Anxiety Disorders: Medical University of South Carolina

Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Borkovec TD, Rickels K, Stein DJ, Wittchen HU. · Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, SC 29425-0742, USA. · J Clin Psychiatry. · Pubmed #11414552 No free full text.

Abstract: OBJECTIVE: To provide primary care clinicians with a better understanding of management issues in generalized anxiety disorder (GAD) and guide clinical practice with recommendations on the appropriate treatment strategy. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R.T. Davidson, Yves Lecrubier, and David J. Nutt. Four additional faculty members invited by the chair were Karl Rickels, Hans-Ulrich Wittchen, Dan J. Stein, and Thomas D. Borkovec. EVIDENCE: The consensus statement is based on the 6 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed the review articles and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees. CONCLUSIONS: GAD is the most common anxiety disorder in primary care and is highly debilitating. Furthermore, it is frequently comorbid with depression and other anxiety disorders, which exacerbates functional impairment. Antidepressants (serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and nonsedating tricyclic antidepressants) are generally the most appropriate first-line pharmacotherapy for GAD, since they are also effective against comorbid psychiatric disorders and are suitable for long-term use. Cognitive-behavioral therapy is the preferred form of psychotherapy for GAD, although when GAD is comorbid with depression, pharmacotherapy is increasingly indicated.

Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, McFarlane AC, Shalev AY. · Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston 29425-0742, USA. · J Clin Psychiatry. · Pubmed #10761680 No free full text.

Abstract: OBJECTIVE: To provide primary care clinicians with a better understanding of management issues in posttraumatic stress disorder (PTSD) and guide clinical practice with recommendations on the appropriate management strategy. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Other faculty invited by the chair were Edna B. Foa, Ronald C. Kessler, Alexander C. McFarlane, and Arieh Y. Shalev. EVIDENCE: The consensus statement is based on the 6 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed the review articles and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees. CONCLUSION: PTSD is often a chronic and recurring condition associated with an increased risk of developing secondary comorbid disorders, such as depression. Selective serotonin reuptake inhibitors are generally the most appropriate choice of first-line medication for PTSD, and effective therapy should be continued for 12 months or longer. The most appropriate psychotherapy is exposure therapy, and it should be continued for 6 months, with follow-up therapy as needed.

Malcolm R, Olive MF, Lechner W. · Medical University of South Carolina, Institute of Psychiatry, 67 President Street, MSC 861, Charleston, SC 29425, USA. · Expert Opin Drug Saf. · Pubmed #18613809 No free full text.

Abstract: BACKGROUND: Disulfiram has demonstrated efficacy in six randomized clinical trials for the treatment of cocaine dependence, but is rarely used in clinical settings because of safety concerns. OBJECTIVE: What are the common and serious side effects of disulfiram in cocaine-dependent individuals with and without alcohol dependence in randomized clinical trials? METHODS: We located Phase I and II randomized trials that discussed the safety of disulfiram. RESULTS/CONCLUSIONS: In randomized clinical trials that eliminated subjects with serious cardiovascular, hepatic, and psychiatric disorders, the most frequent side effects of disulfiram over placebo or index groups include headaches, fatigue, sleepiness, and anxiety. Disulfiram in a dose of <or= 250 mg/day led to only mild interactions with alcohol. When patients are screened for medical and psychiatric stability, and are evaluated for drug interactions, disulfiram has an acceptable side-effect profile for the treatment of cocaine dependence with or without alcohol dependence.

Brady KT, Verduin ML, Tolliver BK. · Clinical Neuroscience Division, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Charleston, SC 29425, USA. · Curr Psychiatry Rep. · Pubmed #17915076 No free full text.

Abstract: Psychiatric disorders and drug and alcohol use disorders commonly co-occur. A growing literature has documented the epidemiology and effects on the course of illness of comorbid psychiatric and substance use disorders (SUDs). Advances in treatment of co-occurring illnesses have progressed more slowly. The current article reviews recent developments in the diagnosis and treatment of co-occurring psychiatric disorders and SUDs with particular focus on psychotic disorders, affective disorders, anxiety disorders, personality disorders, and attention-deficit/hyperactivity disorder. Current treatment options and implications for future research are highlighted.

