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ANZJP Correspondence

A 23-year-old man experienced his first manic episode with psychotic symptoms when he was 20 years old (height, 165 cm; weight, 65 kg; body mass index [BMI]: 23.9; Young Mania Rating Scales [YMRS]: 46). The patient had poor drug compliance with recurrent manic episodes, and his medication was switched to olanzapine 10 mg/ day monotherapy. Nevertheless, undesirable metabolic impact emerged during 6 months treatment, with body weight gain of 29 kg, to a total of 94 kg, and the development of type 2 diabetes mellitus (YMRS: 3–5; BMI: 34.5; HbAlc: 9.3%). Because of these intolerable side effects, we substituted amisulpride 400 mg/day to treat his bipolar symptoms. Notably, the patient has maintained remission status under monotherapy with amisulpride 400 mg/day for the subsequent 2 years until now (YMRS: 3). His weight dropped to 84 kg, and he has experienced less hyperglycemia. This case illustrates that maintenance therapy for bipolar disorder is challenging in clinical practice. SGAs (e.g. olanzapine, aripiprazole and

quetiapine) are used as monotherapy for maintenance of bipolar disorder (Grunze et  al., 2013), but the exact mechanism of action remains controversial and few studies have long-term clinical data. Amisulpride at moderate to high dosage (exceeding 400 mg) decreases dopaminergic transmission through preferentially antagonizing postsynaptic D2/D3 receptors (Curran and Perry, 2001). One study showed that amisulpride at an average dosage of 786  mg/day significantly improved acute manic symptoms of subjects following 6-week treatment (Vieta et al., 2005). Our case suggests some benefits for maintenance treatment of bipolar disorder. Given the highly selective D2 and D3 actions of amisulpride, we hypothesize that dopaminergic antagonism is an important mechanism for bipolar disorder maintenance. Additionally, amisulpride has less risk of sedation, weight gain and diabetogenic effects than other SGAs (Curran and Perry, 2001). Thus, it can help to enhance patient drug compliance and enable maintenance treatment.

To our knowledge, this is the first report of amisulpride as monotherapy in maintenance treatment for a patient with bipolar I disorder and metabolic syndrome.

On the nosology of formal thought disorder Eric J Tan1,2 and Susan L Rossell1,2,3

(Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition [DSM-5]; American Psychiatric Association, 2013) do not reflect (1) the general consensus in the literature for it being associated with neurocognitive deficits or (2) the distinction between positive and negative FTD. This situation should be rectified. In terms of nosology, FTD is currently classified as simply a psychotic feature in the DSM-5. Classification as a psychotic feature traditionally reflects the observations that FTD severity fluctuates between acute and chronic states, much like hallucinations. However, there is evidence suggesting that unlike psychotic symptoms, the impairments observed in patients with FTD never truly recover even when FTD is in remission, i.e., semantic memory deficits (Leeson et al., 2005). Problems with language production are also well-documented in FTD, with

evidence suggesting that language comprehension problems are already present early in the illness (Wood et  al., 2007). The aforementioned work on semantic and language impairments in FTD highlights an underlying continuity of FTD-related impairments. Such a situation is more akin to the classification for cognitive symptoms and differs from the transient nature of psychotic symptoms under which FTD is currently classified. Consequently, it might be time to consider revisiting the nosological debate surrounding FTD, and look at re-classifying it as a neurocognitive phenomenon. Another pertinent reason for change is that the current criteria do not account for the well-observed differences between positive and negative FTD, at both levels of underlying mechanisms and prognostic outcome. The change in nosology is

1Brain

and Psychological Sciences Research Centre, Swinburne University of Technology, Hawthorn, VIC, Australia 2Monash Alfred Psychiatry Research Centre, Monash University and The Alfred Hospital, Melbourne, VIC, Australia 3Department of Psychiatry, St Vincent’s Hospital, Fitzroy, VIC, Australia Corresponding author: Eric J Tan, Monash Alfred Psychiatry Research Centre, Monash University and The Alfred Hospital, Melbourne, Level 4 607 St Kilda Road, Melbourne, VIC 3004 Australia. Email: [email protected] DOI: 10.1177/0004867415577439

To the Editor Current diagnostic criteria for formal thought disorder (FTD) in schizophrenia

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References Curran MP and Perry CM (2001) Amisulpride: A review of its use in the management of schizophrenia. Drugs 61: 2123–2150. Grunze H, Vieta E, Goodwin GM, et al. (2013) The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: Update 2012 on the long-term treatment of bipolar disorder. World Journal of Biological Psychiatry 14: 154–219. Vieta E, Ros S, Goikolea JM, et  al. (2005) An open-label study of amisulpride in the treatment of mania. Journal of Clinical Psychiatry 66: 575–578.

