Friday Factoids: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, or PANDAS for short, was a relatively new term that this writer was not very familiar with more than three weeks ago. For those of you like this writer who were unaware that a neuropsychiatric disorder shared its name with a black and white bear, let me share some information. According to the National Institute of Mental Health (NIMH), PANDAS is a “syndrome” which means it includes a number of disorders and issues that share an origin. This list includes tic disorders, obsessive compulsive disorder, anxiety disorders and some mood/behavior issues (PANDAS, 2015).

 

The shared origin of the disorders and issues listed above, in regards to PANDAS, results in the child having contracted a streptococcal infection (strep throat/scarlet fever). Strep is an extremely old bacterium that survives very well due to its ability to hide from its host’s immune system. It brilliantly has a biological cloaking system called molecular mimicry. Essentially, it places molecules on the outer portion of its cell wall that make it indistinguishable from molecules found within the host child’s brain, heart, joint and skin tissues. This allows it to avoid discovery and rapidly multiply unimpeded for some time. When the intruders are finally recognized, they are attacked by antibodies created by the immune system. However, due to the molecular mimicry, the antibodies attack not only the strep molecules but host’s tissue molecules that were mimicked. Therefore, some anti-bodies target the host’s brain tissue specifically. The result of the attack on the brain tissue is what is said to be causing the symptoms of PANDAS (Streptococcus. 2015).

 

The symptoms of PANDAS are vast and can vary from child to child. The symptoms can include: rapid onset or worsening of symptoms already present, a tic disorder and/or OCD, ADHD symptoms (hyperactivity, inattention, fidgety), physical hyperactivity (or unusual, jerky movements that are not in the child’s control), separation anxiety, mood changes (irritability, emotional lability, sadness), sleep disturbance, gross/fine motor changes (such as changes in handwriting or drawing abilities), anorexia or refusal to eat, night-time bed wetting and/or day-time urinary frequency and joint pains. The age if onset is usually anywhere from three years to the beginning of puberty. The child also must have had a positive strep culture or previous history of scarlet fever. It is important to note that the symptoms can go through an episodic course meaning they can cycle in their presence and severity with each new contraction of a streptococcal infection (PANDAS, 2015).

 

Currently, there is not a lab test used in the diagnosing of PANDAS but, as mentioned above, the child must have had a positive strep culture or previous history of scarlet fever and some combination of the majority symptoms. PANDAS is a clinical diagnosis and must meet a set of specific criteria for the diagnosis to be given.  If you believe your child may suffer from the syndrome, then contact your health care provider to discuss your child’s symptoms. Treatment usually consists of one round of antibiotics to eliminate the streptococcal bacterium. Symptoms will then begin to decrease over the course of several days to weeks.

 

Crystal K. Bray,
WKPIC Doctoral Intern

 

Works Cited
PANDAS: Fact Sheet about Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. (n.d.). Retrieved November 29, 2015, from http://www.nimh.nih.gov/health/publications/pandas/index.shtml

 

Streptococcus. (2015). In Encyclopædia Britannica. Retrieved from http://www.britannica.com/science/Streptococcus

 

Washington, H. (2015, November 3). Catching Madness. Retrieved November 29, 2015, from https://www.psychologytoday.com/articles/201511/catching-madness?collection=1081138

 

Crystal K. Bray,
WKPIC Doctoral Intern

Surviving Match: Personal Stories

 

As more and more strands of my hair began to entwine around the bristles of my brush instead of staying attached to my head, I knew I had a problem. I immediately contacted my family doctor, made an appointment and requested that he run any battery of test needed to determine the cause of why my previously thick and healthy hair was becoming so very thin and brittle. After robbing my veins of several vials worth of blood, he explained at my follow-up appointment, “The tests ran indicated that all of your levels were well within normal range.” Then, he posed the question, “Have you experienced any life changes or been going through any stressful situations?”

 

Well . . .

