The associations between psychopathology and being overweight: a 20-year prospective study

BACKGROUND

Psychiatric disorders and being overweight are major health problems with increasing prevalence. The purpose of this study was to test the hypothesis that being overweight is associated with a range of psychiatric conditions including minor and atypical depressive disorders, binge eating, and aggression.

METHOD

Prospective community-based cohort study of young adults (n = 591) followed between ages 19 and 40. Information derived from six subsequent semi-structured diagnostic interviews conducted by professionals over twenty years. Outcomes were being overweight [body-mass index (BMI)> 25] and average yearly weight change between ages 20 and 40 (BMI slope).

RESULTS

18.9 % of the participants were classified as being overweight. Being overweight turned out to be a stable trait: 77.7% of subjects were assigned to the same weight class at each interview. Atypical depression and binge eating were positively associated with both, increased weight gain and being overweight, while psychiatric conditions associated with aggressive behaviors (aggressive personality traits, sociopathy) were positively associated with being overweight, but were not related to the rate of weight change. Generalized anxiety disorder was negatively associated with overweight. These results persisted after controlling for substance use, levels of physical activity, demographic variables and family history of weight problems.

CONCLUSIONS

This study shows relatively strong associations between eating-related and aggressive psychopathology and being overweight. Given the high prevalence rates of these conditions, this study encourages further research on the causality of psychopathology-overweight associations that might provide insight on novel preventive approaches for major health problems.

Twenty-four-hour cortisol secretion patterns in prepubertal children with anxiety or depressive disorders

BACKGROUND

Previous studies found few abnormalities in hypothalamic-pituitary-adrenal (HPA) axis function in prepubertal children with anxiety or depressive disorders. In this study, we combined data from two independent, consecutive studies to achieve a larger sample size. Our goal was to identify potential alterations in the circadian pattern of cortisol secretion in anxious or depressed children.

METHODS

A total of 124 prepubertal subjects from two independent samples (76 with major depressive disorder, 31 with anxiety disorders, and 17 healthy control subjects) were studied. Blood samples collected for cortisol at hourly intervals over a 24-hour period were examined. Analyses were performed aligning cortisol samples by clock-time. Additional analyses aligning samples by sleep-onset time were performed with a subsample of subjects.

RESULTS

In the combined sample, significant findings emerged that were previously undetected. Anxious children exhibited significantly lower nighttime cortisol levels and an initially sluggish rise in cortisol during the nighttime when compared with depressed and healthy control children. In contrast, depressed children did not show a clear-cut pattern of differences compared with healthy control children.

CONCLUSIONS

Anxious children seem to exhibit an altered pattern of nighttime cortisol secretion, with an initially sluggish or delayed nocturnal rise before reaching similar peak levels of cortisol near the time of awakening. These findings suggest subtle alterations in HPA axis function in prepubertal children with anxiety disorders.

A neuroimaging method for the study of threat in adolescents

Little is understood about the brain basis of anxiety, particularly among youth. However, threat paradigms with animals are delineating the relationship between anxietylike behaviors and brain function. We adapted a threat paradigm for adolescents using functional magnetic resonance imaging. The aim was to examine amygdala activation to fear. The threat was an aversive air blast directed to the larynx. Participants were explicitly informed that they might receive the air blast when viewing one stimulus (threat condition) and would not receive the blast when viewing the other stimulus (safe condition). Participants provided fear ratings immediately after each trial. Based on the relatively mild nature of the air blast, we expected participants to report varying degrees of fear. Those who reported increased fear showed right amygdala activation during the threat condition and left amygdala activation in the safe condition. These procedures offer a promising tool for studying youth with anxiety disorders.

A developmental examination of gender differences in brain engagement during evaluation of threat

BACKGROUND

Females appear to be more sensitive and responsive to social cues, including threat signals, than are males. Recent theoretical models suggest that developmental changes in brain functioning play important roles in the emergence of such gender differences.

