Adolescent Psychiatry (v.5, #4)

Deliberate Foreign Body Ingestion and Hopefulness Across Clinical Settings: An Under-Appreciated, but Significant, Non-Suicidal Self-Injury by Gagandeep Singh, Theodore A. Petti, Michael Gara, Barbara K. Snyder, Mark Rosato (229-236).
Background: Deliberate Foreign Body Ingestion (DFBI) is a form of non-suicidal self-injury (NSSI). DFBI is a problem in longer-term care psychiatric facilities but is poorly detailed in clinical and general pediatric populations. Hopefulness is a construct that may prove useful in formulating diagnosis and treatment for youth with DFBI.
Methods: Adolescents ages 11-18 years from an adolescent medicine clinic and a psychiatric inpatient unit were surveyed to estimate the prevalence and associated factors of DFBI in clinical settings. They were asked to anonymously complete a questionnaire focused on coping styles under stress that elicits basic demographics, positive and negative coping strategies, deliberate self-harm (DSH), and DFBI.
Results: Survey completers, N=253 were ages 11-19 years; 229 responded to the question concerning DFBI. Prevalence of reported DFBI differed with statistical significance between the settings. Neither age nor a sense of hopefulness differed between the groups. All of the youth with DFBI reported being very or somewhat hopeful. Degree of hopefulness reported across the settings differed but for those with DFBI was not significantly different. A history of DSH was correlated with a statistically significant increased risk for DFBI.
Conclusions: DFBI occurs frequently enough to warrant clinician inquiry especially in more restrictive settings in youth with histories of DSH; it should be considered within the NSSI DSM-V diagnostic classification. The sense of hopefulness in those endorsing DFBI and other NSSI should be more fully explored for its role in formulation and treatment planning.

The Use of A Psychodynamic Semi-Structured Personality Assessment Interview in School Settings by Audrey J. Clarkin, Massimo Ammaniti, Andrea Fontana (237-244).
Background and goals: Research on adolescent personality development has been limited and often bases its premises on studies of adult behavior. Growing awareness of the vicissitudes of adolescent development details the developmental pathway between childhood and adulthood and recognizes its unique dimensions. There has been a five-fold increase in empirical studies examining borderline personality disorder (BPD) in adolescents over the last ten years with BPD cited as a general factor of personality pathology. There is a need for practical assessment tools that can measure personality functioning and pathology and can be used by practicing clinicians. Since DSM utilizes adult criteria for the assessment of personality during adolescence it fails to recognize the specific developmental characteristics of PDs, because observable behaviors quickly change while the personality organization could remain more stable or arrested. Recently, a consistent effort has been made in promoting a psychodynamic oriented assessment of PDs even during adolescence, stressing the difference between personality organization and PD considering three domains which have also a neurobiological relevance (1) identity formation, (2) interpersonal relations (3) affect regulation.
Method: This article describes the use of a semi-structured interview, the Interview of Personality Organization Processes in Adolescence (IPOP-A), in the school setting. We present a series of case vignettes to illustrate how it can be employed to assess personality functioning, and also how it can be used to help promote self-reflection in adolescents.
Conclusions: The IPOP-A offers a valid and reliable psychoanalytically oriented empirical instrument highlighting the stages and tasks of adolescence. It addresses functioning in three essential contexts: home (family), peers (social, interpersonal), and school. The interview has proven valuable both with clinical and normal subjects. This article emphasizes adolescence as a second opportunity for self-other development emphasizing change in perspective and behavior. Not all adolescents are the same and the multiple processes of development during this period focus on increasing awareness of self-other, self-regulation and self-determination. The IPOP-A seems to be a promising tool useful in the clinical assessment and in-take sessions with adolescence with emerging patterns of personality pathology and in the field of adolescent personality development research.

Evaluation of a Dramatic Writing Workshop in Youth With or Without Psychiatric Disorders by Elyse Porter-Vignola, Isabelle Daigneault, Patricia Garel, Serge Lecours (245-256).
Background: Metacognitive difficulties are frequent among youth with a psychiatric disorder. The present study evaluates the effectiveness of a dramatic writing workshop on the metacognition of youth aged from 14 to 25 years, the majority presenting a stabilized psychiatric disorder.
Methods: Twenty-four youth were recruited for the study, 12 youth who received the workshop and 12 who did not. Among each group of 12 eligible participants, 10 presented with a stabilized psychiatric disorder and two did not. Metacognition, social cognition, psychological and social functioning measures as well as questionnaires about objectives and appreciation regarding the workshop were used.
Results: Analyses revealed no differences between groups after the workshop in regard to youth's metacognition, social cognition, nor psychological and social functioning. On the other hand, youth who participated in the workshop appreciated their experience, and their psychological and social functioning didn't deteriorate.
Conclusions: Study results suggest that the duration of the workshop and the number of sessions should be extended.

