Faculty Bibliography

As the infant mental health field has turned its focus to the presentation, course, and treatment of clinically significant mental health disorders, the need for reliable and valid criteria for identifying and assessing mental health symptoms and disorders in early childhood has become urgent. In this article we offer a critical perspective on diagnostic classification of mental health disorders in young children. We place the issue of early childhood diagnosis within the context of classification of psychopathology at other ages and describe, in some detail, diagnostic classifications that have been developed specifically for young children, including the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3R; ZERO TO THREE, 2005), a diagnostic classification for mental health symptoms and disorders in infants, toddlers, and preschoolers. We briefly outline the role of diagnostic classification in clinical assessment and treatment planning. Last, we review the limitations of current approaches to the diagnostic classification of mental health disorders in young children.

The concepts of oedipal guilt, survivor guilt, and separation guilt are examined using clinical material from a child case to demonstrate the intermingling of these constructs. A brief review of their evolution in the psychoanalytic literature reveals a frequent conflation of the terms guilt and fear, the former at times standing in for both meanings. The fear/guilt distinction and the subsequent differentiation of guilt into oedipal, survivor, and separation guilt have implications for how analysts understand and interpret particular kinds of clinical material. Two sets of adult clinical data are next presented: the first illustrates a shift from interpreting a patient's fear of retribution for forbidden desires to interpreting guilt over pursuing those desires. The second vignette illustrates a common dynamic in which a patient's fear/anxiety regarding the ability to lead an independent life defends against deeper feelings of guilt over this same desire. This latter dynamic can play an important role in negative therapeutic reactions and interminable analyses. Developmental research suggests that toward the end of the first year of life, infants' capacity to attribute independent mental states and intentionality to self and others allows for the rudimentary experience of guilt

OBJECTIVE: Valproate is associated with polycystic ovary syndrome as well as congenital malformations and developmental delays of infants who were prenatally exposed. The frequency of valproate use for mental health conditions among women of childbearing age was determined. METHODS: Using New York State Medicaid claims for persons with psychiatric disorders, 40,526 individuals with active prescriptions for mood stabilizers (non-antipsychotic) on May 1, 2009, were identified. Chi square tests were used to compare valproate use among women of childbearing age with similarly aged men and older women. RESULTS: Valproate was the most commonly prescribed agent for young women (23.4%). Men were more likely than women, and older women more likely than younger women, to take valproate. CONCLUSIONS: Over 20% of childbearing-aged women receiving mood stabilizers were treated with valproate, although increasing data on the reproductive toxicity of this agent compel consideration of other non-antipsychotic mood stabilizers as first-line choices.

OBJECTIVE: To test the hypothesis that aerobic, but not strength, training would lead to attenuated reactivity to and more rapid recovery from cognitive and orthostatic challenge and that deconditioning would reverse this effect. METHODS: We conducted a randomized controlled trial contrasting the effects of aerobic versus strength training on heart rate, four indices of RR interval variability, and blood pressure reactivity to and recovery from psychological and orthostatic challenge in 149 healthy, young, sedentary adults. Subjects were randomized to 12-week aerobic or strength training programs and studied before and after training and again after 4 weeks of sedentary deconditioning. The data were analyzed by performing a Group (aerobic versus strength) by Session (study entry, post training, and deconditioning), by Period (baseline, speech, Stroop, math, tilt) three-way analysis of variance with prespecified contrasts of the effect of group assignment on reactivity and recovery. RESULTS: Aerobic capacity increased in response to conditioning and decreased after deconditioning in the aerobic, but not the strength, training group. However, the two groups did not differ on heart rate, RR interval variability, or blood pressure reactivity to or recovery from laboratory challenge. CONCLUSIONS: These findings, from the largest randomized controlled trial to address this matter to date, raise doubts about attenuation of reactivity or enhancement of recovery as a putative mechanism underlying the cardioprotective effects of aerobic exercise. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00365196.

