[Study methods of drugs in Alzheimer disease]

The availability of new drugs for Alzheimer's disease, with different pharmacological profiles, leads to a redefinition the relevant methodology for developing drugs in this indication, including the inclusion/exclusion criteria, the duration of the studies, and therefore, the relevant guidelines. This was the purpose of the Giens Round-table devoted to the new methodology for drug development in Alzheimer disease.

[Reviewing the initial plans for the teaching of pharmacology: quality vs. quantity of knowledge, hesitation is no longer possible]

Pharmacology is located at the intersection of several branches of medical education. This position and the exponential development of medical knowledge, constrains university professors of pharmacology to make teaching choices, since time-limited education is imposed in this subject. Thus, it is necessary to list specific educational objectives within a frame of well defined and clear hierarchized pharmacological concepts. General and practical pharmacology teaching is to be preferred since it provides the knowledge base for further acquisition of specialized pharmacology. The necessary data can be easily and rapidly taught by means of clinical observations and case reports in connection with basic pharmacological concepts and therapeutic strategy. The medical student has to acquire rational guidelines for proper drug monitoring. He also has to learn how to assess the efficacy of the prescribed treatment and how to supervise the compliance. When an adverse effect is observed, the future physician must be able to evaluate the benefit-risk ratio. Initiation into the analysis of published clinical trials is the best way to develop a critical sense. Concurrently, pharmacology teachers should make available technical and practical resources to facilitate access to updated scientific data.

A new design of trial for hypnotics comparison: a double-blind cross-over trial with patient's preference assessment and continuation of the preferred treatment

1. This study compared two hypnotics administrated at comparable therapeutic dosages: triazolam (0.25 mg) and loprazolam (1 mg), were administered using an original scheme (cross-over on the first 2 nights, and continuation of the preferred treatment or new randomization). 2. Sixty-seven outpatients complaining of common insomnia participated in this study conducted by general practitioners. 3. Both drugs provided improvement in sleep quality (decreased sleep latency, increased total duration of sleep, decreased number of night awakenings), and are equally well tolerated. 4. For the first 2 nights, triazolam was evaluated to be more efficient than loprazolam (p < 0.001), and patients felt more rested the following day (p < 0.01) with the former drug. Moreover, triazolam is more frequently preferred than loprazolam by 47.7% and 29.2%, respectively, (p = 0.09). 5. No interaction was found between treatment and order of administration or specific effects and order of administration.

Two faces of cholecystokinin: anxiety and schizophrenia

It has been suggested that cholecystokinin (CCK), a gut-brain peptide found in high concentrations in the mammalian brain, might be implicated in the neurobiology of anxiety and panic disorder. The administration of CCK tetrapeptide induced panic attacks analogous to spontaneous ones in patients suffering from panic disorder and to a lesser degree in healthy volunteers. In animal models of anxiety, the pretreatment with CCK agonists and antagonists produced, respectively, anxiogenic- and anxiolytic-like action on the exploratory paradigms. On the other hand, CCK could also play a role in the pathophysiology of schizophrenia. The administration of CCK agonists (caerulein, CCK-8s) to rodents results in behavioural effects analogous to those of antipsychotic drugs. However, CCK agonists lack any activity in rodent behavioural models to reveal antipsychotic drugs. A significant reduction of CCK concentration and CCK receptors has been shown in cortical and limbic structures of patients suffering from schizophrenia. Nevertheless, administration of CCK agonists to these patients does not effect their symptoms. Two major conclusions should be drawn: first, CCK is involved in the neurobiology of anxiety; second, changes in the CCK system in schizophrenia could be linked to a cortical neurodegeneration related to this disease.

The future of antidepressants

A common action of many antidepressants is the inhibition of the reuptake of the biogenic amines norepinephrine, serotonin (5-HT) and/or dopamine into nerve terminals. Another postulated mechanism of action for many antidepressants is the downregulation of beta-adrenergic receptors postsynaptically after chronic administration. Many antidepressants have been reported to produce changes in the regulation of 5-HT1 and 5-HT2 receptors chronically. None of these mechanisms is completely satisfactory as a common antidepressant mechanism of action. Is it possible to unify these hypotheses of antidepressant action? A number of receptor changes have been recognized in depression. Usually, these implicated receptors are linked to a G protein. Thus, it could be hypothesized that depression may be the result of a disorder of the large family of receptor-linked G proteins. Depression, a disorder in which there seems to be an important genetic component, could be expressed in either the receptor or in the G proteins, leading to a defective linkage between the receptor and the G protein, resulting in abnormal transduction mechanisms. The concept of antidepressants is changing rapidly as these agents appear with new therapeutic indications other than depression, such as panic disorder, obsessive compulsive disorder, etc. It can be expected that the presently available antidepressants might eventually be considered anxiolytics or that benzodiazepines and 5-HT1A agonists could come to be viewed as disinhibiting substances.

