Management of Psychiatric Conditions in Patients With Comorbid Postural Orthostatic Tachycardia Syndrome: A Literature Review and Case Vignette.

Importance: Disorders of the autonomic nervous system are relatively common and have a significant impact on quality of life, offer very subtle diagnostic clues, and often mimic other disease processes, including certain psychiatric disorders. Pharmacologic treatment for psychiatric conditions in this group of patients can also be complicated by the pathophysiology of the various syndromes. Postural orthostatic tachycardia syndrome (POTS) is the final common pathway of a heterogenous group of underlying disorders that display similar characteristics.Observations: The current literature regarding the association between POTS and psychiatric conditions was reviewed. The literature showed an increased prevalence of mild/moderate depression and sleep disturbance in this population. Also, when psychiatric disorders occur in patients with POTS, clinicians may face challenges with regard to selecting appropriate psychopharmacologic interventions.Conclusions and Relevance: This review provides an evidence-based approach to treating common psychiatric conditions in those who suffer from POTS, with a particular emphasis on side effects that may worsen the associated symptoms. A list of the classes of psychopharmacologic treatment with a focus on adverse effects on heart rate and blood pressure is included, as is a case vignette of a patient with complex comorbid psychiatric conditions. It is of significant value to highlight the complexities associated with POTS; to raise awareness of the disorder, particularly in the context of psychiatric comorbidities; and to disseminate evidence-based information to aid clinicians in making informed medication choices with their patients.

Brugada syndrome: should we be screening patients before prescribing psychotropic medication?

Brugada syndrome (BrS) presents with a characteristic electrocardiogram (ECG) and is associated with sudden cardiac death. Until now, prolongation of QTc interval and its association with Torsade de Pointe and possible fatal arrhythmia have been the focus of routine baseline ECGs before prescribing psychotropic medication. A semi-systematic literature review was conducted using PubMed. The terms 'Brugada', 'Brugada Syndrome' AND 'psychotropic' 'antipsychotic' 'antidepressant' 'mood stabilisers' 'clozapine' 'Tricyclic Antidepressants' 'Lithium' were searched. From a search that delivered over 200 articles, 82 articles were included. Those that included details around causative medication, doses of medication and where clear timeline on drug cause were included. Where clarification was needed, the manufacturer of the medication was contacted directly. Psychotropic medication can be associated with BrS, Brugada phenocopy or unmasking of BrS, in overdose or in normal doses. Our results include a table summarising a number of psychotropic overdoses that led to BrS unmasking. Routine screening for BrS in patients before prescribing psychotropic medication is a natural extension of the baseline ECG currently routinely done to rule out QTc prolongation. Psychiatrists need to invest in ensuring better skills in interpreting ECGs and work closer with cardiologists in interpreting ECGs.

Attachment-security priming attenuates amygdala activation to social and linguistic threat.

A predominant expectation that social relationships with others are safe (a secure attachment style), has been linked with reduced threat-related amygdala activation. Experimental priming of mental representations of attachment security can modulate neural responding, but the effects of attachment-security priming on threat-related amygdala activation remains untested. Using functional magnetic resonance imaging, the present study examined the effects of trait and primed attachment security on amygdala reactivity to threatening stimuli in an emotional faces and a linguistic dot-probe task in 42 healthy participants. Trait attachment anxiety and attachment avoidance were positively correlated with amygdala activation to threatening faces in the control group, but not in the attachment primed group. Furthermore, participants who received attachment-security priming showed attenuated amygdala activation in both the emotional faces and dot-probe tasks. The current findings demonstrate that variation in state and trait attachment security modulates amygdala reactivity to threat. These findings support the potential use of attachment security-boosting methods as interventions and suggest a neural mechanism for the protective effect of social bonds in anxiety disorders.