Previous research has established that justice-involved youth have higher rates of both learning disabilities and mental health disorders compared to youth in the community. Both need areas raise substantial intervention and rehabilitation concerns that must be addressed via educational and mental health service plans. The current study investigated rates of special education and mental health needs identified at admission in a large sample of youth admitted into a long-term secure custody facility. The proportion of overlap and specific patterns of educational and mental health problems were explored. Special education results were consistent with prior studies in finding an overall learning disability rate of 39.8%. The special education designation of Emotional Disturbance was common among youth with elevated admission mental health screening results. Demographic differences and implications for assessment and long-term service planning are addressed

The DSM-5 formulation presents an opportunity to refine the negative symptom assessments that are crucial for a schizophrenia diagnosis. This review traces the history of negative symptom constructs in neuropsychiatry from their earliest conceptualizations in the 19th century. It presents the relevant literature for distinguishing between different types of negative symptoms. Although a National Institute of Mental Health consensus initiative proposed that there are five separate negative symptom domains, our review of the individual items demonstrates no more than three negative symptom domains. Indeed, numerous factor analyses of separate negative symptom scales routinely identify only two domains: 1) expressive deficits, which include affective, linguistic and paralinguistic expressions, and 2) avolition for daily life and social activities. We propose that a focus on expressive deficits and avolition will be of optimum utility for diagnosis, treatment-considerations, and research purposes compared to other negative symptom constructs. We recommend that these two domains should be assessed as separate dimensions in the DSM-5 criteria

BACKGROUND: The expanded suffocation false alarm theory (SFA) hypothesizes that dysfunction in endogenous opioidergic regulation increases sensitivity to CO2, separation distress and panic attacks. In panic disorder (PD) patients, both spontaneous clinical panics and lactate-induced panics markedly increase tidal volume (TV), whereas normals have a lesser effect, possibly due to their intact endogenous opioid system. We hypothesized that impairing the opioidergic system by naloxone could make normal controls parallel PD patients' response when lactate challenged. Whether actual separations and losses during childhood (childhood parental loss, CPL) affected naloxone-induced respiratory contrasts was explored. Subjective panic-like symptoms were analyzed although pilot work indicated that the subjective aspect of anxious panic was not well modeled by this specific protocol. METHOD: Randomized cross-over sequences of intravenous naloxone (2 mg/kg) followed by lactate (10 mg/kg), or saline followed by lactate, were given to 25 volunteers. Respiratory physiology was objectively recorded by the LifeShirt. Subjective symptomatology was also recorded. RESULTS: Impairment of the endogenous opioid system by naloxone accentuates TV and symptomatic response to lactate. This interaction is substantially lessened by CPL. CONCLUSIONS: Opioidergic dysregulation may underlie respiratory pathophysiology and suffocation sensitivity in PD. Comparing specific anti-panic medications with ineffective anti-panic agents (e.g. propranolol) can test the specificity of the naloxone+lactate model. A screen for putative anti-panic agents and a new pharmacotherapeutic approach are suggested. Heuristically, the experimental unveiling of the endogenous opioid system impairing effects of CPL and separation in normal adults opens a new experimental, investigatory area

BACKGROUND: Social dysfunction is a hallmark symptom of schizophrenia which commonly precedes the onset of psychosis. It is unclear if social symptoms in clinical high-risk patients reflect depressive symptoms or are a manifestation of negative symptoms. METHOD: We compared social function scores on the Social Adjustment Scale-Self Report between 56 young people (aged 13-27 years) at clinical high risk for psychosis and 22 healthy controls. The cases were also assessed for depressive and 'prodromal' symptoms (subthreshold positive, negative, disorganized and general symptoms). RESULTS: Poor social function was related to both depressive and negative symptoms, as well as to disorganized and general symptoms. The symptoms were highly intercorrelated but linear regression analysis demonstrated that poor social function was primarily explained by negative symptoms within this cohort, particularly in ethnic minority patients. CONCLUSIONS: Although this study demonstrated a relationship between social dysfunction and depressive symptoms in clinical high-risk cases, this association was primarily explained by the relationship of each of these to negative symptoms. In individuals at heightened risk for psychosis, affective changes may be related to a progressive decrease in social interaction and loss of reinforcement of social behaviors. These findings have relevance for potential treatment strategies for social dysfunction in schizophrenia and its risk states and predict that antidepressant drugs, cognitive behavioral therapy and/or social skills training may be effective