 

Describing the APPIC Match process as stressful to any student beginning the process is by far one of the understatements of the decade.  Even now, writing the above paragraph and thinking about the initial horror of it all sends waves of nausea throughout my stomach. It was a brutal, agonizing period of time that was never, ever going to come to an end.  If you have ever heard the colloquialism, “ Hurry up and wait!” that’s exactly what it felt like. Well that accompanied with questioning your skills, whether you studied hard enough, how will you compare to other students, why would anyone pick me and any other self-doubting questions you could possibly fathom.  And that’s just submitting your essays and waiting to see if you are selected for an interview!  The fun is yet to come!!

 

So, after weeks and months of writing and re-writing your essays, strategically selecting internships sites that better suit your knowledge base, and finding the needed funds to apply to the allotted amount statistically proven to help you Match; you get invited to interview!!!  Alas, the excitement is short lived because now you have to plan your travel itinerary.

 

 

Intern1Not only does your itinerary have to encompass the locations you are interviewing, but you must tactically juggle it in a way so that you won’t miss or be late for any scheduled or rescheduled interviews. By the way, did I mention you have to pay for your travel, lodging and most of your food out of pocket?  Oh yes!  Most all of your interviews are in person and not by phone. Plus, it’s right around the holiday season when funds are often already strapped.  I hope you remember how to build that bird house out of popsicle sticks you learned in second grade!

 

Nonetheless, here you are. You have arrived. You white-knuckle drove your rental car for hours thru bouts of snow and ice but have somehow made it to your hotel in one piece. The thermometer in your salt covered chariot reads 9 whole degrees Fahrenheit but you don’t care because you’re alive!!  Reality quickly swirls around and thru your clothes as you unload your luggage with glove covered ice cycles that took place of previous fingers.  You penguin waddle into the hotel lobby, hurriedly check in as other guests strangely eye your wildly, windblown hair, drag your belongings to your room and fall face first into the lumpy pillow.

 

The five o’clock a.m. wake-up call you requested comes way too soon. You make your way to the lobby for your “free continental breakfast” not thinking twice about how you look because you….must….have….coffee. If looks truly could kill, all the other patrons partaking in breakfast food and drink would have literally fallen over where they sat. As you slowly begin to resemble some form of intelligent being, your anxiety begins to creep up your back, over your head and into your stomach. So much for free breakfast.

 

There is no time to be sick. You must brush/floss, shower, dry/fix your hair, do your make-up, pack your luggage once more to the rental car and check out of your hotel all before you head to your interview.  In your mind you have planned and allotted so much time for each stage of your “get ready” process.  To save on time, you will brush your teeth as the shower gets warm.  You place your tooth brush in its handy, dandy travel tube, pull back the shower curtain and step in.  BAM!!! There was no shower mat when you stepped in. Your right foot slide on the slick, wet bottom of the tub. You fell into the tub wall landing with all of your weight just beneath your left knee.  You are literally in your birthday suit rocking back in forth on the dirty, hotel bathroom floor. Tears are streaming down your face and you are too afraid to look at your leg because you know it’s broken.

 

Moments to minutes later, you still feel the intense pain but it is accompanied by the throbbing of your heart in your leg. You know you have to look but think to yourself, “What am I going to do if my leg is broke…..I’m naked in the bathroom!” Slowly you peak ever so slightly and see no blood so you open both eyes.  A gigantic, purple plum has sprouted and is now housed on your upper shin. Slowly you climb up on your good leg and try to put weight on your injured one. The intensity of the pain increased under your weight but you can stand flat footed long enough to know if it is broken it’s only fracture. So, you hobble on one leg and shower the best you can.

 

You really will survive this“Oh crap…how long was I on the bathroom floor?!”  You are 18 minutes late. You have to choose from wearing make-up or curling your hair so you forgo the curlers and opt to straighten your two cowlicks instead. You still have to make up time. You swiftly hobble around your hotel room like a puny tornado that has lost its wind and try to repack all of your belongings. Dragging your bags and injured leg to the reception desk, you check out. An attractive male and female take pity on you and help you carry your bags to your car. Normally, you would turn down the gesture because you never can be too safe but pain overrides intelligence when it is severe enough.