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ANZJP Correspondence important as it results in clearer diagnostic criteria that better reflect the nature of the symptom as well as schizophrenia itself. This in turn will help better inform treatment and rehabilitation options for individuals with FTD. While we acknowledge that these top-level changes unfortunately do not happen quickly, there are some measures that can be adopted in the interim. First, it would be beneficial to avoid use of the term ‘disorganised thoughts’ in positive symptom classifications of schizophrenia to avoid confusion with ‘thought disorder’. This would better facilitate

the identification of FTD as being of a different nature. Second, distinctions between positive and negative FTD should continue to be recognised and adopted. Finally, continued examination of the cognitive mechanisms underlying individual FTD symptoms, particularly longitudinal work, would help in further fine-tuning the growing understanding of the disorder and strengthen the case for nosological change.

Piaget and electronic medical record Florence Levy1 and Alison Crawford2

about alcohol use, the most important from a child psychiatric perspective is the Mental Status examination. The developmental insights provided by Piaget (1926) could form the basis of a more useful approach, which reflect a child’s intellectual capacity at particular stages of development. Most important are two crucial developments. The first is the development of spoken language, which allows the transition from sensori-motor intelligence to representational thought, freeing the child from the limitations of direct action. According to Wadsworth (1984), Piaget believed that affective development is also based on capacity for representation and reciprocity of attitudes and values between the young child and others. This development is thought to occur during the stage of preoperational thought from the age of 2 to 7 years. A further major and significant change occurs around the age of 11– 15 years with the development of formal operations, where there is a further ‘freeing’ of thought from direct experience. Formal operations differ from concrete operations in that they allow the child or early adolescent to think about thoughts, namely, to reflect. Thus, formal operations are characterised by ‘scientific reasoning and hypothesis building’ (Wadsworth, 1984). Importantly, there are major changes in moral development during this stage, where there

1Child

and Family East, Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia 2Psychiatry Registrar, Prince of Wales Hospital, Sydney, NSW, Australia Corresponding author: Florence Levy, Child and Family East, Prince of Wales Hospital, University of New South Wales, Sydney, NSW 2031, Australia. Email: [email protected] DOI: 10.1177/0004867415578934

To the Editor The advent of electronic medical record (EMR) in the New South Wales Health Department has highlighted long-standing issues in relation to the assessment and recording of child psychiatric information. In particular, the use of universal EMR protocols makes the incorrect assumption that prepubertal children are small adults and can be assessed with the same set of data files. This reflects common misunderstanding of child development, but could present an opportunity to incorporate a more accurate and useful developmental approach into the assessment of children and early adolescents. While changes might be made in a number of areas such as questions

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA: American Psychiatric Publishing. Leeson VC, McKenna PJ, Murray G, et al. (2005) What happens to semantic memory when formal thought disorder remits? Cognitive Neuropsychiatry 10: 57–71. Wood SJ, Tarnawski AU, Proffitt TM, et al. (2007) Fractionation of verbal memory impairment in schizophrenia and schizophreniform psychosis. Australian and New Zealand Journal of Psychiatry 41: 732–739.

is an evolution from asocial judgement (expiatory punishment) to social judgements (reciprocity), where intent and circumstances can be considered. This is an intensely idealistic stage of development and perhaps accounts for positive and negative influences on idealism and philosophical adolescent thinking. Classical Piagetian teaching could be considered specialised, but it provides a body developmental understandings that are in danger of being forgotten, as well as potential for further updated investigation. A more recent set of child Mental Status examinations is provided in Kaplan et  al. (2014) textbook, which also indicates childhood differences. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References Kaplan BJ, Sadock VA and Ruiz P (2014) Assessment, examination, and psychological testing. In: Sadock BJ, Sadock VA and Ruiz P (eds) Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/ Clinical Psychology, 11th Edition. Philadelphia, PA: Wolters Kluwer, pp. 1107–1117. Piaget J (1926) The Language and Thought of the Child. New York: Harcourt Brace Jovanovich. Wadsworth BJ (1984) Piaget’s Theory of Affective Development. White Plains, NY: Longman Inc.

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On the nosology of formal thought disorder.

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