Negative life events and stress sensitivity in youth's daily life: an ecological momentary assessment study

PURPOSE

Negative life events (LEs) are associated with mental health problems in youth. However, little is known about underlying mechanisms. The aim of the study was to investigate whether exposure to LEs modifies stress sensitivity in youth's daily life.

METHODS

Ecological Momentary Assessment (EMA) was used to assess stress sensitivity (i.e., association of momentary stress with (i) negative affect and (ii) psychotic experiences) in 99 adolescents and young adults (42 service users, 17 siblings, and 40 controls; M_age 15 years). Before EMA, exposure to LEs (e.g., intrusive threats, experience of loss, serious illness) was assessed.

RESULTS

Lifetime as well as previous-year exposure to LEs modified stress sensitivity in service users: they experienced more intense negative affect and psychotic experiences in response to stress when high vs. low exposure levels were compared. In contrast, controls showed no differences in stress sensitivity by exposure levels. Looking at specific types of LEs, controls showed less intense negative affect in response to stress when high vs. low exposure levels to threatening events during the last year, but not lifetime exposure, were compared. In siblings, no evidence was found that LEs modified stress sensitivity.

CONCLUSION

Stress sensitivity may constitute a putative risk mechanism linking LEs and mental health in help-seeking youth, while unfavourable effects of LEs on stress sensitivity may attenuate over time or do not occur in controls and siblings. Targeting individuals' sensitivity to stress in daily life using novel digital interventions may be a promising approach towards improving youth mental health.

Bullying victimization and stress sensitivity in help-seeking youth: findings from an experience sampling study

Bullying victimization confers the risk for developing various mental disorders, but studies investigating candidate mechanisms remain scarce, especially in the realm of youth mental health. Elevated stress sensitivity may constitute a mechanism linking bullying victimization and mental health problems. In the current study, we aimed to investigate whether exposure to bullying victimization amplifies stress sensitivity in youth's daily life. The Experience Sampling Method (ESM) was used to measure stress sensitivity [i.e. the association of momentary stress with (i) negative affect and (ii) psychotic experiences] in 42 help-seeking youths (service users), 17 siblings, and 40 comparison subjects (mean age 15 years). Before ESM assessments, bullying victimization at school as well as various psychopathological domains (i.e. depression, anxiety, psychosis) were assessed. Service users exposed to high levels of overall (primary hypotheses) as well as specific types (secondary hypotheses; physical and indirect, but not verbal) of bullying victimization experienced more intense negative affect and psychotic experiences in response to stress compared to those with low exposure levels (all p < 0.05), whereas, in contrast, controls showed either less intense negative affect or no marked differences in stress sensitivity by exposure levels. In siblings, a less consistent pattern of findings was observed. Findings suggest that stress sensitivity may constitute a potential risk and resilience mechanism linking bullying victimization and youth mental health. Interventions that directly target individuals' reactivity to stress by providing treatment components in real-life using mHealth tools may be a promising novel therapeutic approach.

Between being healthy and becoming comatose: the neuropsychiatric landscape of critical illness with a focus on delirium, DSM-5 and ICD-11

BACKGROUND

One of the most important questions remaining in matters of critical illness in the year 2019 is arguably how to address the diverse neuropsychiatric complications of critical illness.

MAIN TEXT

The ICD-11 and DSM-5, two of the world's leading classification systems, disagree regarding important aspects of delirium; moreover, they do not mention critical illness and its neuropsychiatric complications at all.

CONCLUSIONS

It would have been desirable for the committees revising the DSM-IV-TR and ICD-10 to have joined forces in order to generate classification systems that complement each other and, moreover, that address the "The Neuro-Psychiatry of Critical Illness".

Stress sensitivity as a putative mechanism linking childhood trauma and psychopathology in youth's daily life

OBJECTIVE

Childhood trauma (CT) is associated with a range of psychopathologies, including psychosis. However, evidence on underlying mechanisms remains limited. The study aimed to investigate whether CT impacts on youth mental health by modifying sensitivity to stress in daily life.