 

The smooth yet oddly irritating voice of your GPS comes to life directing you where to  turn and leads you towards your destination. You know you have to speed but potentially will still be late. Once again, you find yourself white knuckle driving, weaving in and out of morning traffic. All speed limit signs are being ignored and you pray that any and all police officers on your route are getting coffee and not gunning for speeding cars. “Do they really like donuts?” Shaking this ridiculous thought from your head you try to be hyper vigilant as you barrel down the parkway, come to your exit and make a screeching stop at the bottom. Your destination is so about a mile on the right and you have 5 minutes to spare.

 

You literally slide in the drive-way on two wheels and hope your professors were just hazing you when they claimed some interview sites watch and judge you from the moment you arrive on their property. Three minutes!!  You whip around their circle drive and are lucky to find ONE parking spot open. You zoom in, jump out quickly remembering your injured leg and hobble up the walk to the….”Oh no, stairs!.”  “Don’t cry. You are an adult. You are a professional.” As quickly as possible, you make your way up each agonizing step and come to the door. You walk in and see a couple of other people in the same black suit that you are wearing and sigh in relief. You might be one minute late but so are they and there does not appear to be anyone in the group that is in an official capacity. You have not missed your interview and the important people who you hope to impress do not know you are late. You still have a chance with the site that you most hoped to make a good impression on.

 

FriendsThe accounts above are true and will not soon be forgotten. Short of a tragic accident or actual broken limb, I could not imagine a worse start to an interview or a more stressful period in my life. However, with passing time comes perception and clarity. The anxiety and stress that I placed on myself by questioning my abilities, measuring my worth in terms of interview invites and viewing any outcome but a match with catastrophic thinking was ridiculous and harmful. My anxiety levels were so extreme that my hair was literally falling out! I was creating a toxic environment for myself when I needed to be at the top of my game. And furthermore, my emotions really did not fit the situation.

 

Be mindful of your emotions and the reality of the Match process. We all know entering that there simply are more students seeking placements then there are placements to be offered. When you break it down, it’s simple math.  Additionally, this is a time in your life that you should be celebrating because a long, arduous course of education is finally being put to use. This is our transitional time from student to professional. And guess what, if you don’t match the sun is still going to rise tomorrow and a new day begins. We all blossom when it is meant for us to do so. Your not matching with a site that may not suit your individual personality, skill set and future objectives is a good thing.  Build your wall of support with the boulders of like-minded individuals who share you ideals, not the pebbles of those you maybe can tolerate for a year.

 

askstephan

 

 

Crystal K. Bray,
WKPIC Doctoral Intern

 

**Director’s note:  We had no idea this poor woman had wrecked her leg prior to interview and made her walk all over the hospital! And, clearly, she is our intern, so the interview went well despite all the outside disasters. And this:  no matter how Match goes for you, you will get through it, and ultimately persist and prevail, if not this year, then another. You are all valuable to the field. You can do this!                                                         –sv

Friday Factoids: Islamophobia

At the beginning of the 1990s, the term Islamophobia emerged for the first time in the United States and Great Britain. It is a term used to describe an intense fear, dislike or hate of Muslims. A wealth of misinformation actively promotes Islamophobia in America. Self-reported knowledge, whether accurate or not, about the religion of Islam seems to affect Americans’ feelings of prejudice toward Muslims. Researchers are beginning to explore the impact that Islamophobia can have on the mental and physical health of Muslim-Americans.

 

Muslims constitute approximately 23 percent of the world’s population and serve as a majority in approximately 50 countries. The population of Muslims in the U.S. has grown to more than 2.6 million. Many of them arrived in North America hoping to escape the discrimination and hate occurring in their country. It is important to be aware that Muslims can have various races and ethnicities, since Islam is a religion and not an ethnicity. For example, in America the three largest ethnic Muslim groups are Arab Americans, African Americans and South Asians.