Zinzow HM, Grubaugh AL, Monnier J, Suffoletta-Maierle S, Frueh BC. · National Crime Victims Research and Treatment Center, Medical University of South Carolina, SC, USA. · Trauma Violence Abuse. · Pubmed #17846179 No free full text.

Abstract: This article reviews the literature documenting the nature and prevalence of traumatic experiences, trauma-related mental and physical health problems, and service use among female veterans. Existing research indicates that female veterans experience higher rates of trauma exposure in comparison to the general population. Emerging data also suggest that female veterans may be as likely to be exposed to combat as male veterans, although not as directly or as frequently. Female veterans also report high rates of posttraumatic stress disorder, which has been associated with poor psychiatric and physical functioning. Although sexual assault history has been related to increased medical service use, further research is needed to understand relationships between trauma history and patterns of medical and mental health service use. Researchers also are encouraged to employ standardized definitions of trauma and to investigate new areas, such as treatment outcomes and mediators of trauma and health. Policy and practice implications are discussed.

Brewerton TD. · Medical University of South Carolina, Charleston, South Carolina, USA. · Eat Disord. · Pubmed #17710567 No free full text.

Abstract: This paper reviews the relationships among eating disorders (EDs), trauma, and comorbid psychiatric disorders, with a particular focus on posttraumatic stress disorder (PTSD). There have been a number of significant conclusions in the literature, applicable to clinical practice, which are essential to the understanding of the relationships between EDs and trauma. These are summarized as follows: a) childhood sexual abuse (CSA) is a nonspecific risk factor for EDs; b) the spectrum of trauma linked to EDs has been extended from CSA to include a variety of other forms of abuse and neglect; c) trauma is more common in bulimic EDs compared to nonbulimic EDs; d) findings linking EDs with trauma have been extended to children and adolescents with EDs; e) findings linking EDs with trauma have been extended to boys and men with EDs; f) multiple episodes or forms of trauma are associated with EDs; g) trauma is not necessarily associated with greater ED severity; h) trauma is associated with greater comorbidity (including and often mediated by PTSD) in ED subjects; i) partial or subthreshold PTSD may also be a risk factor for BN and bulimic symptoms; and j) the trauma and PTSD or its symptoms must be expressly and satisfactorily addressed in order to facilitate full recovery from the ED and all associated comorbidity.

Amstadter A. · Auburn University, USA. · J Anxiety Disord. · Pubmed #17349775 No free full text.

Abstract: Recent attention has been given to the role of emotion regulation in the development and maintenance of psychopathology. Gross [Gross, J. J., & John, O. P. (1998). Mapping the domain of expressivity: multimethod evidence for a hierarchical model. Journal of Personality and Social Psychology, 74, 170-191] provided a framework from which to understand emotion regulation processes, and it is within this framework that the literature on emotion regulation/dysregulation in the anxiety disorder population is reviewed, with a focus on possible deficiencies that lead to or maintain the disorders. The present paper aims to: (1) briefly introduce emotion regulation strategies of suppression and reappraisal; (2) summarize the empirical studies of emotion regulation within anxiety disorders; (3) discuss the neurobiological markers of emotion regulation within these disorders; (4) provide future directions for research; and (5) summarize possible treatment implications resulting from this important area of research.

Danielson CK, de Arellano MA, Ehrenreich JT, Suárez LM, Bennett SM, Cheron DM, Goldstein CR, Jakle KR, Landon TM, Trosper SE. · National crime Victims Research & treatment Center, Medical University of South Carolina, Charleston, SC 29403, USA. · J Psychiatr Pract. · Pubmed #17122697 No free full text.

Abstract: An adolescent's possible response to being the victim of interpersonal violence is not limited to posttraumatic stress disorder and depression but may also involve a host of developmental effects, including the occurrence of high-risk behaviors that may have a significant and negative impact on the adolescent's psychological and physical health. Identifying such high-risk behaviors, understanding their possible link to a previous victimization incident, and implementing interventions that have been demonstrated to reduce such behaviors may help decrease potential reciprocal interactions between these areas. Clinicians in psychiatric practice may be in a unique position to make these connections, since parents of adolescents may perceive a greater need for mental health services for youth engaging in problematic externalizing behaviors than for those displaying internalizing symptoms. In this article, the authors first describe high-risk behaviors, including substance use, delinquent behavior, risky sexual behaviors, and self-injurious behaviors, that have been linked with experiencing interpersonal violence. They then review empirically based treatments that have been indicated to treat these deleterious behaviors in order to help clinicians select appropriate psychosocial interventions for this population. Recommendations for future research on the treatment of high-risk behaviors in adolescents are also presented.

