions: genetic, neurobiological, pharmacological, and psychodynamic. This chapter addresses the definitions of both personality and personality disorder and outlines the two sets of diagnostic criteria: primary characteristics of personality disorder and the three main categories/clusters of personality disorder. It also discusses incidence of the specific disorders and relevant treatment modalities. Treatments plans should include psychotherapy, psychopharmacology, and psychoeducation, as well as treatment of comorbidities and crises. Psychotherapy has been the intervention of choice for most personality disorders, with pharmacological treatment usually auxiliary and focused on symptoms. Clinician skill is a key element of diagnosis and treatment. An experienced clinician should be able to differentiate between personality traits or styles and actual personality disorders, a particularly challenging task when a patient presents in crisis. Individuals with personality disorders can manifest a disturbed pattern in interpersonal relationships that can be deleterious in the therapeutic relationship if not approached with skill.
Based on Dr Colin Espie's 45 years of clinical and research experience, this expert manual for clinicians and healthcare professionals shows how best to assess insomnia and deliver effective treatment in everyday practice using cognitive and behavioural therapeutics (CBTx). The book provides in-depth background on the importance of sleep, the interactions between sleep and health, what insomnia is, and insomnia's negative impact on patients. Using detailed examples, metaphors, and practical guidance, it provides clear instructions on the evaluation of sleep complaints and on the why and how of selecting and providing a specific CBTx to suit the presenting patient. Delving beyond treating patients at the individual level, the book also considers how to develop an effective and efficient insomnia service at population scale.
A 20-year-old previously healthy man suddenly noticed that he was unable to run. The next day he could not climb the stairs and lost strength in his arms. He was admitted to hospital, and over the next hours he progressively lost muscle power in his arms and legs. Swallowing was progressively impaired, and he noticed minor tingling in both hands and feet. He had had a minor upper respiratory tract infection a week prior to admission.
A previously healthy, very active 68-year-old man, who usually cycled over 100 km several times a week, noticed progressive tingling in his feet and lower legs that increased over several weeks. This was followed by progressive weakness in the arms and legs exceeding a period of eight weeks. After three months of progression, weakness became so severe that he could not even walk without help. He did not use drugs or drink alcohol.
A 50-year-old man was initially seen by a rheumatologist because he had crooked fingers on the left hand and painful cramps. No rheumatological abnormalities were found. In the next three years, he developed severe atrophy and weakness of the left hand, and could not hold a glass of water. There were no sensory complaints. His GP considered motor neuron disease.
To outline the life and work of Greek physician Asclepiades of Bithynia (124–40 BC), especially his contributions to thinking about mental illness.
Methods:
Review and discussion of relevant fragments of Asclepiades’ work that survive and review of secondary literature, supplemented by relevant systematic literature searches (e.g. PubMed).
Results:
Asclepiades challenged the long-standing Hippocratic doctrine of the four humours and developed an approach to physical and mental illness that was humane, reasoned, and a forerunner of later developments in psychiatry. Asclepiades argued that the human body, like everything in the universe, comprised tiny, imperceptible particles, which he called önkoi, seamless masses in perpetual motion. In consequence, Yapijakis describes Asclepiades as ‘the father of molecular medicine’. Asclepiades held that good health was maintained by free, balanced motion of önkoi through theoretical pores, while disease resulted from blockage or impaction of önkoi passing through pores in various body parts (e.g. brain). Based on this idea, Asclepiades recommended releasing people with apparent mental illness from confinement and using judicious combinations of diet, exercise, massage, bathing, and music to treat ‘phrenitis’ (delirium) and melancholia. He suggested that the physician act ‘safely, swiftly and pleasantly’ (‘cito, tutu, jucunde’) for both physical and mental illness.
Conclusions:
Asclepiades belongs to the historical tradition of progressive medical approaches to mental illness, not least because he applied his principles for the treatment of physical illness to mental illness. His ideas about psychiatry set the scene for further evolution of attitudes to mental illness and its treatment over subsequent centuries.
An introduction and overview of the mental health conditions relevant to people with intellectual disability. The chapter focuses on the evidence base to support or refute whether they suffer greater rates of mental health problems, Psychiatric classification and prescribing; Comparison tables of international classification of diseases (ICD) versions 10 and 11; and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) 4 and 5 and DC-LD.