 

Perceptions of the Muslim community have changed dramatically after 9/11. The expected reaction to any terrorism attack is to point the finger at Muslims. Even though less than 2 percent of all terrorist attacks over the past five years have been religiously motivated. An FBI report shows only 6 percent of all terrorism attacks in the U.S. between 1980 and 2005 were committed by Muslims. Research shows that the U.S. identified more than 160 Muslim-American terrorist suspects in the decade since 9/11. That is just a percentage of the thousands of acts of violence that occur in the United States each year. According to the Muslim Public Affairs Counsel, since 9/11, the Muslim-American community has helped security and law enforcement officials prevent nearly two of every five al Qaeda terrorist plots threatening the United States. It is from government prosecution and media coverage that brings Muslim-American terrorism suspects to the national spotlight. As a consequence, many Muslims feel vulnerable.

 

Few studies on Muslim health exist. Most studies identified that daily, repetitive harassment is the biggest factor contributing to long-term mental health issues in Muslim populations. In a 2011 study on Muslim-Americans, researchers found that the vast majority of participants said they felt extremely safe prior to 9/11. Following the attack, 82 percent of them felt extremely unsafe. The researchers later found many of those studied developed Post Traumatic Stress Disorder from constant anxiety and abuse. Mental illness is often stigmatized in Muslim culture. Research by Allen and Nielsen (2002), indicated that one of the best predictors of becoming a victim of discrimination or harassment was being perceived as a Muslim. Having an Arab appearance or wearing specific garments such as a hijab was most closely associated with such incidents.

 

Many Muslims choose prayer or private coping before they seek professional help. Physical or mental illness may be seen as an opportunity to remedy disconnection from Allah or a lack of faith through regular prayer and a sense of self-responsibility (Padella et al., 2012). Imams (traditional spiritual leaders) are often seen as indirect agents of Allah’s will and facilitators of the healing process. Imams may also play central roles in shaping family and community attitudes and responses to illness guidelines, or birth customs (Padella et al., 2012). Many American physicians are not well versed on Muslim culture, including health-related traditions and beliefs like long fasts or end-of-life care. This may discourage many Muslims from seeking treatment.

 

In 2007 the Muslim Council of Britain issued the following statement: “Muslims everywhere consider all acts of terrorism that aim to murder and maim innocent human beings utterly reprehensible and abhorrent. There is no theological basis whatsoever for such acts in our faith. The very meaning of the word ‘Islam’ is peace. It rejects terror and promotes peace and harmony.”

 

 

References:

 

Abdullah, T., & Brown, T. L. (2011). Mental illness stigma and ethnocultural beliefs, values, and norms: An integrative review. Clinical Psychology Review, 31, 934-948.

 

Abu-Ras, W. & Abu-Bader, S. H. (2008). The Impact of the September 11, 2001 Attacks on the well-being of Arab Americans in New York City. Journal of Muslim Mental Health, 3, 217-239.

 

Ali, O. M., Milstein, G., & Marzuk, P. M. (2005). The imam’s role in meeting the counseling needs of Muslim communities in the United States. Psychiatric Services, 56, 2-5.

 

Allen, C., & Nielsen, J. S. (2002). Summary report on Islamaphobia in the EU after 11

September 2001. Vienna: European Monitoring Center on Racism and Xenophobia.

 

Muslim Public Affairs Counsel. (2013). A tracking of plots by Muslim and non-Muslim violent extremists against the United States. Retrieved from: http://www.mpac.org/publications/policy-papers/post-911-terrorism-database.php

 

Padela, A. I., Killawi, A., Forman, J., DeMonner, S., & Heisler, M. (2012). American Muslim perceptions of healing key agents in healing, and their roles. Qualitative Health Research, 22, 846-858.

