Several psychiatric disorders, including borderline personality disorder (BPD), are characterized by emotional dysregulation and impulse dyscontrol. More specifically, symptoms in patients with BPD often occur within the context of disruptions in attachment and related distortions in cognitive-affective processing of the self and others. From a neurocircuitry perspective, findings include prefrontal hypoactivity, amygdala hyperreactivity, and alterations in prefrontal-limbic interaction. Molecular pathways relevant to these circuits include the serotonergic, noradrenergic, and dopaminergic systems, and there is some evidence that pharmacotherapy with agents that act on these systems may be useful. Given the disruptions in attachment and schemas of the self and others in BPD, establishing a therapeutic alliance is crucial while psychotherapy remains the cornerstone of an integrated approach to management.

N-acetyl cysteine (NAC) is a widely available nutraceutical with a variety of actions. As a precursor of cysteine and glutathione, it has antioxidant properties that may impact on mood and contribute to an effect on impulsivity and obsessive behaviour. Via its additional effect on glutamate via the cystine-glutamate exchange system, NAC has been shown to mediate impulsivity in preclinical models of addiction, reduce craving, and cue extinction. Further, by boosting glutathione, NAC acts as a potent antioxidant and has been shown in two positive, large-scale randomized placebo-controlled trials to affect negative symptoms in schizophrenia and depression in bipolar disorder. We describe three cases in which its actions specifically on nail-biting and associated anxiety may offer a potential treatment. The spontaneous findings are reported as part of an ongoing treatment trial examining the utility of NAC in bipolar disorder. Its actions, if robustly replicated, also point to potential treatment targets in glutathione or glutamate pathways in the brain.

Introduction: Research suggests that obsessive-compulsive disorder (OCD) is not a unitary entity, but rather a highly heterogeneous condition, with complex and variable clinical manifestations.

Objective: The aims of this study were to compare clinical and demographic characteristics of OCD patients with early and late age of onset of obsessive-compulsive symptoms (OCS); and to compare the same features in early onset OCD with and without tics. The independent impact of age at onset and presence of tics on comorbidity patterns was investigated.

Methods: Three hundred and thirty consecutive outpatients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for OCD were evaluated: 160 patients belonged to the “early onset” group (EOG): before 11 years of age, 75 patients had

Results: The EOG had a predominance of males, higher frequency of family history of OCS, higher mean scores on the “aggression/violence” and “miscellaneous” dimensions, and higher mean global DY-BOCS scores. Patients with EOG without tic disorders presented higher mean global DY-BOCS scores and higher mean scores in the “contamination/cleaning” dimension.

Conclusion: The current results disentangle some of the clinical overlap between early onset OCD with and without tics.

Introduction: The objective of the study was to examine gender differences in the relationship between weight group (under-weight to severely obese), and Axis I and Axis II psychopathology.

Methods: Data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) were analyzed. Logistic regression models examined the past-year likelihood for meeting diagnostic criteria for psychiatric disorders. Interactions between weight group and gender were utilized to determine whether associations were significantly different in men and women after adjusting for demographic characteristics.

Results: First, consistent with previous NESARC analyses, the prevalence estimates of psychiatric disorders were higher among people of higher body mass index groups, regardless of gender. However, these patterns differed across genders. Both severely obese women and men, in comparison to normal weight respondents, were much more likely to meet criteria for affective and anxiety disorders, but these associations were significantly (1.5–2 times) stronger among women. For Axis II disorders, while there were very few associations between personality disorders and weight in men, among women increases in weight group were associated with increases in the likelihood of meeting criteria for a personality disorder.

Conclusion: Weight and psychopathology appear more strongly associated in women than in men. While these data do not allow for identification of underlying mechanisms, they highlight the importance of assessing for psychopathology in overweight and obese patients, and suggest that weight management may be an important consideration in the treatment of psychiatric disorders.

Alcohol withdrawal continues to present significant morbidity and mortality in hospitalized medical/surgical patients. The authors present a case of a patient with delirium tremens requiring up to 1,600 mg/day of lorazepam and discuss alternative treatments for alcohol withdrawal.