Background/Objective: This study was needed to determine if religious retreats, particularly extended three-day retreats, had any impact on the disruptive behavior of incarcerated adolescents attending the retreat compared to those who did not attend.
Method: The authors compared the number of Behavior Time-Outs (BTOs) assigned by staff (a measure of disruptive behaviors) to those attending the retreat and to those who did not attend the retreat; these were compared for both groups at one month before the retreat and at one and three months after the retreat. The retreat and control groups were compared for using statistical analysis (chi square, t test and repeated measure ANOVA) to detect differences between the groups and the statistical significance of the retreat on BTOs for the retreat group.
Results: The number of BTOs in the retreat group fell from a baseline of 3.82 to 2.42 per week at one month and 2.26 per week at three months. At the same time the control group displayed an increase in BTOs from 3.84 at baseline to 4.06 at one month and then to 3.50 at three months. When the retreat group BTOs were compared to that of the control group over time, our analyses revealed a significant within group by time interaction, F = 4.42, p 0.039. We also noted a significant between effect for groups at F= 5.26, p = 0.024.
Conclusions: These data suggest that a religious retreat like Epiphany can lower disruptive behavior, at least over a three month term. Correctional facilities may want to investigate the addition of similar types of faithbased interventions to the milieu. Further studies are needed to substantiate this finding.

Narcolepsy in Adolescents: A Review and Three Case Reports by Swarnalata Debbarma, Karim Sedky (264-272).
Background: Narcolepsy is a chronic neurological disorder characterized by excessive daytime sleepiness, cataplexy, hypnagogic and/or hypnopompic hallucinations, and sleep paralysis. Due to symptom overlap and comorbidity between narcolepsy and other psychiatric disorders, narcolepsy in children and adolescents can be easily misdiagnosed. Diagnostic delay is common.
Method: We review the clinical presentations, epidemiology, etiology, diagnostic criteria, and treatment of this disabling disorder. We also present three examples of cases initially diagnosed as either a medical or psychiatric disorder, leading to a delay in management ranging from seven months to seven years.
Discussion: These cases highlight the importance for psychiatrists and other mental health professionals who work with adolescents to become familiar with this uncommon disorder to shorten time to treatment of this patient population.

A Possible Case of Bipolar Disorder Unmasked by Dextromethorphan in a 16-year-old Adolescent by Daniel P. Witter, Lalita Ramnaraine, Michael A. Shapiro (273-276).
Background/Objective: Several case reports have described psychosis or mania in patients abusing dextromethorphan. In each of the cases of mania, the symptoms resolved rapidly after the dextromethorphan was metabolized. To our knowledge, no cases have been reported of an underlying diagnosis of bipolar disorder that has been revealed by abuse of dextromethorphan. This report describes such a possible case.
Method: We describe clinical observations and treatment of patient who received standard level of care for bipolar disorder.
Results: Our patient presented with symptoms of mania after ingesting 300 mg of dextromethorphan. His symptoms lasted for over one week after the dextromethorphan was out of his system, even after an antimanic agent was started. This is a significantly longer symptomatic period of time than has previously been reported in the literature.
Conclusions: While this case technically meets criteria for dextromethorphan-induced bipolar disorder according to DSM-5, we suggest that the prolonged course of symptoms may be more indicative of a primary bipolar disorder. We propose that this case might be more similar to the unmasking of bipolar symptoms by anti-depressant medications, which would be supported by the hypothesized acute anti-depressant effects of dextromethorphan.

Obsessional Fear of Getting Into a Relationship: A Case Report by Sandeep Motichand, Joyita Sinha, Sakshi Rai, Vinod K. Sinha, Nishant Goyal (277-280).
Background: Once perceived to be rare in childhood, obsessive compulsive disorder (OCD) is now recognized to be fairly common among children and adolescents. However, lack of recognition of the disorder and delays in treatment continue to be frequent. The occurrence of unusual or unfamiliar symptoms may be one of the reasons for under-detection of OCD. Obsessions related to romantic relationships have been described in adults; usually these involve doubts and fears about the relationship.
Method: We report an uncommon obsessional fear of getting into a romantic relationship in an adolescent girl who had been previously well functioning. This patient experienced significant distress and dysfunction due to these repetitive thoughts. After intervention with medication and cognitive behavioral therapy her symptoms diminished and she returned to pre-morbid functioning.
Discussion: Unusual presentations of the symptoms may lead to diagnostic confusion and delay in treatment. In adolescents, for example, who are navigating one of the normal developmental challenges—intimacy, are vulnerable to develop anxiety, which may manifest unusually as OCD. It is essential that clinicians recognize how varied the nature of obsessions can be.