Background
Post Traumatic Stress Disorder (PTSD) is a disorder characterized by exposure to some traumatic event leaving the individual with a variety of symptoms that can result in debilitating disability. Treatment has historically been centered around Cognitive Processing Therapy (CPT) and literature has shown a significant risk of suicide in those left untreated. Thus, the importance of appropriate healthcare utilization is important for addressing morbidity and mortality of PTSD. Determining appropriate utilization is not well recorded in the literature though some studies show increased utilization with increased symptom severity. The aim of
this study is to replicate these findings and determine if there exists any range of symptom severity that over or under-utilizes the healthcare system.

Methods
Data was collected by Rosen et al. 2012 through Project VALOR, a longitudinal registry of PTSD in combat exposed veterans of Afghanistan and Iraqi military theaters. PTSD checklist (PCL) scores and data regarding number of healthcare utilizations for PTSD treatment year to year were recorded over a five-year period. Utilization of healthcare services for PTSD were stratified by this study into categories and compared against PCL scores using an ordinal logistical regression model to predict probability of being placed in a higher utilization category. Quadratic analysis was conducted on the PCL scores to determine linear relationship of findings.

Results
Ordinal logistical regression of mean centered PCL value was 1.042 (p=0.000). Quadratic effect of ordinal logistical regression of mean centered PCL2 was determined to be 0.99 (p=0.061).

Conclusion
Self-reported PCL scores are positively predictive of healthcare utilization. For every 1 increase in PCL score, there is a predicted 4.29% increased chance of being placed into the next highest utilization category (p=0.000). In addition, the relationship between PCL score and healthcare utilization was determined to be log-linear due to quadratic effect being found not significant 0.99 (p=0.061). This indicates no PCL score is correlated with increased probability of increased or decreased healthcare utilization. This likely represents healthcare services are appropriately being administered based on symptom severity and no group is over or under-utilizing resources. Ultimately, this study replicates previous literature that increased severity is associated with increased healthcare utilization while also quantifying the predictive value of increasing PCL scores. Currently the healthcare system is correctly identifying and capturing individuals who would in theory benefit from increased healthcare utilization. Additional research into capture strength would be beneficial in determining impact of hospital system capture rate of at risk patients.

Increasing PTSD Symptom Severity Predicts Increasing Healthcare Utilization Among OEF/OIF Veterans.

Background
Recent evidence suggests that the high rates of comorbidity between obsessive-compulsive symptoms (OCS) and psychosis may warrant the diagnosis of a specific condition known as schizo-obsessive disorder. Nonetheless, the lack of official diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for this condition and limited research on optimal management for the overlapping symptom presentations complicate both diagnosis and treatment.

Case Presentation
CM is an 18-year-old female with a history of five past psychiatric hospitalizations resulting in various diagnoses including obsessive-compulsive disorder (OCD); anxiety; hypothyroidism, psychosis, unspecified; and schizoaffective disorder. She was brought to the hospital by ambulance after a physical dispute with her mother following months of worsening agitation. Her history is also notable for severe anxiety preventing her from attending school, compulsions causing her to command her mother to perform repetitive actions (resulting in significant interpersonal conflict), command auditory hallucinations involving angels and the devil, and persecutory delusions of being watched in public. Treatment with fluphenazine and risperidone in two prior hospitalizations resulted in the development of extra-parkinsonism symptoms (EPS). She has repeatedly displayed non-adherence to medications including sertraline and levothyroxine between hospitalizations, reporting both side effects and ineffectiveness in managing her symptoms. Throughout this active hospitalization, CM has endorsed intrusive audio-visual thoughts and isolative behavior. She also displays avolition, anhedonia, flat affect, thought blocking, and negativism. CM continuously fluctuates between acknowledging and denying her symptoms, indicating poor insight into her condition. She is currently being transitioned from oral to intramuscular paliperidone to manage her symptoms of psychosis, as well as oral clomipramine to treat her OCS. She is under routine monitoring for EPS and signs of adverse drug interactions.

Discussion
CM’s significant history of recurrent psychiatric hospitalizations, her unstable relationship with her mother, and her poor insight into her condition may be partially explained by the inconsistencies in her diagnoses over time. With schizo-obsessive disorder, difficulties in distinguishing obsessive and compulsive symptoms from potential delusions secondary to psychosis can result in unstandardized, overcomplicated treatment plans. This can lead to adverse effects such as EPS, worsening of either OCS or psychotic symptoms, medication non-adherence, or deleterious drug interactions. Further research is warranted to better understand the intersection of OCD and psychotic disorders such as schizophrenia. In addition, more research should be conducted on improving therapeutic practices and pharmacological treatment plans that target the related symptomatology while minimizing adverse effects.