METHOD

The experience sampling method (ESM) was used to measure momentary stress, negative affect and psychotic experiences in 99 adolescents and young adults (43 help-seeking service users, 16 siblings and 40 controls). Before ESM assessments, CT and depressive, anxiety and psychotic symptoms were assessed.

RESULTS

Stress sensitivity, that is, the association between momentary stress and (i) negative affect and (ii) psychotic experiences, was modified by physical and emotional abuse and, partially, emotional and physical neglect, but not sexual abuse in service users and controls. While there was strong evidence for increased stress sensitivity in service users when high vs. low levels of CT were compared, a pattern of resilience was evident in controls, with attenuated, or no differences in, stress sensitivity in those with high vs. low CT levels. Less consistent findings were observed in siblings.

CONCLUSIONS

Stress sensitivity may be an important risk and resilience mechanism through which CT impacts on mental health in youth.

Cyclic Vomiting Syndrome: An Update Illustrated by a Case Report

OBJECTIVE

This article presents an update on cyclic vomiting syndrome, a potentially exhausting disorder that can occur in children, adolescents, and adults and and has a huge impact on the quality of life. A structured literature search was conducted to explore the current knowledge about antipsychotics in the treatment of cyclic vomiting syndrome. A case report is presented of a 15-year-old boy with refractory cyclic vomiting syndrome (ICD-10 criteria), who finally responded to a unique combination of risperidone and amitriptyline.

DATA SOURCES

A literature search of English articles was performed in November 2015 using PubMed and the Cochrane Library with cyclic vomiting syndrome, cyclic vomiting, risperidone, and antipsychotics as key words. All types of publications were included. The publication period covered a span from 1976 to 2014.

STUDY SELECTION AND DATA EXTRACTION

In total, 13 articles were found. After screening the title and abstract, only 2 were selected.

RESULTS

In the current literature, only the use of chlorpromazine in the treatment of cyclic vomiting syndrome is mentioned. The possible underlying working mechanism of chlorpromazine is not clarified.

CONCLUSIONS

Antipsychotics are hardly mentioned in the literature with regard to their antiemetic properties. Antipsychotics like risperidone, and its unique combination with amitriptyline, might be an important alternative to achieve a satisfactory treatment result in refractory cases of cyclic vomiting syndrome.

[SSRIs for adolescents with medically unexplained symptoms]

BACKGROUND

Medically unexplained symptoms (MUS) are somatic symptoms without a clear physical cause. MUS are highly prevalent amongst adolescents and result in overconsumption of healthcare and functional impairment. Current treatment options are limited and failing treatment results in high societal costs.

CASE DESCRIPTION

We report the cases of two fifteen-year-old girls who were referred to us with an extensive history of MUS and affective symptoms resulting in general functional impairment and frequent visits to specialists. Previous treatments had been unsuccessful. Both adolescents were given selective serotonin reuptake inhibitor (SSRI) solution which resulted in impressive improvement of general functioning. At four to five months of follow-up these improvements had remained consistent.

CONCLUSION

MUS can have extremely negative effects on adolescents, their support system and society. SSRIs may be a successful treatment option, but more research in adolescents is needed.

[Movement disorders in anti-N-NMDA receptor encephalitis]

BACKGROUND

Anti-N-methyl-D-aspartate receptor encephalitis (anmdare) is a serious disease, that has only been known since 2007; movement disorders form part of the neuropsychiatric symptomatology.

AIM

To provide an overview of movement disorders in anmdare and to emphasise the complexity of this disease with regard to diagnostics and treatment.

METHOD

We searched the literature using PubMed, Medline and Cochrane and the search terms 'Anti-N-Methyl-D-Aspartate Receptor Encephalitis' OR 'anti-nmda receptor encephalitis' OR 'anti-nmdar encephalitis' AND 'movement disorders' OR 'catatonia'.

RESULTS

Orofacial dyskinesia is the most characteristic movement disorder in anmdare. Dyskinesia was observed in 80% of the patients; young children (<12 years old) have movement disorders more often.

CONCLUSION

Movement disorders are typical but aspecific symptoms of anmdare. More than one movement disorder is present in nearly all cases, a factor that can make early diagnosis difficult and can delay the start of appropriate treatment.