Sigma ligand S14905 and locomotor activity in mice

The binding and locomotor profile of a new sigma ligand, S14905, (isobutyl-N-(1-indan-2yl-piperid-4-yl)N-methyl carbamate, furamate) was studied. The binding data revealed that S14905 has a high affinity for sigma receptors and very low affinity for both dopamine D1 and D2 receptors. We have demonstrated that this sigma ligand prevents the locomotor stimulation induced by morphine (32 and 64 mg/kg), cocaine (16 mg/kg), amphetamine (4 mg/kg) and adrafinil (32 mg/kg) at doses lower than those required to depress spontaneous locomotor activity. The antagonism observed in the present study seems to be more specific of morphine induced hyperlocomotion. The high affinity of this compound for sigma receptors makes it a good choice to study the role of this receptor in the CNS. In addition, S14905 does not directly block dopamine receptors but may modulate them in some manner, and would thus warrant further study as a potential atypical antipsychotic agent, and an antagonist for the hyperactivity induced by opiate drug.

[Experimental and clinical pharmacology of psychostimulants]

OBJECTIVE

To examine the fact that, after 50 years, the introduction of amphetamines for therapeutic purposes, psychostimulants such as methylphenidate have proved to be effective medications used in the treatment of childhood hyperactivity, yet misunderstood.

METHOD

A review of the literature is undertaken on the use of psychostimulants in children and adults.

RESULTS

Studies evaluating their helpfulness in adults are for the most part outdated and nonexploratory.

CONCLUSION

their rehabilitation could prove to be useful for young and older adults, on condition that their target syndromes are studied more thoroughly.

The additive effects of quinine on antidepressant drugs in the forced swimming test in mice

The aim of this study was to investigate if quinine plus antidepressant drugs (ADS) leads to an additive effect in the forced swimming test. Quinine (0.125, 0.5 mg/kg) and ADS (subactive doses) were given IP 45 and 30 min, respectively, before the test. When combined with QUIN, all drugs that act via inhibition of 5-HT uptake (imipramine, amitriptyline, citalopram, paroxetine, fluoxetine and fluvoxamine) significantly increased the swimming time of mice. Among trazodone, mianserin and iprindole (atypical ADS), only iprindole combined with quinine decreased the immobility (increased swimming) of the animals. The specific noradrenaline (NA) uptake inhibitors, desipramine and viloxazine, but not maprotiline, were also found to reduce the immobility time when pretreated with quinine. The mixed monoamine oxidase (MAO) inhibitor (pargyline) and MAO-A inhibitor (moclobemide) also shortened the period of immobility whereas the MAO-B inhibitor (nialamide) and the dopamine (DA) uptake inhibitor (bupropion) did not. Quinine's additive effects on several types of ADS is likely a result of blockade of potassium channels.

Inhibition of nitric oxide synthase causes anxiolytic-like behaviour in an elevated plus-maze

The action of inhibition of nitric oxide (NO) synthase by NG-nitro-L-arginine methyl ester (L-NAME) (1-20 mg kg-1) on the exploratory behaviour of rats in the elevated plus-maze was studied. L-NAME induced an anxiolytic-like effect in the plus-maze test, showing a reverse U-shape action behaviour, with a maximal effect at 10 mg kg-1. This effect was not related to a non-specific increase in motor activity, since in the open field test L-NAME did not affect locomotor activity of rats. Pretreatment of rats with L-NAME (1-10 mg kg-1) also tended to attenuate the anti-exploratory action of CCK agonist caerulein (5 micrograms kg-1), but this action was not significant. In conclusion, it appears that NO may be involved in the process that can lead to anxiety in the rat.

[The future of pharmacological models]

Do pharmacological models have a future? This was the question that had to be answered during seminar n.3 of the annual clinical pharmacology meeting in GIENS. The concept of 'model' is very extensive: it comprises both simple physiological testing and the replication in animals of human diseases. The main problems of pharmacological models are their predictive value and their validity in relation to the pragmatic target of finding new active molecules. Among numerous models proposed by the participants, three types have been selected as examples in this paper: a human model (cholecystokinin inducing panic attacks), the goal of which is to discover new molecules active in panic disorders. an animal model close to clinical features (coronary restenosis) which was to date unable to help in identifying molecules acting in human pathology transgenic animals as tools in drug development. The guidelines are very clear: models, however far they are from human pathology, are useful in predicting new molecular developments. Models are necessary steps to go from receptors to ill patients.