Deas D, Brown ES. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, USA. · J Clin Psychiatry. · Pubmed #17107227 No free full text.

Abstract: The use and abuse of substances-including alcohol, nicotine, marijuana, inhalants, and other drugs-are commonly found to be comorbid with psychiatric conditions in adolescents. This dual diagnosis requires special attention and treatment, especially as substance use often begins during this developmental period. Adolescents may be diagnosed with substance abuse, substance dependence, or substance use disorder not otherwise specified, which indicates a developing substance use problem that includes symptoms of but does not meet criteria for substance dependence. Psychiatric comorbidity in adolescents who abuse substances is the rule rather the exception, and common comorbidities include depression, anxiety, bipolar disorder, conduct disorder, and attention-deficit/hyperactivity disorder. Treatment of the psychiatric disorder often helps to alleviate the substance use disorder as well. This activity discusses the epidemiology, assessment, and treatment of this dual diagnosis.

Hinson VK, Haren WB. · Department of Neurosciences, Murray Center for Research on Parkinson's Disease and Related Disorders, Medical University of South Carolina, Charleston Memorial Hospital, Charleston, SC 29425, USA. · Lancet Neurol. · Pubmed #16857575 No free full text.

Abstract: Diagnosis and treatment of psychogenic movement disorders are challenging for both neurologists and psychiatrists. Symptoms can mimic the full range of organic abnormal involuntary movements, affect gait and speech, or present as unusual undifferentiated movements. Typical clinical characteristics of these disorders are acute onset, fast progression, movement patterns incongruent with organic movement disorders, distractibility, variability, and simultaneous occurrence of various abnormal movements and dysfunctions. Avoidance of iatrogenic damage by unnecessary invasive tests or inappropriate medication, as well as use of appropriate psychiatric treatments are pivotal steps in the management of these disorders. The few clinical trials specific to psychogenic movement disorders focus on antidepressants and psychotherapy. Presence of a comorbid psychiatric diagnosis of depression or an anxiety disorder is a positive prognostic factor, whereas long-standing symptoms, insidious onset of movements, and a psychiatric diagnosis of hypochondriasis, factitious disorder, or malingering are associated with poor outcome.

DeVane CL, Stowe ZN, Donovan JL, Newport DJ, Pennell PB, Ritchie JC, Owens MJ, Wang JS. · Laboratory of Drug Disposition and Pharmacogenetics, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA. · J Psychopharmacol. · Pubmed #16785271 No free full text.

Abstract: Various symptoms of mental illness occur commonly during pregnancy. It is estimated that serious mental disorders, including major depression, bipolar disorder, schizophrenia, panic and other anxiety disorders, occur with a frequency of 10 to 25% in community samples of US women in their child-bearing years. As a result, approximately a third of all women take at least one psychoactive drug during pregnancy. Fetal drug exposure has been documented for all psychoactive drugs studied to date. However, the rate and extent of placental transfer within and between psychoactive drug classes remains ill defined. The contribution of various genetic factors such as the role of polymorphic drug metabolizing enzymes and drug transporters in controlling the variability of fetal drug exposure is also unclear. Therapeutic drug monitoring (TDM) has traditionally played an important role in psychiatric pharmacotherapy during pregnancy to ensure an adequate drug dose to achieve desired benefits while avoiding excessive fetal accumulation for drugs. In the genomic era, individualized treatment with specific drugs tailored to the mother's and fetus's genotype should eventually become the standard of care. Several methodological problems need to be overcome for this prediction to become reality. One approach to this goal taken by the Specialized Center of Research on Sex and Gender Factors Affecting Women's Health at the Emory University Women's Mental Health Program is described. This research is grounded on TDM of pregnant women receiving antidepressants, antipsychotics, anti-epileptic drugs and mood stabilizers. The use of pharmacokinetic and pharmacogenetic models to predict maternal plasma drug concentrations, fetal drug exposure, and maternal and neonatal outcomes, is expected to improve our understanding of dose-response relationships of psychoactive drugs in pregnancy.

Brady KT, Verduin ML. · Institute of Psychiatry, Medical University of South Carolina, Charleston, South Carolina 29425, USA. · Subst Use Misuse. · Pubmed #16282091 No free full text.