The forthcoming DSM-5, critical care medicine, and pediatric neuropsychiatry: which new concepts do we need?

Examination and comparison of the current DSM-IV-TR and the proposed revisions for the forthcoming DSM-5, with regard to neuropsychiatric aspects of critical illness, identified five important issues. These remain to be addressed in order to improve the care of critically ill patients. These are 1) sickness behavior, as part of the organic reaction types of the brain; 2) delirium in children and the "Differential Diagnosis of Mental Disorders Due to a General Medical Condition" in children; 3) catatonia; 4) regressive disorders in childhood in relation to somatic disorders (e.g., anti-NMDAR encephalitis); 5) age-related diagnostic criteria in relation to neuro-psychiatric disorders.

First-onset psychosis, anti-NMDAR encephalitis, schizophrenia and Consultation-Liaison psychiatry

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a new, severe and possibly life-threatening disorder as illustrated by a 25% mortality or severe disability rate. Its neuropsychiatric presentation closely resembles schizophrenia. In this paper, the relationship of anti-NMDAR encephalitis to schizophrenia and its consequences in Consultation-Liaison service for diagnostic workup in patients with first-episode psychosis are addressed.

Post-hoc revision of the pediatric anesthesia emergence delirium rating scale: clinical improvement of a bedside-tool?

BACKGROUND

Pediatric delirium (PD) is a severe neuropsychiatric disorder often seen at the pediatric intensive care unit (PICU). The Pediatric Anesthesia Emergence Delirium (PAED) scale assesses five behavioral items on a five-level severity scale, and is easily applicable in children. However, the five-level severity scales are rather arbitrarily anchored and subjective. This study aimed to pilot a practical and clinical improvement of the PAED by condensing the five-level scales of the five behavioral items to a more objectively anchored two- and three-point scale.

METHODS

Post-hoc analysis of routine data in an eight-bed PICU in a tertiary university hospital. 144 critically ill, non-electively admitted patients, aged 1-18 years, were included between November 2006 and February 2010. Scales of the five PAED-items were condensed post-hoc from five to two- and three levels of severity. Five scale properties were analyzed: 1) internal consistency; 2) item-total score correlations; 3) inter-rater agreement; 4) sensitivity and specificity; and 5) discriminative diagnostic ability.

RESULTS

Three-level PAED-items post-hoc displayed Cronbach's alpha of 0.86, and mean item-total score correlation was 0.71 (range 0.60 to 0.79). Inter-rater agreement was high (0.90). The most optimal cut-off was 8 (sensitivity=100%, specificity=96.7%) with an area under the curve (AUC) of 0.98. Likelihood ratio for a positive test result (LR+) was 30.3.

CONCLUSION

A three-level severity scale for the five PAED-items may be optimal to diagnose PD. Further prospective research is required to determine whether a revised PAED has adequate psychometric properties and is applicable across different clinical settings.

[Anti-NMDA-receptor encephalitis: a new axis-III disorder in the differential diagnosis of childhood disintegrative disorder, early onset schizophrenia and late onset autism]

Childhood disintegrative disorder (CDD), early onset schizophrenia (EOS), and late onset autism (LOA) often follow a similar course: initially, development is normal, then there is a sudden neuropsychiatric deterioration of social interaction and communication skills, which is combined with a decline in intelligence and reduction in daily activities. A 9-year-old boy was admitted to the paediatric ward with acute onset of secondary epileptic seizures. It was not long until the boy's symptoms resembled that of patients with cdd, eos and loa. Intensive tests led to the diagnosis of anti-NMDA-receptor encephalitis. Anti-NMDA-receptor encephalitis should be regarded as a possible organic cause underlying the syndromal presentation of CDD, EOS and LOA.

[Pathological hoarding by children and adolescents]

BACKGROUND

There is a dearth of knowledge and understanding concerning hoarding by children and adolescents. Psychiatrists need to know more about the phenomenon of hoarding since it can be a marker of psychopathology and it sometimes is symptomatic of a psychiatric disorder.