METHODS

We used functional magnetic resonance imaging to examine developmental and gender differences in activation of neural structures thought to mediate attention to emotional faces depicting varying degrees of threat. Analyses focused on the orbitofrontal cortex, amygdala, and anterior cingulate cortex during the evaluation of threat conveyed by faces. Healthy adolescents (n = 17; 53% male) and adults (n = 17; 53% male) were scanned while they rated how threatening pictures of neutral and emotional (angry, fearful, or happy) faces appeared.

RESULTS

Results indicate significant interactions among age, gender, and face type for activation during explicit threat monitoring. In particular, adult women activated orbitofrontal cortex and amygdala selectively to unambiguous threat (angry) cues, while adult men showed a less discriminating pattern of activation. No gender differences were evident for adolescents, who as a group resembled adult males.

CONCLUSIONS

These findings suggest that there are gender differences in patterns of neural responses to emotional faces that are not fully apparent until adulthood.

Integrating Research on Developmental Psychopathology and Neuroscience in the Study of Adolescence: Introduction to Part II

This chapter introduces three papers that summarize research findings in clinical and basic neuroscience. They integrate prior research on clinical aspects of developmental psychopathology, basic research on brain development in nonhuman primates, and neuroimaging research on both normal and abnormal human development. From the clinical perspective these papers call attention to the unique relationship between adolescence and psychopathology. From the basic science perspective they call attention to the sequence of events that culminates in a fully mature central nervous system.

Fear conditioning in virtual reality contexts: a new tool for the study of anxiety

BACKGROUND

Context conditioning has been suggested to model clinical anxiety, but context, as manipulated in animal models, has not been translated to human studies. A virtual environment might prove to be the ideal tool for innovative experimental paradigms to study explicitly cued fear and contextual anxiety in humans.

METHODS

Subjects were guided through a virtual environment that consisted of two rooms connected by a street scene. In each of the rooms, a blue and a yellow panel on a wall served as explicit conditioned stimuli (CS). The panels were displayed several times. One of the panels (CS+) was associated with a shock in one of the rooms (shock room). No shock was administered in the other room (safe room). Acoustic startle stimuli were administered in the presence and in the absence of the panels to assess explicit cued conditioning to the CS and context conditioning to the rooms, respectively.

RESULTS

Startle was potentiated by the CS+ in both rooms, which suggests generalization of fear across contexts. After acquisition, startle was potentiated in the shock room, compared with the safe room, in the absence of the CS+.

CONCLUSIONS

These results support the future use of virtual reality to design new conditioning experiments to study both fear and anxiety.

Irritability in pediatric mania and other childhood psychopathology

Irritability is an important symptom in childhood psychopathology that has received relatively little research attention. Recent controversy concerning the diagnosis of mania in children has focused attention on how little is known about how to assess irritability in a systematic way, and about its diagnostic associations. For example, subtyping irritability according to course (chronic vs. episodic), precipitants, and family history may facilitate the identification of psychopathology and the study of pathophysiology. While normative and pathologic irritability can be differentiated reliably, the validity of the distinction is unclear. In addition, there is a need for scales designed to measure the severity of irritability in children with mood and anxiety disorders. In order to facilitate research, we propose a definition of irritability from the perspective of affective neuroscience. Because reactive aggression may be a helpful animal model for irritability, we review the neural circuitry mediating this behavior. Behavioral paradigms that evoke frustration, as well as those that assess the ability to inhibit a prepotent motor response, maintain attentional focus, execute response reversal, recognize angry faces, and regulate emotional responses, may be useful in the study of irritability. Examples of such paradigms are described, and the pharmacology of irritability is reviewed briefly.

Clinical correlates of episodicity in juvenile mania

OBJECTIVE

Researchers debate whether the diagnostic criteria for mania should differ between children and adults. Specifically, although the Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM-IV) requires episodic mood changes, children commonly are diagnosed as manic on the basis of chronic irritability. In this preliminary study, children carrying a diagnosis of bipolar disorder (BPD) in the community were classified as having either episodic or chronic symptoms. We hypothesized that the episodic group would be more likely to have a history of psychosis and a parental history of BPD, whereas the chronic group would be more likely to have conduct disorder.

