Trauma, multiple sclerosis, delayed sleep phase disorder, subjective experiences, and duration of illness in GAD.

Dr. Hollander is the editor of this journal, Esther and Joseph Klingenstein Professor and Chairman of Psychiatry at the Mount Sinai School of Medicine, and director of the Seaver and New York Autism Center of Excellence in New York City. In this month’s issue we launch the new series, Grand Rounds. The first installment is from a presentation at the Mount Sinai School of Medicine. In it, Noah DeGaetano, MD, describes a fascinating case of posttraumatic stress disorder (PTSD) with an unusual presentation and discusses the case from various formulations, including a psychodynamic perspective. The discussant, Rachel Yehuda, PhD, questions whether making a diagnosis of PTSD helps in the healing, explores the true source of the trauma, the impact of earlier attachment issues, and the use of cognitive techniques to accelerate treatment response in this patient. We hope that this series eventually spreads to other academic and international departments of psychiatry and neurology. Pain, spasticity, tremor, spasms, poor sleep quality, and bladder and bowel dysfunction, among other symptoms, contribute significantly to the disability and impaired quality of life of many patients with multiple sclerosis (MS). Motor symptoms referable to the basal ganglia, especially paroxysmal dystonia, occur rarely and contribute to the experience of distress. A substantial percentage of patients with MS report subjective benefit from what is often illicit abuse of extracts of the Cannabis sativa plant; the main cannabinoids include delta-9-tetrahydrocannabinol (Δ9-THC) and cannabidiol. Clinical trials of cannabis plant extracts and synthetic Δ9-THC provide support for therapeutic benefit on at least some patient self-report measures. Stephen I. Deutsch, MD, PhD, and colleagues describe a case of a 52-year-old woman with MS, paroxysmal dystonia, complex vocal tics, and marijuana dependence. The patient was started on a trial of dronabinol, an encapsulated form of synthetic Δ9-THC that is usually prescribed as an adjunctive medication for patients undergoing cancer chemotherapy. She reported a dramatic reduction of craving and illicit use, and did not experience a “high”. The patient also reported an improvement in the quality of her sleep with diminished awakenings during the night, decreased vocalizations, and the tension associated with their emission, decreased anxiety and a decreased frequency of paroxysmal dystonia. Clearly, the risks versus benefits of such an approach need to be studied in more systematic trials, but this case is informative. Suman Mukhopadhyay, MRCPsych, and colleagues studied the prevalence of delayed sleep phase (DSP) in a cohort of inpatients with severe obsessive-compulsive disorder (OCD) to identify clinical and demographic correlates. Out of 187 patients, 33 (17.6%) fulfilled criteria for DSP after exclusion of possible confounding factors. All the patients with DSP were unemployed. Phaseshifted patients were significantly younger than non-shifted patients and reported an earlier age of onset of their OCD. There was a non-significant trend toward more severe OCD in the phaseshifted group, but they were not more depressed than their non-shifted counterparts. Thus, a substantial number of patients with severe, enduring OCD also suffer with DSP, which seems to be specifically linked to OCD as opposed to comorbid depression. Clarification of the etiology within Editor’s Letter