Abstract: Mood and anxiety disorders commonly co-occur with substance use disorders. Exploration of the neurobiology of substance use disorders and mood and anxiety disorders have found that the neural circuitry in mood, anxiety, and substance use disorders is clearly overlapping. These discoveries have encouraged the exploration of a number of pharmacotherapeutic agents in the treatment of co-occurring mood, anxiety, and substance use disorders. In this article, recent data on the pharmacotherapeutic treatment of mood and anxiety disorders in individuals with substance use disorders are reviewed. Some of the barriers to the use of pharmacotherapy in individuals with substance use disorders are discussed.

Devane CL, Chiao E, Franklin M, Kruep EJ. · Department of Psychiatry, Medical University of South Carolina, 67 President Street, P.O. Box 250861, Room PH246, Charleston, SC 29425, USA. · Am J Manag Care. · Pubmed #16236016 links to  free full text

Abstract: Anxiety disorders are highly prevalent in adults and often coexist with depression. Patients with anxiety commonly present to their primary care doctors, or in other medical settings, reflecting a high utilization of medical services. Furthermore, some patients initially complain of only somatic symptoms before they are ultimately diagnosed with a primary anxiety disorder. Approaches to management include both nondrug and drug treatments, and pharmacotherapy has substantial evidence-based support for efficacy. Of the drugs available for use, an antidepressant, and in particular a selective serotonin reuptake inhibitor, is the preferred initial treatment for most patients. This choice is based on the drug's proven efficacy, favorable adverse event profile, relative safety in overdose, and better management of comorbid depression. The treatment of anxiety disorders has multiple potential benefits in systems of managed care. These include the ability to maintain remission or prevent relapse, a decrease in comorbid depression, promotion of adherence with improvement in quality of life, and reduction in claims for medical care. This overview of the anxiety disorders sets the stage for subsequent discussions of managed care datasets highlighting the opportunities for making informed decisions about access to care and treatment that can lead to economic benefits, especially in light of the Medicare Modernization Act.

Hamner MB, Robert S. · Department of Psychiatry, Ralph H Johnson Department of Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC 29401, USA. · Expert Rev Neurother. · Pubmed #15853496 No free full text.

Abstract: Post-traumatic stress disorder is an anxiety disorder that may occur after the individual is exposed to severe psychologic trauma such as combat, sexual assault, or childhood physical or sexual abuse. Chronic post-traumatic stress disorder may result in considerable psychologic pain and suffering for the individual in addition to significant functional impairment. In addition to the heterogeneity of symptoms that occur in post-traumatic stress disorder, there may also be extensive comorbidity with other anxiety disorders, mood disorders, psychotic disorders, and other psychiatric disorders. This complicates the treatment picture. Currently, accepted treatments for post-traumatic stress disorder include psychotherapy, in particular cognitive behavioral-based approaches and antidepressant medication. However, many patients are refractory to these initial treatments or have only a partial response. In light of this, may clinicians combine additional classes of psychotropic agents and different psychotherapeutic approaches to enhance treatment response. This article reviews the literature on the use of atypical antipsychotics in the treatment of post-traumatic stress disorder. Most of the research to date has involved combat veterans partially responsive or refractory to treatment, namely with antidepressants. Studies have shown improvement across post-traumatic stress disorder symptom clusters, as well as improvement in comorbid psychotic symptoms or disorders. More research is needed to confirm these recent findings and further delineate the role of atypical antipsychotics in the treatment of post-traumatic stress disorder. Currently, possible indications for their use include treatment-resistant post-traumatic stress disorder and post-traumatic stress disorder with comorbid psychotic features.