METHODS

Parents of children carrying the BPD diagnosis were interviewed on the telephone to obtain psychiatric and family histories. Children were considered episodic (n = 34) if they had a history of one or more DSM-IV manic/hypomanic episodes meeting full duration criteria and chronic (n = 53) if they had no discernable episodes.

RESULTS

The episodic group was more likely to have had psychosis, parental history of BPD, and to have experienced each manic symptom except for irritability and psychomotor agitation. Children in the episodic group were also more likely to have had a depressive episode meeting full DSM-IV criteria and were more likely to have made a suicide attempt. Children in the chronic group were not more likely to meet criteria for conduct disorder but were more likely to exhibit violence toward others.

CONCLUSIONS

These preliminary data indicate that, among children being treated for BPD in the community, those with discrete episodes of mania may be more likely to have a lifetime history of psychosis and a parental history of BPD. The latter hypothesis should be tested in a sample where relatives are interviewed directly.

Neuropsychological performance in pediatric bipolar disorder

BACKGROUND

Growing awareness of childhood bipolar disorder necessitates further cognitive neuroscience research to determine unique developmental differences between pediatric and adult onset bipolar disorder. We sought to examine whether neuropsychological function in children with bipolar disorder resembles that in adults with the illness and to extend our knowledge about cognitive function in pediatric bipolar disorder.

METHODS

We administered a computerized neuropsychological test battery known as the Cambridge Neuropsychological Test Automated Battery to a sample of 21 children and adolescents with bipolar disorder and compared them with 21 age- and gender-matched controls.

RESULTS

In comparison to controls, children with bipolar disorder were impaired on measures of attentional set-shifting and visuospatial memory. Post hoc analyses in pediatric bipolar disorder subjects did not show significant associations between neuropsychological performance and manic symptomatology or attention-deficit/hyperactivity disorder comorbidity.

CONCLUSIONS

Cambridge Neuropsychological Test Automated Battery data presented here in pediatric bipolar disorder fit well within the broader framework of known neurocognitive deficits in adult bipolar disorder. Our pediatric bipolar disorder subjects demonstrated selective deficiencies in attentional set-shifting and visuospatial memory. Our work suggests altered ventrolateral prefrontal cortex function, especially when linked to other lesion and neuroimaging studies.

Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents

OBJECTIVE

To focus attention on the critical unmet needs of children and adolescents with mood disorders and to make recommendations for future research and allocation of healthcare resources.

METHOD

The 36-member Consensus Development Panel consisted of experts in child/adolescent or adult psychiatry and psychology, pediatrics, and mental health advocacy. Reviews of the literature concerning youth mood disorders were performed on the subjects of risk factors, prevention, diagnosis, treatment, and services delivery, and opinions and experiences of mental health advocates were obtained.

RESULTS

The Consensus Development Panel listened to presentations and participated in discussions. Independent workgroups of clinicians, scientists, and mental health advocates considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed by the entire group and edited to incorporate input from all participants.

CONCLUSIONS

Evidence suggests high rates of unmet needs for children and adolescents with depression or bipolar disorder. Training is largely limited to child mental health specialists; general psychiatrists, pediatricians, and other primary care physicians receive little or no training. As a result, treatment patterns may reflect adult treatment plans that are not validated for youths. Effective treatments have been identified and some preliminary prevention models have been developed, but they are not yet widely applied. Patients experience limited exposure to clinicians adequately trained to address their problems and little information to guide care decisions, particularly concerning bipolar disorder. National efforts are required to restructure healthcare delivery and provider training and to immediately develop more advanced research on pathophysiology, prevention, and services delivery effectiveness.