AIM

To review hoarding from an epidemiological and psychopathological perspective and to discuss it in relation to the developmental aspect of the first object acquisition: the transitional object.

METHOD

We conducted a literature search in PubMed, Medline, PsycINFO and the Cochranedatabase using primarily the search term ‘hoarding', but also in combination with the terms: primates, child, adolescent, psych*, klepto*, transitional object, obsessive-compulsive disorder, collecting and attachment.

RESULTS

Both animals and humans engage frequently in collecting and hoarding. Up to 60% of normally functioning children and adolescents are involved in collecting. A strong emotional attachment to possessions may be a response to an attachment problem. Hoarding combined with psychopathology is seen in persons of all ages but the prevalence rates for children and adults are unknown.

CONCLUSION

Hoarding is a worrisome type of behaviour which must be regarded as an indication of serious comorbid psychopathology. It can occur either as a symptom of an existing disorder or as a separate disorder. Finally we recommend that hoarding be included in the diagnostic criteria of the dsm and icd.

Pediatric delirium in the pediatric intensive care unit: a systematic review and an update on key issues and research questions

There was a dearth in awareness and knowledge regarding pediatric delirium (PD) at the pediatric intensive care unit (PICU). The aim of this study is to highlight the most recent and up-to-date findings of current literature -by means of a systematic review (SR) method-, and to present the key issues and research questions. A SR of the literature published between 24 March 2009 and 10 March 2011. Eight new articles were identified which included (literature) reviews, journal commentaries, and observational studies. There still is a dearth of literature on PD, with also a variable level of evidence (1b - 5), especially in relation to critical illness. To be able to further clarify PD in the PICU, additional research questions are provided for future research.

On the utility of diagnostic instruments for pediatric delirium in critical illness: an evaluation of the Pediatric Anesthesia Emergence Delirium Scale, the Delirium Rating Scale 88, and the Delirium Rating Scale-Revised R-98

Purpose

Delirium is a poor-prognosis neuropsychiatric disorder. Pediatric delirium (PD) remains understudied, particularly at pediatric intensive care units (PICU). Although the Pediatric Anesthesia Emergence Delirium (PAED) scale, the Delirium Rating Scale (DRS-88), and the Delirium Rating Scale-Revised (DRS-R-98) are available, none have been validated for use in PICU settings. The aim of the present study was to investigate the use of the DRS/PAED instruments as diagnostic tools for PD in the PICU.

Methods

A prospective panel study was conducted, under circumstances of routine clinical care, investigating the diagnostic properties of the PAED, DRS-88, and DRS-R-98 in PICU patients at a tertiary university medical center. A total of 182 non-electively admitted, critically ill pediatric patients, aged 1–17 years, were included between November 2006 and February 2010. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated. Three psychometric properties were analyzed: (1) internal consistency (2) proportion of items not rateable, and (3) discriminative ability.

Results

The PAED could be completed in 144 (93.5%) patients, much more frequently than either the DRS-88 (66.9%) or the DRS-R-98 (46.8%). Compared with the clinical gold standard diagnosis of delirium, the PAED had a sensitivity of 91% and a specificity of 98% (AUC 0.99). The optimal PAED cutoff score as a screening instrument in this PICU setting was 8. Cronbach’s alpha was 0.89; discriminative ability was high.

Conclusions

The PAED is a valid instrument for PD in critically ill children, given its reliance on routinely rateable observational signs and symptoms.

Prolonged stay at the paediatric intensive care unit associated with paediatric delirium

The objective of this study was to investigate, under circumstances of routine care, the impact of paediatric delirium (PD) on length of stay in the paediatric intensive care unit (PICU) as well as on direct financial costs. A five-year prospective observational study (2002-2007) was carried out in a tertiary eight-bed PICU in the Netherlands. Critically ill children aged 1 to 18 years who were acutely, non-electively and consecutively admitted to the PICU and detected as having PD in routine care were compared to critically ill children aged 1 to 18 years without signs of PD. PD, population characteristics and severity of illness at admission were used as predictors for length of PICU stay. Differences in length of stay yielded short-term, direct medical costs associated with PD. Forty-nine children with and 98 children without PD were included. PD prolonged length of PICU stay with 2.39 days, independent of severity of illness, age, gender, mechanical ventilation and medical indication for admission (B = 0.38, P < 0.001). PD increased direct medical costs with 1.5%. The results suggest a negative prognostic influence of PD on duration of PICU stay in routine care, resulting in an increase of direct medical costs.