Scott RW, Mughelli K, Deas D. · Medical University of South Carolina, Charleston, SC 29425, USA. · J Natl Med Assoc. · Pubmed #15719867 links to  free full text

Abstract: OBJECTIVE: Although several treatments for children and adolescents with anxiety disorders are available, there are few well-controlled studies in the literature that compare these treatments for efficacy. The objective of this paper is to provide an overview of controlled treatment studies for children and adolescents with anxiety disorders. METHOD: The research literature on controlled treatment studies of anxiety disorders in children and adolescents was systematically reviewed through a search of PsycINFO and Medline. Studies that did not compare the efficacy of treatment modalities were excluded. RESULTS: This review focuses specifically on three main treatment modalities: cognitive-behavioral therapy, both individual and group; family-based interventions; and pharmacotherapy. Each of these modalities is reviewed in the context of the separate disorders as defined by DSM-III-R and/or DSM-IV. The results are especially promising for cognitive-behavioral therapy and pharmacotherapy for many of the anxiety disorders; however, there are concerns about small sample sizes, lack of described comorbidity within the groups and generalizability. CONCLUSION: While great strides have been made in the treatment of child and adolescent anxiety disorders, empirically based studies are quantitatively limited. More research is needed involving head-to-head trials of the different modalities.

Hamner MB, Robert S, Frueh BC. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, USA. · CNS Spectr. · Pubmed #15448585 links to  free full text

Abstract: The mainstay of treatment for chronic posttraumatic stress disorder (PTSD) is a combination of psychotherapy and medication treatments. The first-line medications for PTSD are antidepressants, with two selective serotonin reuptake inhibitors (sertraline and paroxetine) currently Food and Drug Administration-indicated for PTSD. However, many patients do not have an adequate response to antidepressants, therefore, combinations with other antidepressants or with other classes of psychotropic medication are often utilized to enhance the therapeutic response. Other agents that have been used include mood stabilizers, anti-adrenergics, anxiolytics, and atypical antipsychotics. The heterogeneity of symptom clusters in PTSD as well as the complex psychiatric comorbidities (eg, with depression or substance abuse) further support the notion that combinations of medications may be needed. To date, there is a paucity of data to support specific strategies for augmenting antidepressants in PTSD. This review will address representative existing studies and discuss several potential pharmacologic strategies for patients suffering from treatment-refractory PTSD.

Frueh BC, Buckley TC, Cusack KJ, Kimble MO, Grubaugh AL, Turner SM, Keane TM. · Medical University of South Carolina and Veterans Affairs Medical Center, Charleston 29401-5799, USA. · J Psychiatr Pract. · Pubmed #15334985 No free full text.

Abstract: The lifetime prevalence of posttraumatic stress disorder (PTSD) is about 8%-14% in the general population, and trauma victimization (51%-98%) and PTSD (up to 42%) are even more prevalent among persons treated within public-sector mental health clinics. Despite this, individuals with PTSD and severe mental illness (SMI) who are treated within the public sector tend to receive inadequate mental health services. In addition, treatments for PTSD for this population remain undeveloped, with virtually no available empirical treatment outcome data to guide clinicians. We propose a model for a comprehensive, multicomponent cognitive-behavioral treatment program for this target population that includes elements of consumer education, anxiety management training, social skills training, exposure therapy, "homework" assignments, and long-term follow-up care. Special considerations for public-sector consumers with PTSD and SMI are addressed, as are directions for future research.

Brawman-Mintzer O, Yonkers KA. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29406, USA. · CNS Spectr. · Pubmed #15303077 No free full text.

Abstract: Anxiety disorders are among the most prevalent psychiatric disorders in the general population, found nearly twice as often in women, and estimated to affect 26.9 million individuals in the United States alone. Anxiety disorders are associated with considerable chronicity, morbidity, and disability. Treatment of anxiety disorders includes pharmacologic and nonpharmacologic approaches. The first-line pharmacologic treatments currently include the use of serotonin reuptake inhibitors and selective serotonin reuptake inhibitors. However, despite the general success of the available treatments, no single anxiolytic appears to be effective for all patients suffering from anxiety. Low recovery rates have been reported in all anxiety disorders, underscoring the need for optimizing treatment for these disabling disorders. In recent years, there is increasing interest in the use of atypical neuroleptics in the treatment of anxiety disorders patients. This article discusses the emerging data on the use of these agents in the treatment of anxiety with a focus on treatment-refractory patients and on the implications for the treatment of women suffering from anxiety disorders.