Adolescent immaturity in attention-related brain engagement to emotional facial expressions

Selective attention, particularly during the processing of emotionally evocative events, is a crucial component of adolescent development. We used functional magnetic resonance imagining (fMRI) with adolescents and adults to examine developmental differences in activation in a paradigm that involved selective attention during the viewing of emotionally engaging face stimuli. We evaluated developmental differences in neural activation for three comparisons: (1) directing attention to subjective responses to fearful facial expressions relative to directing attention to a nonemotional aspect (nose width) of fearful faces, (2) viewing fearful relative to neutral faces while attending to a nonemotional aspect of the face, and (3) viewing fearful relative to neutral faces while attention was unconstrained (passive viewing). The comparison of activation across attention tasks revealed greater activation in the orbital frontal cortex in adults than in adolescents. Conversely, when subjects attended to a nonemotional feature, fearful relative to neutral faces influenced activation in the anterior cingulate more in adolescents than in adults. When attention was unconstrained, adolescents relative to adults showed greater activation in the anterior cingulate, bilateral orbitofrontal cortex, and right amygdala in response to the fearful relative to neutral faces. These findings suggest that adults show greater modulation of activity in relevant brain structures based on attentional demands, whereas adolescents exhibit greater modulation based on emotional content.

Neurological soft signs and disruptive behavior among children of opiate dependent parents

The present study investigates the relationship between neurological soft signs and psychiatric symptoms among children of opiate dependent parents. A consecutive series of 102 children of opiate dependent parents received standardized psychiatric and neurological assessments. Symptoms of externalizing but not internalizing disorders associated with poor performance on the soft sign exam, controlling for age, intelligence, and socioeconomic status. Given the importance of externalizing disorders in the development of substance use disorders, studies of children at high risk for substance use disorder should also consider screening and assessment of children for soft neurological signs.

Developmental differences in neuronal engagement during implicit encoding of emotional faces: an event-related fMRI study

BACKGROUND

Prior studies document strong interactions between emotional and mnemonic processes. These interactions have been shown to vary across development and psychopathology, particularly mood and anxiety disorders.

METHODS

The present study used functional neuroimaging to assess the degree to which adolescents and adults differ in patterns of neuronal engagement during implicit encoding of affective stimuli. Subjects underwent rapid event-related fMRI while viewing faces with angry, fearful, happy, and neutral expressions. A surprise post-scan memory test was administered.

RESULTS

Consistent with previous findings, both adolescents and adults displayed engagement of left ventrolateral prefrontal cortex when viewing subsequently recognized stimuli. Age differences emerged in patterns of neuronal activation associated with subsequent recognition of specific face-emotion types. Relative to adults, adolescents displayed more activity in the anterior cingulate when viewing subsequently remembered angry faces, and more activity in the right temporal pole when viewing subsequently remembered fear faces. Conversely, adults displayed more activity in the subgenual anterior cingulate when viewing subsequently remembered happy faces and more activity in the right posterior hippocampus when viewing subsequently remembered neutral faces. These age-related differences emerged in the absence of differences in behavioral performance.

CONCLUSIONS

These findings document developmental differences in the degree to which engagement of affective circuitry contributes to memory formation.

The effects of trauma on children: working to define roles for mental health professionals

Interest concerning the effects of trauma on the mental health of children has grown markedly during the past few years. At least three factors contribute to this growing concern.

The effects of trauma on children: working to define roles for mental health professionals

Interest concerning the effects of trauma on the mental health of children has grown markedly during the past few years. At least three factors contribute to this growing concern.

Lung disease and internalizing disorders. Is childhood abuse a shared etiologic factor?

OBJECTIVE

To investigate the role of childhood abuse in the relationship between panic attack, depression and lung disease among adults in the population.

METHODS

Data were drawn from the National Comorbidity Survey (n=5877), a representative sample of adults age 15-54 in the United States. Multiple logistic regression analyses were used to determine the association between childhood abuse and lung disease, and to determine whether childhood abuse is an independent predictor of the co-occurrence of lung disease, panic attack and depression.

RESULTS

Childhood abuse was associated with significantly increased odds of panic attacks (OR=2.2 (1.5, 3.1)) and depression (OR=1.6 (1.1, 2.3)). Childhood abuse increased likelihood of lung disease (OR=1.5 (1.1, 2.2)). Childhood abuse independently predicted the co-occurrence of lung disease, panic attack and depression (OR=10.7 (2.2, 51.5)).