Placebo and nocebo effects are widely reported across psychiatric conditions, yet have seldom been examined in the context of gambling disorder. Through meta-analysis, we examined placebo effects, their moderating factors, and nocebo effects, from available randomised, controlled pharmacological clinical trials in gambling disorder.
Methods:
We searched, up to 19 February 2024, a broad range of databases, for double-blind randomised controlled trials (RCTs) of medications for gambling disorder. Outcomes were gambling symptom severity and quality of life (for efficacy), and drop outs due to medication side effects in the placebo arms.
Results:
We included 16 RCTs (n = 833) in the meta-analysis. The overall effect size for gambling severity reduction in the placebo arms was 1.18 (95%CI 0.91–1.46) and for quality of life improvement was 0.63 (0.42-0.83). Medication class, study sponsorship, trial duration, baseline severity of gambling and publication year significantly moderated effect sizes for at least some of these outcome measures. Author conflict of interest, placebo run-in, gender split, severity scale choice, age of participants or unbalanced randomisation did not moderate effect sizes. Nocebo effects leading to drop out from the trial were observed in 6% of participants in trials involving antipsychotics, while this was less for other medication types.
Conclusion:
Placebo effects in trials of pharmacological treatment of gambling disorder are large, and there are several moderators of this effect. Nocebo effects were measureable and may be influenced by medication class being studied. Practical implications of these new findings for the field are discussed, along with recommendations for future clinical trials.
Giant coronary artery aneurysms are rare but potentially fatal complications of Kawasaki disease. The lack of evidence-based recommendations on their management and treatment cause guidelines and practices to differ. We aimed to assess these variations.
Methods:
An anonymous online survey regarding surveillance, imaging, pharmacological management, and interventional practices was distributed among 134 physicians attending to Kawasaki disease patients worldwide. A p-value of <0.05 was deemed significant.
Results:
The majority (60%) of respondents were general paediatric cardiologists, and 29% interventional specialists. The average years in practice was 15 ± 9.6. Physicians from Asia had the most experience with giant coronary artery aneurysms. American practitioners preferred combining anticoagulants with aspirin. Beta-blockers and statins were more likely used in teenagers versus younger children. Cardiac catheterisation was most (52%) chosen for coronary surveillance in patients with echocardiogram anomalies, followed by Coronary CT-angiography. The indications for coronary intervention were split among respondents, regardless of geographic region or experience. The preferred treatment of coronary stenosis was percutaneous intervention (69%) versus bypass surgery. For thrombosis, thrombolytics (50%) were preferred over percutaneous (39%) and surgical (11%) interventions. Most (92%) preferred intervening in young children in a paediatric facility but were split between a paediatric and adult facility for older children. Most chose combined management by adult and paediatric specialists for either age-scenarios (70, 82%).
Conclusion:
As identified by our study, the lack of large studies and evidence-based recommendations cause uncertainty and ambivalence towards certain treatments. International collaborative efforts are needed to provide more robust evidence in the management of these patients.
Gender is a socially constructed concept influenced by social practices, norms, and expectations. The impact of gender differences on mental health has been long recognized, with consequences such as over-diagnosis and pathologization or under-diagnosis of some disorders depending on gender. This also has implications for the treatments that each gender receives. In this narrative review, we will analyze (a) the gender differences in the prevalence of mental disorders, (b) the explanations for gender differences in mental health, including biological, social constructionist, and sociocultural risk factors, and (c) the gender differences in the treatment of mental disorders, including differences in health-seeking behavior and treatment outcomes. Overall, there is a consistent pattern of differences in prevalence, with women more likely to have internalizing disorders (e.g., anxiety or depression) and men more likely to have externalizing disorders (e.g., antisocial personality or substance use). The explanations aimed at disentangling the reasons for these gender differences are complex, and several approaches should be considered to achieve a comprehensive explanation. In addition to biological factors (e.g., hormonal changes), social constructionist factors (e.g., biased diagnostic criteria and clinicians’ gender bias) and sociocultural factors (e.g., feminization of poverty, gender discrimination, violence against women, and prescriptive beauty standards) should be considered. Future studies in the field of mental health should consider gender differences and explore the bio-psycho-socio-cultural factors that may underlie these differences.