Diagnostic considerations regarding pediatric delirium: a review and a proposal for an algorithm for pediatric intensive care units

CONTEXT

If delirium is not diagnosed, it is unlikely that any effort will be made to reverse it. Given evidence for under-diagnosis, tools that aid recognition are required.

OBJECTIVE

Relating three presentations of pediatric delirium (PD) to standard criteria and developing a diagnostic algorithm.

RESULTS

Delirium-inducing factors, disturbance of consciousness and inattention are common in PICU patients: a pre-delirious state is present in most. An algorithm is introduced, containing (1) evaluation of the sedation-agitation level, (2) psychometric assessment of behavior and (3) opinion of the caregivers.

DISCUSSION

It may be argued that the behavioral focus of the algorithm would benefit from the inclusion of neurocognitive measures.

LIMITATIONS

No sufficiently validated diagnostic instrument covering the entire algorithm is available yet.

CONCLUSION

This is the first proposal for a PD diagnostic algorithm. Given the high prevalence of predelirious states at the PICU, daily evaluation is mandatory. Future algorithmic refinement is urgently required.

Pervasive refusal syndrome as part of the refusal-withdrawal-regression spectrum: critical review of the literature illustrated by a case report

Pervasive refusal syndrome (PRS) is a rare child psychiatric disorder characterized by pervasive refusal, active/angry resistance to help and social withdrawal leading to an endangered state. Little has been written about PRS. A literature search yielded only 15 relevant articles, all published between 1991 and 2006. This article presents a critical review of the published literature, illustrated by a case report of an 11-year-old girl. PRS most often affects girls (75%). The mean age of the known population is 10.5 years. A premorbid high-achieving, perfectionist, conscientious personality seems to play an important role in the aetiology of PRS, as can a psychiatric history of parents or child and environmental stressors. PRS shows a symptom overlap with many other psychiatric disorders. However, none of the current DSM diagnoses can account for the full range of symptoms seen in PRS, and the active/angry resistance can be considered as the main distinguishing feature. Treatment should be multidisciplinary and characterized by patience, gentle encouragement and tender loving care. Hospitalization, ideally in a child and adolescent psychiatric unit, is almost always required. Although the recovery process is painfully slow (average duration of therapy 12.8 months), most children recover fully (complete recovery in 67% of known cases). In our opinion, it is important to increase knowledge of PRS, not only because of its disabling, potential life-threatening character, but also because there is hope for recovery through suitable treatment. We therefore propose an incorporation of PRS into the DSM and ICD classifications. However, an adaptation of the current diagnostic criteria is needed. We also consider PRS closely related to regression, which is why we introduce a new concept: "the refusal-withdrawal-regression spectrum".

A comparison of the phenomenology of pediatric, adult, and geriatric delirium

BACKGROUND

The phenomenology of delirium in childhood is understudied.

OBJECTIVE

The objective of the study is to compare the phenomenology of delirium in children, adults and geriatric patients.

POPULATION AND METHODS

Forty-six children [mean age 8.3, S.D. 5.6, range 0-17 years (inclusive)], admitted to the pediatric intensive care unit of Maastricht University Hospital, with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) delirium, underwent assessment with the Delirium Rating Scale (DRS). The scores are compared with those of 49 adult (mean age 55.4, S.D. 7.9, range 18-65 years) and 70 geriatric patients (mean age 76.2, S.D. 6.1, range 66-91 years) with DSM-IV delirium, occurring in a palliative care unit. Score profiles across groups, as well as differences in individual item scores across groups are analysed with multiple analysis of variance, applying a Bonferroni correction.