CONCLUSION

These data are preliminary, but if replicated, suggest that childhood abuse may be associated with increased risk of lung disease during adulthood, and further may reflect a shared vulnerability for the co-occurrence of lung disease, panic attack and depression in the community. Future studies are needed to further explore the mechanism of this association.

Children, stress, and context: integrating basic, clinical, and experimental prevention research

Findings from the Watamura, Donzella, Alwin, and Gunnar (this issue) study support the growing recognition of the importance of context on physiology and affective and behavioral regulation early in human development. This discussion focuses on the role of context and development on hypothalamic-pituitary-adrenal (HPA) axis regulation in young children. Discussed in this article are the Watamura et al. findings with regard to relevant animal studies, extension of these observations to samples of children at elevated risk for psychopathology, and experimental prevention studies with young children. It is contended that environmental factors operating at key points in development may shape affective and behavioral regulation as well as HPA axis function in children, much as environmental factors have been shown to shape HPA axis regulation in animals.

Researching the pathophysiology of pediatric bipolar disorder

We suggest that the core feature of bipolar disorder (BPD) is marked state fluctuations. The pathophysiology of switches into depressed, irritable, and extreme positive valence states requires study, with the latter deserving particular focus because it represents a pathognomonic feature of BPD in both adults and children. Hypotheses regarding the pathophysiology of pediatric BPD must account for these marked state fluctuations as well as for specific developmental aspects of the illness. These developmental aspects include marked irritability (in addition to euphoria and depression) and very rapid cycles, along with high rates of attention-deficit/hyperactivity disorder. We review research on neural mechanisms underlying positive valence states and state regulation, focusing on those data relevant to BPD and to development. Researchers are beginning to explore the response of manic patients and control subjects to positive affective stimuli, and considerable research in both nonhuman primates and humans has focused on the cortico-limbic-striatal circuits mediating responses to rewarding stimuli. In control subjects, positive affect affects cognition, and data indicate that prefrontal electroencephalogram asymmetry may differ between control subjects with consistently positive affect and those with more negative affect; however, this latter generalization may not apply to adolescents. With regard to the pathophysiology of state switching in pediatric BPD, data in control subjects indicating that attention regulation plays a role in emotion regulation may be germane. In addition, research detailing physiologic and psychological responses to negative emotional stimuli in bipolar patients and control subjects may increase our understanding of the mechanisms underlying both irritability and rapid cycling seen in children with BPD. Potential foci for research on the pathophysiology of pediatric BPD include reactivity to standardized positive and negative emotional stimuli, and the interaction between emotion regulation and attentional processes.

Facial expression recognition in adolescents with mood and anxiety disorders

OBJECTIVE

The authors examined facial expression recognition in adolescents with mood and anxiety disorders.

METHOD

Standard facial emotion identification tests were given to youth with bipolar disorder (N=11) or DSM-IV anxiety disorders (N=10) and a group of healthy comparison subjects (N=25).

RESULTS

Relative to the anxiety disorder and healthy comparison groups, the subjects with bipolar disorder made more emotion recognition errors when presented with faces of children. Unlike the anxious and comparison subjects, bipolar disorder youth were prone to misidentify faces as angry. No differences in emotion recognition errors were seen when the adolescents were presented with adult faces.

CONCLUSIONS

A bias to misinterpret the facial expressions of peers as angry may characterize youth with bipolar disorder but not youth with anxiety disorders. This bias may relate to social impairment in youth with bipolar disorder.

Developmental psychobiology and response to threats: relevance to trauma in children and adolescents

Interest in developmental and psychobiological aspects of trauma has grown with recent research in adults with mood and anxiety disorders reporting histories of trauma during childhood. Studies conducted directly in children and adolescents could add much to ongoing research in this area. This review summarizes data in three areas of developmental science that might inform future studies. First, the review briefly summarizes current data on clinical aspects of trauma in juveniles, focusing on associations with psychopathology and moderators of outcome. Second, the review summarizes data from the basic sciences delineating experiential and developmental changes in brain systems involved in threat perception and response. This review incorporates knowledge gained from research examining the effects of rearing manipulations on regulation of the stress response in rodents and primates. Third, the review summarizes data from cognitive neuroscience studies among both adults and children, again focusing on studies examining aspects of the threat response. This summary includes a review from studies in patients with posttraumatic stress disorder.

