Human social motivation is characterized by the pursuit of social reward and the avoidance of social punishment. The ventral striatum/nucleus accumbens (VS/Nacc), in particular, has been implicated in the reward component of social motivation, i.e., the ‘wanting’ of social incentives like approval. However, it is unclear to what extent the VS/Nacc is involved in avoiding social punishment like disapproval, an intrinsically pleasant outcome. Thus, we conducted an event-related functional magnetic resonance imaging (fMRI) study using a social incentive delay task with dynamic video stimuli instead of static pictures as social incentives in order to examine participants' motivation for social reward gain and social punishment avoidance. As predicted, the anticipation of avoidable social punishment (i.e., disapproval) recruited the VS/Nacc in a manner that was similar to VS/Nacc activation observed during the anticipation of social reward gain (i.e., approval). Stronger VS/Nacc activity was accompanied by faster reaction times of the participants to obtain those desired outcomes. This data support the assumption that dynamic social incentives elicit robust VS/Nacc activity, which likely reflects motivation to obtain social reward and to avoid social punishment. Clinical implications regarding the involvement of the VS/Nacc in social motivation dysfunction in autism and social phobia are discussed.

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In a much-publicized paper, Zhong and Liljenquist (2006) reported evidence that feelings of moral cleanliness are grounded in feelings of physical cleanliness: a threat to people's moral purity leads them to seek, literally, to cleanse themselves. In an attempt to replicate and build upon these findings, we conducted a pilot study in which we unexpectedly failed to replicate the original results from the second study of Zhong and Liljenquist's report. To investigate the source of this issue, we conducted a series of direct replications of Study 2 as reported in Zhong and Liljenquist (2006). We used the authors' original materials and methods; we investigated samples that were more representative of the general population than in the original experiments;we investigated samples from different countries and cultures; and we substantially increased the power of our statistical tests. Nevertheless, we still failed to replicate Zhong and Liljenquist's initial reported findings. Our research suggests that more work is needed to clarify the scope and robustness of the original results.

Background Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers. Methods We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP. Results We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions. Conclusions Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population.

Clinical observations suggest that the nervous and immune systems are closely related. For example, inflammatory skin disorders; such as psoriasis, atopic dermatitis, rosacea and acne; are widely believed to be exacerbated by stress. A growing body of research now suggests that neuropeptides and neurotransmitters serve as a link between these two systems. Neuropeptides and neurotransmitters are released by nerves innervating the skin to influence important actors of the immune system, such as Langerhans cells and mast cells, which are located within close anatomic proximity. Catecholamines and other sympathetic transmitters that are released in response to activation of the sympathetic nervous system are also able to reach the skin and affect immune cells. Neuropeptides appear to direct the outcome of Langerhans cell antigen presentation with regard to the subtypes of Th cells generated and neuropeptides induce the degranulation of mast cells, among other effects. Additionally, endothelial cells, which release many inflammatory mediators and express cell surface molecules that allow leukocytes to exit the bloodstream, appear to be regulated by certain neuropeptides and transmitters. This review focuses on the evidence that products of nerves have important regulatory activities on antigen presentation, mast cell function and endothelial cell biology. These activities are highly likely to have clinical and therapeutic relevance.

Patients with functional neurological disorders (FND)/conversion disorder commonly present to outpatient clinics. FND is now a 'rule in' diagnosis based on neurological examination findings and semiological features. While neurologists may be more comfortable diagnosing patients with FND, there is only limited guidance as to how to conduct follow-up outpatient visits. Using clinical vignettes, we provide practical suggestions that may help guide clinical encounters including how to: (1) explore illness beliefs openly; (2) enquire longitudinally about predisposing vulnerabilities, acute precipitants and perpetuating factors that may be further elucidated over time; (3) facilitate psychotherapy engagement by actively listening for potentially unhelpful or maladaptive patterns of thoughts, behaviours, fears or psychosocial stressors that can be reflected back to the patient and (4) enquire about the fidelity of individual treatments and educate other providers who may be less familiar with FND. These suggestions, while important to individualise, provide a blueprint for follow-up FND clinical care.

Background: Exclusion diets for gastrointestinal symptom management have been hypothesized to be a risk factor for avoidant/restrictive food intake disorder (ARFID; a non-body image-based eating disorder). In a retrospective study of pediatric and adult neurogastroenterology patients, we aimed to (1) identify the prevalence and characteristics of an exclusion diet history and (2) evaluate if an exclusion diet history was concurrently associated with the presence of ARFID symptoms. Methods:We conducted a chart review of 539 consecutive referrals (ages 6-90, 69% female) to adult (n = 410; January-December 2016) and pediatric (n = 129; January 2016-December 2018) neurogastroenterology clinics. Masked coders (n = 4) retrospectively applied DSM-5 criteria for ARFID and a separate coder assessed documentation of exclusion diet history. We excluded patients with no documentation of diet in the chart (n = 35) or who were not orally fed (n = 9).Results: Of 495 patients included, 194 (39%) had an exclusion diet history, and 118 (24%) had symptoms of ARFID. Of reported diets, dairy-free was the most frequent (45%), followed by gluten-free (36%). Where documented, exclusion diets were selfinitiated by patients/parents in 66% of cases, and recommended by gastroenterology providers in 30%. Exclusion diet history was significantly associated with the presence of ARFID symptoms (OR = 3.12[95% CI 1.92-5.14], p < 0.001). Conclusions: History of following an exclusion diet was common and was most oftenpatient-initiated among pediatric and adult neurogastroenterology patients. As patients with self-reported exclusion diet history were over three times as likely to have ARFID symptoms, providers should be cognizant of this potential association when considering dietary interventions. K E Y W O R D Savoidant/restrictive food intake disorder, disorders of gut-brain interaction, feeding and eating disorders, functional gastrointestinal disorders How to cite this article: Atkins M, Zar-Kessler C, Madva EN, et al. History of trying exclusion diets and association with avoidant/restrictive food intake disorder in neurogastroenterology patients: A retrospective chart review.

Most mid-life adults have at least one chronic medical condition (CMC) and are at risk for developing additional CMCs. Stressors specific to this life stage may contribute to CMC development by hindering healthy behaviors. The goal of this study was to compare sources and intensity of distress, as they relate to health behaviors, between mid-life and non-mid-life adults with CMCs. We utilized a mixed-methods approach by analyzing quantitative self-report measures of psychiatric symptoms and psychological well-being, with in-depth, semi-structured qualitative interviews to identify sources of stress in three cohorts of patients with CMCs (heart failure, type 2 diabetes, and coronary artery disease). Between-group differences on self-report measures were compared via independent samples t-tests and relevant themes from interview transcripts were compared via chi-square analysis. We found that mid-life participants (n = 30) reported greater psychological distress (depression/anxiety) than non-mid-life (n = 62) participants (Hospital Anxiety and Depression Scale scores 13.8 [SD 7.3] vs. 10.6 [SD 6.6]; t(90)=2.13; p = .035), and qualitative analysis revealed several specific sources of stress significantly more common (p < .001) in mid-life adults. Interventions targeting the needs of this population could reduce distress, improve health behaviors, and have a major impact on public health.