 

 

Jonathan Torres, M.S.
WKPIC Doctoral Intern

 

First Episode Psychosis: A Review of NIMH’S White Paper

The National Institute of Mental Health’s White Paper on evidenced-based programs for first episode psychosis (FEP) suggests treatments which are not currently in place in Western Kentucky.  At the time of this article review, twenty states currently have evidence based FEP programs, but Kentucky is not one of them.  The Recovery After an Initial Schizophrenia Episode program (RAISE) is an NIMH initiative to investigate early community treatment of FEP, and the RAISE paper discusses an evidence-based model for treatment of FEP that might be beneficial for the State of Kentucky to adopt.

 

States implementing evidence-based FEP programs provide services that are driven by treatment teams and specific to the developmental tasks of young adulthood. Since a majority of patients experience their first episode of psychosis (FEP) between 15-25 years old, programs are targeted toward teen and early adult populations. Within these evidence-based models, research notes that patients experiencing FEP are in the process of acquiring the social, relational, academic, and vocational skills upon which the rest of their adult life may be built upon—so disruption in this normal developmental process can be catastrophic. The lack of development in these vital areas then contributes to accumulated disability for people with psychotic disorders. The work of other states and countries has provided two decades of research to draw upon guiding program development in the United States This research strongly supports early intervention’s ability to stop the accumulated disability in young people who develop psychotic disorders.

 

Coordinated Specialty Care (CSC) is the model that has been implemented in other countries and in some areas of the United States. CSC has the potential to mitigate and possibly even stop the damage caused by psychotic disorders. Some elements of the CSC framework exist in Western Kentucky, making the development and implementation of a CSC program a reasonable goal. Other RAISE programs have been embedded into existing healthcare services. CSC resembles the Assertive Community Treatment (ACT) model in some ways but very much differs in others. The presence of ACT teams and community mental health centers may be a starting framework for CSC.

 

Additional components of CSC include assertive case management, Individual Resiliency Training (IRT) model based psychotherapy, family education and support, supported employment and education services, and low doses of select antipsychotics. CSC emphasizes a youth driven structure, a relationship with a primary staff member, and small caseloads for staff. CSC is a team driven approach involving the patient and family members. Collaborative treatment planning helps to increase compliance with treatment.  CSC emphasizes shared decision-making and a therapeutic alliances with patients in order to maintain engagement in the program over time.  One CSC staff member is always identified as the patient’s principal care manager.

 

CSC strives to bridge the gap between hospitalization and engagement in outpatient services. Referred individuals may be interviewed for eligibility while hospitalized and ‘in reach’ services provided.  This gives patients a chance to form an alliance with CSC staff prior to discharge. The CSC program then contacts the patient no less than 7 days after discharge to begin program entry. Since there is heavy emphasis on a person-centered, therapeutic alliance approach, primary clinicians should be a first point of contact. Research supports care of up to 5 years post-onset of FEP in order to maintain gains made in treatment. Maintaining engagement over a 5 year period requires a strong collaborative alliance with patients and families.  CSC programs should engage in strong outreach activities to schools, emergency rooms, jails and police departments, youth care agencies and any agency in their catchment area having contact with youth.  The outreach program must have expertise in relationship formation in order to maintain collaborative relationships with other community agencies and bridge the gaps in care for FEP.

 

The youth driven structure of CSC means that all aspects of the program need to be tailored to adolescents and young adults.  Reception and treatment areas of clinics should be decorated with youth in mind. Some CSC programs have separate waiting areas within existing healthcare clinics to facilitate a comprehensive youth-centered environment. Trends for adolescent and youth populations change more quickly than adult populations, and this should be taken into account when creating the clinic environment. Reception staff should be trained in dealing with youth and their families. Experienced mental health clinic receptionists may have more experience assisting adults with chronic mental illness versus youth experiencing FEP. CSC staff must be highly motivated to work with the complexities of FEP youth and their families. Flexibility is an absolute must. Weekend and evening appointments are necessary with this population in order to accommodate and encourage work and academic schedules. FEP peers who can help direct the youth friendliness of the clinic may provide valuable insight to clinic staff.