Where Obsession Meets Psychosis: A Case Study on Co-Occurring OCD and Schizophrenia in Adolescents

Background
Delirium, defined as a disturbance in attention and awareness that cannot be better explained by a medical condition1, is a serious complication of hospitalization for the elderly population, impacting 8-17% of older adults in the emergency room and up to 40% of nursing home residents. Development of delirium is associated with long term poor health outcomes, including dementia, institutionalization, and death. While the presentation of delirium can sometimes mimic a catatonic state with psychomotor retardation, echolalia, the inappropriate repetition of words spoken by others, is not common. More frequently, echolalia is cited as a symptom of catatonia. This case report describes a patient with minimal psychiatric history who experienced oxycodone-induced delirium, with unique primary presenting symptoms of echolalia and narration. A thorough search of existing literature has found no similar examples.

Case Presentation
We present a case report of an 80-year-old female who presented with altered mental status and mental status exam significant for overproduction of speech and echolalia. The patient was found to have a recent history of spinal surgery performed at an outside hospital and was discharged to home on baclofen and oxycodone four days prior to admission. Extensive diagnostic work-up that included routine blood work, blood and CSF cultures, EEG, and neuroradiological studies were all within normal limits. The patient’s echolalia and narration extinguished and her mental status improved by day three of admission after discontinuing oxycodone and empiric treatment with acyclovir and thiamine.

Discussion
Narcotic analgesics have long been explained as a cause of delirium in elderly patients. This patient showed acute emergence of symptoms following onset of treatment with opioid analgesic, oxycodone. Although this presentation is complicated by the patient’s recent operation, lack of symptoms post-op and the disappearance of symptoms following cessation of the drug suggest that oxycodone was the cause of her delirium. Notably, this patient presented to the hospital exhibiting echolalia, the inappropriate repetition of words spoken by others. These behaviors are more commonly associated with catatonia, and have yet to be described as a primary presenting feature of delirium.

In conclusion, physicians should be aware of the possible deliriogenic properties of all narcotic substances, including oxycodone. Furthermore, atypical presenting symptoms of delirium including echolalia and narration should be considered when establishing a diagnosis. Additional research is warranted to examine whether such symptoms are more commonly associated with delirium in general or that associated with narcotics than is currently suspected. 



Echolalia as the Presenting Symptom of Opioid-Induced Delirium: A Case Report

Background
A paucity of literature delineates psychiatric symptoms in osmotic demyelination syndrome (ODS). Though clinical manifestations of ODS are canonically limited to the neurologic, some existing literature has identified psychiatric sequelae of ODS including: psychosis, catatonia, mania, behavioral changes, and cognitive disturbances. This case report discusses psychiatric sequelae of ODS, specifically manic-like symptoms, and the importance of judicious medical work-up for new onset psychiatric symptoms. This neuropsychiatric case highlights interdisciplinary collaboration between inpatient psychiatry and neurology in promptly recognizing and treating a neurologic emergency. 
Case Introduction
A 37-year-old female with a past psychiatric history of generalized anxiety disorder, no history of inpatient psychiatric admissions, initially presented to inpatient psychiatry with new onset: lack of sleep, disorganization, distractibility, behavioral disinhibition, destruction of property, complaint of foot tremor and drooling. On initial inpatient psychiatric exam, the patient presented with seemingly manic symptoms and notable cranial nerve deficits including: drooling, diplopia, dysphagia, dysdiadochokinesia, dystonic posturing of bilateral lower extremities, postural and action tremor of bilateral upper extremities, gait instability. It was noted that 8 days prior to psychiatric presentation, the patient had been admitted to the intensive care unit for severe hyponatremia and prolonged QTc following elective submental liposuction. This constellation of symptoms was concerning for ODS, prompting immediate MRI and neurology consult. 
Results
MRI brain demonstrated marked symmetric T2 FLAIR hyperintense signal in the bilateral putamen, bilateral caudate heads, and the cortex of the bilateral hand knobs, without associated reduced diffusion. Within the central pons, there was focal T2 hyperintense signal. Findings were consistent with acute/subacute osmotic demyelination and extrapontine osmotic demyelination, in the setting of recently overcorrected hyponatremia. 
The patient was immediately transferred to the neurointensive care unit for stabilization with IVIG and Decadron taper. Behavioral disinhibition resolved with short-course valproic acid. Upon neuropsychiatric stabilization, the patient was discharged home with outpatient physical rehab, occupational rehab, neurology, psychiatry, plastic surgery, and primary care follow-up. 
Discussion
Medical etiologies of seemingly manic presentations must be judiciously worked-up prior to diagnosing primary psychiatric etiology. ODS can present with psychiatric symptomatology in addition to neurologic. This case demonstrates mania-like symptoms secondary to general medical condition. Interdisciplinary collaboration was critical in pursuing timely medical work-up and treatment of ODS, thus preventing serious adverse outcomes such as progression to locked-in syndrome. Inpatient psychiatry promptly recognized a neurologic emergency through its psychiatric manifestation, allowing for immediate neurointensive treatment and stabilization.