Asthma and panic attacks among youth in the community

OBJECTIVE

To determine the association between asthma and panic attacks among youth in the community.

METHOD

Data were drawn from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study (n = 1285), a community-based sample of youth age 9-17 in the United States. Multivariate logistic regression analyses were used to determine the association between asthma and both panic attacks and panic disorder, adjusting for differences in sociodemographic characteristics and comorbid mental disorders.

RESULTS

Asthma was associated with a significantly increased likelihood of panic attacks [OR= 1.5 (1.01, 2.2)]. This effect was specific and persisted after adjusting for differences in demographics and psychiatric comorbidity. Severe asthma was associated with an even greater likelihood of panic attacks [OR = 2.2 (1.3, 4.0)]. There was a dose-response relationship between number of panic symptoms during a panic attack and the likelihood of asthma [OR = 1.2 (1.1, 1.3)] and severe asthma [OR = 1.3 (1.1, 1.4)], which remained significant after adjusting for differences in sociodemographic characteristics and comorbid mental disorders.

CONCLUSIONS

These data suggest a significant association between asthma, severe asthma, and panic attacks among youth in the community. Replication of these findings is needed, as are future studies that investigate the nature of these links. In light of the increasing prevalence of asthma and hospitalization for asthma among youth in the United States and worldwide, these associations may be worthwhile to consider in future investigations.

Defining clinical phenotypes of juvenile mania

OBJECTIVE

The authors suggest criteria for a range of narrow to broad phenotypes of bipolar disorder in children, differentiated according to the characteristics of the manic or hypomanic episodes, and present methods for validation of the criteria.

METHOD

Relevant literature describing bipolar disorder in both children and adults was reviewed critically, and the input of experts was sought.

RESULTS

Areas of controversy include whether the diagnosis of bipolar disorder should require clearly demarcated affective episodes and, if so, of what duration, and whether specific hallmark symptoms of mania should be required for the diagnosis. The authors suggest a phenotypic system of juvenile mania consisting of a narrow phenotype, two intermediate phenotypes, and a broad phenotype. The narrow phenotype is exhibited by patients who meet the full DSM-IV diagnostic criteria for hypomania or mania, including the duration criterion, and also have hallmark symptoms of elevated mood or grandiosity. The intermediate phenotypes include 1) hypomania or mania not otherwise specified, in which the patient has clear episodes and hallmark symptoms, but the episodes are between 1 and 3 days in duration, and 2) irritable hypomania or mania, in which the patient has demarcated episodes with irritable, but not elevated, mood. The broad phenotype is exhibited by patients who have a chronic, nonepisodic illness that does not include the hallmark symptoms of mania but shares with the narrower phenotypes the symptoms of severe irritability and hyperarousal.

CONCLUSIONS

The presence of distinct episodes and hallmark symptoms can be used to differentiate clinical phenotypes of juvenile mania. The utility and validity of this system can be tested in subsequent research.

Treating children and adolescents with selective serotonin reuptake inhibitors: how long is appropriate?

This article addresses a key question on the use of selective serotonin reuptake inhibitors (SSRIs) among children and adolescents. As briefly reviewed, recent randomized controlled trials have established the safety and efficacy of SSRIs in the acute treatment of major depression and anxiety disorders among children and adolescents. Major questions emerge in light of these data concerning the potential risks and benefits of long-term SSRI use among children and adolescents who receive significant short-term benefits from SSRI treatment. The current review summarizes research on longitudinal outcomes, neuroscience, and psychopharmacology to formulate a set of preliminary recommendations on long-term SSRI use. A review of data in these areas supports three conclusions. First, for children who achieve marked reduction in anxiety or depressive symptoms on an SSRI, clinicians should consider recommending a medication-free trial. Second, when indicated, this medication-free trial should coincide with the first low-stress period occurring after 1 year of continual SSRI treatment. Third, SSRI treatment should be reinitiated in children who exhibit signs of relapse during this medication-free trial.