 

CSC provides a comprehensive, evidence based model of FEP treatment. Western Kentucky could benefit greatly from such a program serving youth. CSC programs are likely to decrease the cost of utilization of other community resources including state psychiatric hospitals, medical facilities and criminal justice resources. Infrastructure within current community mental health exists making development and implementation of CSC  feasible.

 

http://www.nimh.nih.gov/health/topics/schizophrenia/raise/nimh-white-paper-csc-for-fep_147096.pdf

 

Rain Blohm, MS
WKPIC Doctoral Intern

 

 

Friday Factoid: Sleep is More Than a Symptom

 

Americans are notoriously sleep deprived, but those with psychiatric conditions are affected even more. Chronic sleep problems affect 50 percent to 80 percent of patients in a psychiatric setting, compared with 10 percent to 18 percent of adults in the general U.S. population. Sleep problems are particularly common in patients with anxiety, depression, bipolar disorder, and attention deficit hyperactivity disorder. An increasing body of literature is suggesting that clinicians should turn their attention to closely monitor and treat our most basic function.

 

While we sleep, we progress through five stages of increasingly deep sleep. During this time, body temperature drops, muscles relax, and heart rate and breathing slow. The deepest stage of sleep produces physiological changes that help boost immune system functioning. When a person transitions into REM (rapid eye movement), body temperature, blood pressure, heart rate, and breathing increase to levels measured when people are awake. Studies report that REM sleep enhances learning and memory, and contributes to emotional health. When sleep is disrupted it can affect levels of neurotransmitters and stress hormones, impair thinking and emotional regulation. Poor sleep can lead to health issues such as Type II Diabetes, cardiovascular disease, reduced immunity, or altered endocrine functions. The effects of poor sleep may intensify the effects of psychiatric disorders.

 

Longitudinal studies suggest that sleep problems worsen before an episode of mania or bipolar depression, and lack of sleep can trigger mania. Sleep problems also adversely affect mood and contribute to relapse. Sleep disruptions in PTSD may contribute to retention of negative emotional memories and prevent patients from benefiting from fear-extinguishing therapies. Problems with sleep are a better predictor of severe depression than thoughts of or wishes for death, feeling of worthlessness and guilt, psychomotor retardation, weight problems or fatigue. Furthermore, individuals identified as “at risk” of developing bipolar disorder and childhood-onset schizophrenia typically show problems with sleep before any clinical diagnosis of illness. Such findings raise the possibility that sleep disruption may be an important factor in the early diagnosis of individuals with mental illness.

 

Traditionally, clinicians treating patients with psychiatric disorders have viewed sleep disorders as symptoms. But studies in both adults and children suggest that sleep problems may raise risk for, and even directly contribute to, the development of some psychiatric disorders. This research has clinical application, because treating a sleep disorder may also help alleviate symptoms of a co-occurring mental health problem. Neuroimaging and neurochemistry studies suggest that a good night’s sleep helps foster both mental and emotional resilience, while chronic sleep disruptions set the stage for negative thinking and emotional vulnerability.  One study managed to reduce sleep disruptions using cognitive behavioral therapy in patients with schizophrenia who showed persecutory delusions and found that a better night’s sleep was associated with a decrease in paranoid thinking along with a reduction in anxiety and depression. It is clear that sleep problems in mental illness is not simply the inconvenience of being unable to sleep at an appropriate time but is an agent that exacerbates or causes serious health problems.

 

For an interesting video on sleep, check out this TED Talk!

 

References:

 

Germain, A. (2008). “Sleep-Specific Mechanisms Underlying Post-traumatic Stress Disorder: Integrative Review and Neurobiological Hypotheses,” Sleep Medicine, 12, 185–95.

 

Gregory, A. (2009). “The Direction of Longitudinal Associations Between Sleep Problems and Depression Symptoms: A Study of Twins Aged 8 and 10 Years,” Sleep, 32, 189–99.

 

Krystal, A. (2006). “Sleep and Psychiatric Disorders: Future Directions,” Psychiatric Clinics of North America, 29, 1115–30.

 

 

 

Jonathan Torres
WKPIC Doctoral Intern