Dickerson LM, King DE. · Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina 29406, USA. · Am Fam Physician. · Pubmed #15259526 links to  free full text

Abstract: When no organic cause for dyspepsia is found, the condition generally is considered to be functional, or idiopathic. Nonulcer dyspepsia can cause a variety of symptoms, including abdominal pain, bloating, nausea, and vomiting. Many patients with nonulcer dyspepsia have multiple somatic complaints, as well as symptoms of anxiety and depression. Extensive diagnostic testing is not recommended, except in patients with serious risk factors such as dysphagia, protracted vomiting, anorexia, melena, anemia, or a palpable mass. In these patients, endoscopy should be considered to exclude gastroesophageal reflux disease, peptic or duodenal ulcer, and gastric cancer. In patients without risk factors, consideration should be given to empiric therapy with a prokinetic agent (e.g., metoclopramide), an acid suppressant (histamine-H2 receptor antagonist), or an antimicrobial agent with activity against Helicobacter pylori. Treatment of patients with H. pylori infection and nonulcer dyspepsia (rather than peptic ulcer) is controversial and should be undertaken only when the pathogen has been identified. Psychotropic agents should be used in patients with comorbid anxiety or depression. Treatment of nonulcer dyspepsia can be challenging because of the need to balance medical management strategies with treatments for psychologic or functional disease.

Barkley RA. · Department of Psychiatry, Medical University of South Carolina, Harborview Office Tower, 19 Hagood Avenue, Room 910, Charleston, SC 29425, USA. · Psychiatr Clin North Am. · Pubmed #15063996 No free full text.

Abstract: Available research provides compelling evidence that ADHD is associated with significantly increased risks for various adverse outcomes while driving, including increased traffic citations (particularly speeding), motor vehicle crashes for which the driver is at fault, repeated crash occurrences,and more severe crashes as determined from dollar damage and likelihood of bodily injuries from the crash. Not surprisingly, teens and adults with ADHD are more likely to have their licenses suspended and even fully revoked. Research further suggests that these driving risks cannot be accounted for by the comorbid disorders likely to be associated with ADHD, such as ODD, conduct disorder (CD), depression, or anxiety, or by lower than normal levels of intelligence.Recent attempts to study the processes or mechanisms involved in driving in adults with ADHD offer some explanation of how the disorder conveys such increased risks. Driving can be conceptualized usefully as involving at least three or more dimensions or levels, including basic cognitive abilities necessary for driving (operational), actual skills for maneuvering the vehicle in traffic (tactical), and the more executive, goal-directed aspects of driving(strategic). The findings of studies indicate that ADHD interferes with the basic operational components of driving by means of the impairments it produces in attention, resistance to distraction, response inhibition, slower and more variable reaction time, and the capacity to follow rules that may compete with ongoing sensory information. Accumulating evidence also points to a problem in the tactical level of driving, such that those with ADHDrate themselves and are rated by others as employing less safe driving habits during their normal operation of a vehicle than are adults in community control groups. Although this has been more elusive to demonstrate through the use of simple laboratory-based driving simulators. more modern virtual reality driving platforms offer greater promise in providing more realistic appraisals of driving performance and thus more direct evidence of the problems that occur at the tactical level from the disorder. Research has not examined the impact of ADHD at the higher strategic level or goal-directed aspects of driving. But given the mounting evidence that ADHD adversely affects executive functioning in adults, the author and colleagues anticipate that this level also will be found to be impaired in adults with ADHD. Indeed,it recently has been shown that adults with ADHD overestimate their driving abilities relative to normal adults, a problem that likely can be ascribed to more limited self-awareness and related meta-cognitive abilities for self-evaluation arising from the disorder.Although further research on the driving problems posed by ADHD is in order, sufficient evidence exists to warrant focus on possible treatments that may serve to improve these driving problems and reduce the risk for these adverse outcomes. High on the list of such treatments deserving further research and clinical attention is the use of stimulant medication. The more recent noradrenergic reuptake inhibitor. atomoxetine, also may have some promise in this regard. Studies are underway in the author's driving laboratory to see if this is the case. Meanwhile, adults with ADHD and parents of teens with ADHD should be advised about these heightened risks and encouraged to take steps that may reduce them, including the consideration of more graduated licensing for adolescents with ADHD and the possible use of stimulant medication in teens and adults with ADHD while they are operating a motor vehicle.