Psychiatric Symptoms in Osmotic Demyelination Syndrome: A Neuropsychiatric Treatment Effort

According to the Alzheimer Association, dementia is an overall term that covers a wide range of specific medical conditions such as progressive loss of memory and other neuropsychological functions (e.g., praxis, speech).  These symptoms are usually severe enough to impair a patient’s daily life. Alzheimer's disease (AD) accounts for two thirds of dementia syndromes in people older than 65 years.  According to the World Alzheimer Record 2020, over 50 million people are living with dementia worldwide. And this number is expected to double every 20 years, reaching 152 million cases of dementia in 2050.  The Dementia in Europe Yearbook 2019 recored that in Italy there were 1.279.366 cases in 2018 (2.12% of population), which are set to increase to 1.460.570 cases in 2025 (2.44% of population) and 2.247.715 cases in 2050 (4.13% of population). It is therefore imperative for governments, policy makers, scientific and cultural institutions to be able to respond properly to the challenges that come with a rising number of people with dementia within their countries. In this context, cultural institutions as museums play a pivotal role in dementia awareness and education. They can serve as safe places in which run a variety of activities through an ethical use of their collections as encouraged by Convention on the Value of Cultural Heritage for Society (2005). However, the existing literature focuses particularly on museum-led programs involving art galleries and collections (e.g., the MoMa Alzheimer’s Project). The goal of this presentation is to introduce attendees to the programs for people with dementia and their caregivers that have been developed at the Museum of Planetary Sciences (MSP) in Prato. This presentation will show the positive use of meteorite samples in multisensorial activities aiming to improve patients’ and their carers’ mood and self-esteem. The impact of such non-medical treatment, its incidence on lowering dementia caregivers stress levels, and the ascertain of the participants’ satisfaction levels will be also provided. Since its establishment in 2005, MSP is actively engaged in creating successful experiences for visitors with disabilities (e.g., blindness, visual impairment, autism), and is piloting at a national level diverse multisensory stimulation programs for people with dementia and their caregivers using astromaterials. For evaluation, quantitative and qualitative data were collected using the Neuropsychiatric Inventory Questionnaire (NPI-Q), the Mini-Mental State Examination (MMSE) test, and the Cornell Scale for Depression in Dementia (CSDD) interview. This presentation will also present the activities that have been performed during the Covid-19 pandemic. By assisting the patients and their caregivers, MSP provides an example of a much more comprehensive and meaningful museum therapy project, which represent a glimpse into the future of scientific museum programming.

Meteoritics as a source of well-being for people with dementia: an experience in the Planetary Sciences Museum of Prato (Italy)

Attention-Deficit/Hyperactivity Disorder (ADHD) has been the subject of a growing body of psychological and recently, neurological research. The majority of this research has been behavioral and deficit-oriented, focused on “coping” and ways of controlling ADHD behavior to function within institutional norms. This focus persists despite compelling evidence that physiological variations are responsible for ADHD behavior, over which “control” is limited and institutional “functionality” becomes discriminatory. This is evidenced by the lack of scientific works examining ADHD from a positive perspective. In this study, we analyze interviews of STEM students and faculty at Texas State University (a large Hispanic-Serving Institution) who have been diagnosed with ADHD. These interviews will explore learner variability based on interviewees’ experiences in STEM fields, and their perceptions of personal strengths that may be unique to their variant neurobiology and/or their life experience as members of a marginalized academic group.