RESULTS

Although the range of symptoms occurring in all three groups was similar, DRS score profiles differed significantly across the three groups (Wilks lambda=0.019, F=804.206, P<.001). On item level, childhood delirium is characterized by a more acute onset, more severe perceptual disturbances, more frequent visual hallucinations, more severe delusions, more severe lability of mood, greater agitation, less severe cognitive deficits, less severe sleep-wake cycle disturbance, and less variability of symptoms over time. Adult and geriatric delirium do not differ in their presentations, except for the presence of more severe cognitive symptoms in geriatric delirium (P=.001).

CONCLUSION

Childhood delirium has a different course and symptom profile than adult and geriatric delirium. Adult and geriatric delirium differ only in the severity of cognitive symptoms.

Pediatric delirium in critical illness: phenomenology, clinical correlates and treatment response in 40 cases in the pediatric intensive care unit

Objective

To study the phenomenology, clinical correlates, and response to treatment of delirium in critically ill children in the pediatric intensive care unit (PICU).

Design, setting and patients

Descriptive study of a cohort of child psychiatric consultations from a tertiary PICU between January 2002 and December 2005. Demographic data, clinical presentation, and response to treatment of children subsequently diagnosed with delirium were analyzed.

Results

Out of 877 admissions (age distribution 0–18 years) arose 61 requests for psychiatric assessment. Of the 61 children, 40 (15 girls and 25 boys) were diagnosed with delirium (cumulative incidence 5%; mean age 7.6 years). Age-specific incidence rates varied from 3% (0–3 years) to 19% (16–18 years). In addition to the classical hypoactive and hyperactive presentations, a third presentation was apparent, characterized mainly by anxiety, with a higher prevalence in boys. All but 2 of the 40 children received antipsychotic medication: 27 (68%) haloperidol, 10 (25%) risperidone, and 1 both in succession. Two children treated with haloperidol experienced an acute torticollis as side effect. All children made a complete recovery from the delirium; five, however, died of their underlying disease.

Conclusion

The rate of delirium in critically ill children on a PICU is not negligible, yet prospective studies of the phenomenology, risk factors and treatment of childhood delirium are very rare. Once pediatric delirium has been recognized, it generally responds well to treatment.

[Delirium in critically ill children in a paediatric intensive care unit]

Two critically ill girls, aged 2.3 years and 3.5 years respectively, developed delirium in the Paediatric Intensive Care Unit (PICU). The first child, admitted with meningococcal meningitis and septic shock with respiratory failure, suffered from hyperactive delirium which started 2 hours post-extubation. The second child, admitted due to an exacerbation of cystic fibrosis with the threat of respiratory failure, suffered from hypoactive delirium with regression, inconsolability, dyspraxia and dysphasia. Both patients responded well to a single intravenous dose of haloperidol. Although delirium occurs in critically ill children, it often goes unrecognized, particularly in its hypoactive form. It should nevertheless be considered as a medical emergency, particularly in a PICU setting, and should be treated accordingly. Physicians are generally reluctant to consider psychopharmacological treatment of childhood delirium. Haloperidol is considered as the drug of choice, but risperidone can also be used successfully.

Case Reports With A Child Psychiatric Exploration of Catatonia, Autism, and Delirium

This chapter starts with some remarks on the conceptual history of catatonia, which begins with Kahlbaum and continues with Kraeplin, Bleuler, and Leonhard. The Diagnostic and Statistical Manual, 4th ed., Text Revision, criteria for catatonia and the multicausal origin of the disorder are discussed. So, not only schizophrenia and mood disorders associated with catatonia, which is the primary form, are introduced but also an extensive list of somatic disorders-resulting in secondary catatonia-along with the work of Gelenberg and Wing. Next, two very difficult cases, of boys with autism, catatonia, and one of them with mental retardation as well, are presented. Major textbooks, PubMed, and Medline were used for a select literature search. The results show the main and really relevant but scarce data concerning primary and secondary catatonia. In the discussion the topics are this dearth in knowledge, the concept of catatonia and its similarities with delirium, and the relation catatonia-autism, and where to find the data. The conclusions summarize the main points and end with a gentle reminder, or is it an appeal?