DeVane CL. · Laboratory of Drug Disposition and Pharmacogenetics, Medical University of South Carolina, 67 President Street, Suite 246 North, Charleston, SC 29425, USA. · Psychopharmacol Bull. · Pubmed #14624231 links to  free full text

Abstract: Valproate is a branched-chain carboxylic acid with an extensive history of use as an antiepileptic drug. In recent years, multiple uses for valproate have been found in psychiatry. As divalproex sodium, it is currently approved for the treatment of manic episodes associated with bipolar disorder and for migraine headache prophylaxis. Accumulating evidence suggests it may also be beneficial in several anxiety disorders. Valproate's pharmacokinetic profile has been extensively studied, mostly within the context of treatment of epilepsy. This review summarizes valproate's pharmacokinetics, drug interactions, and tolerability as an aid to promote individualized pharmacotherapy. Valproate is characterized by dose-limited absorption, nonlinear plasma protein binding, and multiple metabolic pathways of elimination. Pharmacokinetic drug interactions involving valproate result from its susceptibility to the effects of both enzyme induction and inhibition, along with an ability for weak to moderate inhibition of the metabolic elimination of other drugs. Valproate has an extensive record of use across the lifespan and a good record of tolerability. Some precautions are warranted in its use, but valproate is generally safe whether administered alone or in combination with other therapies.

DeVane CL. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA. · Psychopharmacol Bull. · Pubmed #14566199 links to  free full text

Abstract: The development of paroxetine hydrochloride began in the late 1970s. An abundance of data have been accumulated from clinical investigations demonstrating the efficacy of paroxetine in the treatment of major depression and anxiety disorders. The published literature contains a substantial amount of supportive data documenting the safety, tolerability, and pharmacokinetic and pharmacodynamic properties of paroxetine. The role of paroxetine in clinically significant drug-drug interactions, especially involving metabolic inhibitory effects on the substrates of cytochrome p450 2D6, has long been suspected, but only isolated cases provide any evidence. Published data for widespread patient morbidity from drug interactions with paroxetine are almost nonexistent. Considerations of the pharmacokinetic properties of paroxetine support a rationale for the development of new dosage forms that maintain the efficacy yet improve the tolerability profile of the selective serotonin reuptake inhibitors. Paroxetine controlled-release is an enteric-coated formulation with release features that may enhance clinical outcome by modifying absorption-related pharmacokinetics, improving tolerability, and maintaining therapeutic benefits

Kilpatrick DG, Acierno R. · National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, 29425, USA. · J Trauma Stress. · Pubmed #12699200 No free full text.

Abstract: This paper reviews epidemiological estimates of criminal victimization derived largely from nationally based studies in the United States. Origins of conflicting rates and prevalences are explained in terms of varying methodology. Risk factors for victimization, including age, race, gender, and disability, are also outlined, and derived from both national and geographically limited U.S.-based studies. Finally, mental health outcomes of violence are documented, with conclusions drawing on both national and regionally specific studies. These outcomes focus on posttraumatic stress disorder, but also include depression, substance abuse, and panic.

Lydiard RB. · Medical University of South Carolina, Charleston, USA. · J Clin Psychiatry. · Pubmed #12662130 No free full text.

Abstract: Anxiety stems from and perpetuates dysregulation of neurobiological systems, but the exact mechanisms of anxiety disorders are still only partially understood. Gamma-aminobutyric acid (GABA) is the primary inhibitory neurotransmitter known to counterbalance the action of the excitatory neurotransmitter glutamate. Several pharmacologic agents target the GABA system and modulate the overall effect of GABA. This article highlights multiple neurobiological interactions that play a role in anxiety and reviews selected studies of plasma neurosteroid levels, plasma GABA levels, and benzodiazepine binding site sensitivity and density in patients with anxiety disorders. The article concludes with further support for the role of the GABA system in anxiety by summarizing the current evidence supporting the use of novel GABAergic agents including tiagabine in the treatment of anxiety disorders.

Hiott DW, Labbate L. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Ralph H. Johnson VAMC, Charleston 29412, USA. · NeuroRehabilitation. · Pubmed #12547982 No free full text.

Abstract: Anxiety disorders are common in the general population and may be even more common in people with traumatic brain injuries. This article presents a review of the literature on anxiety disorders as a result of traumatic brain injury, specifically post-traumatic stress disorder, generalized anxiety disorder, obsessive compulsive disorder, and panic disorder. Our current understanding suggests that the increased frequency of anxiety disorders after TBI may reflect an overlap between brain regions vulnerable to traumatic brain injury, and the neural circuitry of these disorders. Issues regarding treatment are largely anecdotal, and much remains unsettled. More research is needed, both in terms of diagnosis and treatment.