Exploring learner variability and disability identity in STEM students with ADHD

Novel neuroimaging biomarkers are urgently being sought to characterize early changes to the brain in mild cognitive impairment (MCI), typically a precursor to Alzheimer’s disease (AD). As the hippocampus is a critical site of AD pathogenesis that underlies principal symptoms of memory impairment, numerous studies have utilized multiple imaging modalities to characterize hippocampal integrity. The purpose of this study was to utilize a wide range of neuroimaging techniques to determine which measures were the most sensitive in detecting differences in hippocampal integrity between cognitively healthy older adults (OA) and those with amnestic MCI. We used a multimodal neuroimaging approach consisting of measures of hippocampal viscoelasticity, volume, perfusion, and diffusion – including neurite orientation and dispersion density imaging (NODDI) metrics – resulting in a total of twelve separate measures of hippocampal health. We recruited 23 OA and 7 MCI participants. A binomial logistical regression was performed to establish the effect of the 12 hippocampal measures on the likelihood of an MCI diagnosis. We also assessed the odds ratio as a measure of effect size. The full model correctly classified 92% of cases. Viscoelastic damping ratio (DR) from MRE was 27% higher in the MCI group and was the only significant predictor in differentiating between OA and MCI (p=0.024). The significant relationship between MCI status and DR (B=0.911, S.E.=0.404, after adjusting for age and sex) suggests that for every 0.01 increase in DR, the likelihood of having MCI is 2.49 times higher. No other hippocampal measures were significant predictors in the model, although hippocampal volume was close to approaching significance (p=0.056). Viscoelastic damping ratio of the hippocampus was the only significant predictor of MCI. This suggests that MRE measures of viscoelasticity may provide a unique and highly sensitive biophysical signature of hippocampal health relevant to microstructural changes that are expected to occur in MCI.

Multimodal Characterization of Hippocampal Integrity in Mild Cognitive Impairment: Combining Volumetry, Diffusion, Perfusion, and Viscoelasticity from Magnetic Resonance Imaging

Introduction: Transcranial magnetic stimulation (TMS) is extensively used in research and clinical applications pertaining to psychiatric and neurological disorders [1]. The current TMS treatments are all single-focus treatments. To satisfy the requirements of clinical treatment and improve the understanding of the synergies among different brain regions [2,3], researchers are investigating TMS that can stimulate multi brain regions. However, it is not clear whether the TMS can also develop multiple stimulation focal points in the deep brain region. Purpose: The purpose of this study is to investigate whether is it possible to use TMS for multi-focus deep brain stimulation Methods: We first established a mathematical relationship between the multi-focus electric field distribution and the winding of the TMS coil, thereby realizing the stream-function-based inverse design algorithm that can automatically generate the TMS coil winding pattern by setting the target E-field. Thereafter, we fixed the offset distance between the two-focal points of target electric fields and generated the corresponding coils by setting the focal points at different depths, thereby verifying whether the TMS coil can achieve multi-focus E-field to the deep target. Results: When the distance between the two focal points was set to 5 cm, through different depth settings and appropriate parameter selection, we theoretically found that the TMS coil can be developed for a depth that is several times the distance between the two focal points. Moreover, after further verification of the electric field generated by these coils, we found that they all meet the conditions for generating multiple focal points in the deep brain regions. Therefore, we theoretically confirmed that it is possible to use TMS for multi-focus deep brain stimulation.

![](https://assets.underline.io/uploads/markdown_image/1/image/e36c6a4ee603254bec558c7ce93578d4.jpg)

Fig.1 Generation of multi-focus TMS winding when the distance between the two focal points is fixed at 5 cm and are at different depths.

Underline digital video library

Increasing PTSD Symptom Severity Predicts Increasing Healthcare Utilization Among OEF/OIF Veterans.

Where Obsession Meets Psychosis: A Case Study on Co-Occurring OCD and Schizophrenia in Adolescents

Echolalia as the Presenting Symptom of Opioid-Induced Delirium: A Case Report

Psychiatric Symptoms in Osmotic Demyelination Syndrome: A Neuropsychiatric Treatment Effort

Meteoritics as a source of well-being for people with dementia: an experience in the Planetary Sciences Museum of Prato (Italy)

Exploring learner variability and disability identity in STEM students with ADHD

Multimodal Characterization of Hippocampal Integrity in Mild Cognitive Impairment: Combining Volumetry, Diffusion, Perfusion, and Viscoelasticity from Magnetic Resonance Imaging

Is it possible to use transcranial magnetic stimulation for multi-focus deep brain stimulation?

Stay up to date with the latest Underline news!

PRESENTATIONS

CONFERENCES

COMPANY

RESOURCES