Part VI outlines several future directions for orthorexia nervosa, including a health-promotion perspective, a holistic approach to orthorexia nervosa treatment and indications of how specialists may assess orthorexia nervosa and the future way forward (conceptual, methodological and research issues). The commentaries of the invited international experts (Professor Phillipa Hay, Western Sydney University, Australia and Professor Thom Dunn, the University of Northern Colorado, USA) provide valuable insights on orthorexia nervosa.
Difficulty falling asleep and/or maintaining sleep are common complaints in patients visiting medical clinics. Insomnia can occur alone or in combination with other medical or psychiatric disorders. Diagnosis and management of insomnia at times are perplexing. This updated study review aimed at a clinical algorithm for diagnosis and treatment of insomnia in adults. We developed an easy-to-apply algorithm to diagnose and manage insomnia that can be used by general practitioners and non-sleep specialists. To this end, our team reviewed the previous studies to determine the prevalence, evaluation, and treatment of insomnia. We used the results to develop a clinical algorithm for diagnosing and managing insomnia.
Insomnia occurs in a short (less than 3 months duration) or chronic form (≥3 months duration). Insomnia management includes both pharmacological and non-pharmacological interventions. There is ample research evidence for the impact of a variety of non-pharmacological treatments, but both types of treatments can be used for each patient. If there are any contradictions in the diagnosis process, therapists should use objective instruments, such as polysomnography, but they should not be in a hurry to use these instruments.
Whilst many people try to make healthy food choices to improve their health, for others the focus on healthy eating can become obsessive and lead to maladaptive eating behaviours and poorer health. Orthorexia nervosa is a preoccupation with the quality of healthy food, where a refusal of certain foods is driven by the desire to be healthy. Orthorexia Nervosa: Current Understanding and Perspectives is the first clinical book that systematically explores this condition. The book contains in-depth information, with chapters highlighting diagnostic criteria, assessment, prevalence, multidimensional characteristics, future directions and treatment. Additional expert commentary delivers valuable insights to further provide readers with a better understanding of this condition. This informative and engaging book is a valuable resource for academics, researchers, health professionals and students interested in eating behaviour. It is an essential read for anyone wanting a better understanding of orthorexia nervosa and its impact on individuals' health.
Edited by
Laurie J. Mckenzie, University of Texas MD Anderson Cancer Center, Houston,Denise R. Nebgen, University of Texas MD Anderson Cancer Center, Houston
Vulvar melanoma is a rare malignant tumor of the female genital tract that affects mostly women in the 5th−8th decade of life. A histopathological evaluation and immunohistochemical analysis are paramount to confirm the diagnosis. Treatment requires a multidisciplinary approach. Secondary to a high metastatic potential as well as late diagnosis due to non-specific clinical signs, the prognosis is typically poor. Close monitoring, patient education regarding self-skin examination and screening are necessary for all atypical lesions and to identify local recurrences.
The clinical course of major depressive disorder (MDD) is heterogeneous, and early-onset MDD often has a more severe and complex clinical course. Our goal was to determine whether polygenic scores (PGSs) for psychiatric disorders are associated with treatment trajectories in early-onset MDD treated in secondary care.
Methods
Data were drawn from the iPSYCH2015 sample, which includes all individuals born in Denmark between 1981 and 2008 who were treated in secondary care for depression between 1995 and 2015. We selected unrelated individuals of European ancestry with an MDD diagnosis between ages 10–25 (N = 10577). Seven-year trajectories of hospital contacts for depression were modeled using Latent Class Growth Analysis. Associations between PGS for MDD, bipolar disorder, schizophrenia, ADHD, and anorexia and trajectories of MDD contacts were modeled using multinomial logistic regressions.
Results
We identified four trajectory patterns: brief contact (65%), prolonged initial contact (20%), later re-entry (8%), and persistent contact (7%). Relative to the brief contact trajectory, higher PGS for ADHD was associated with a decreased odds of membership in the prolonged initial contact (odds ratio = 1.06, 95% confidence interval = 1.01–1.11) and persistent contact (1.12, 1.03–1.21) trajectories, while PGS-AN was associated with increased odds of membership in the persistent contact trajectory (1.12, 1.03–1.21).
Conclusions
We found significant associations between polygenic liabilities for psychiatric disorders and treatment trajectories in patients with secondary-treated early-onset MDD. These findings help elucidate the relationship between a patient's genetics and their clinical course; however, the effect sizes are small and therefore unlikely to have predictive value in clinical settings.