Controlled comparison of the effects and abrupt discontinuation of buspirone and lorazepam

1. The purpose of this study was to compare the effects and abrupt discontinuation of buspirone 15 or 20 mg tid and lorazepam 3 or 4 mg tid following 8 weeks of treatment. A total of 43 outpatients with generalized anxiety disorder were included in the study and 39 entered the withdrawal phase. 2. Clinical assessments were performed at baseline, 2, 4, 6 and 8 weeks (active phase) and after 9 and 10 weeks (withdrawal phase). These included the Hamilton anxiety scale, the visual analogue scale, the CHESS 84 (a check list for the evaluation of somatic symptoms) and the Lader tranquilizer withdrawal scale (translated in french). 3. Results show similar efficacy for lorazepam and buspirone during the active phase with a higher significant difference for buspirone on the CHESS 84 in relation with neurovegetatives symptoms: lorazepam D0 :16.30 +/- 3.14 D56: 5.10 +/- 0.93 (p < or = 0.01) buspirone D0 :18.82 +/- 3.4 D56: 4.73 +/- 1.18 (p < or = 0.001) No withdrawal phenomena was observed for both drugs using HAM-A lorazepam D63 :12.59 +/- 2.26 D70: 12.0 +/- 1.75 (p = ns) buspirone D63 :10.05 +/- 1.28 D70: 10.32 +/- 1.82 (p = ns) and the same significant difference using Lader scale: lorazepam D63 :4.44 +/- 0.89 D70: 6.96 +/- 1.28 (p < or = 0.05) buspirone D63 :2.95 +/- 0.66 D70: 4.15 +/- 0.92 (p < or = 0.05). 4. This study confirmed that buspirone was as effective as lorazepam at D56 in monitored outpatients with generalized anxiety disorder.(ABSTRACT TRUNCATED AT 250 WORDS)

Provocative agents in panic disorder

The pharmacological challenge strategy involves giving a provoking agent under controlled rules to clarify some aspect of behavioural or biological function. Various agents such as sodium lactate, carbon dioxide, caffeine, yohimbine, isoprenaline and now cholecystokinin have been used as provoking agents in healthy volunteers as well as in panic patients. Results obtained in this field are updated, with emphasis on the potential mechanisms of action. It is concluded that there may be a final pathway between carbon dioxide, sodium lactate, and cholecystokinin inducing panic attacks.

Role of N-methyl-D-aspartic acid and cholecystokinin receptors in apomorphine-induced aggressive behaviour in rats

We studied the aggressive behaviour induced by repeated treatment with apomorphine, a dopamine agonist (0.5 mg/kg s.c. twice daily, 10 days), in rats. The first signs of defensive aggressiveness appeared on the third day of apomorphine treatment and were generally seen on the 7th day. Aggressiveness induced by a challenge dose of apomorphine (0.5 mg/kg s.c.) on the 11th day was antagonized by haloperidol (0.05 and 0.1 mg/kg i.p.) and clozapine (10 mg/kg i.p.). An antagonist of N-methyl-D-aspartate (NMDA)-gated channels, dizocilpine (MK-801), also blocked the aggressive behaviour at 0.25 and 0.5 mg/kg i.p. but caused ataxia. When dizocilpine (0.25 mg/kg i.p.) and apomorphine were coadministered for 10 days, aggressive behaviour did not develop. At 0.025 mg/kg i.p., dizocilpine even accelerated the appearance of apomorphine-induced aggressive behaviour, which manifested on the 3rd day in all rats. In a separate study, a 7-day treatment with dizocilpine (0.25-1 mg/kg i.p.) of rats, sensitized by a prior 10-day apomorphine treatment, did not reverse the established aggressive behaviour. The coadministration of apomorphine and cholecystokinin (CCK) -A or -B antagonists, devazepide or L-365,260 (0.01-2.5 mg/kg i.p.) respectively, neither affected development of apomorphine-induced aggressive behaviour nor intensity of aggressiveness in the sensitized rats. In binding studies neither density nor affinity of striatal dopamine D2 receptors was changed by acute or chronic apomorphine treatment. The number of [3H]pCCK-8 binding sites in the frontal cortex increased already after a single injection of apomorphine.(ABSTRACT TRUNCATED AT 250 WORDS)

Lorazepam 0.25 mg twice a day improves aspects of psychometric performance in healthy volunteers

The effects of lorazepam (0.25 mg) twice a day on several cognitive and performance tasks, pictures test, digit-symbol substitution test (DSST), choice reaction time (CRT) and critical flicker fusion (CFF), were investigated in healthy students. A double-blind independent group design was used to compare placebo and lorazepam (30 volunteers in each group). After randomisation, all subjects received placebo for 3 days (D), followed by 14 days of treatment, with either lorazepam or placebo. Subjects completed a battery of tests at Do, then D(3), D(7) , D(10) and D(14). D(3) performance was poorer in the lorazepam group except for CFF (ascending values and total values), yet the only significant improvement was in total reaction time on the CRT test. However, a significant improvement of performance was shown at D(7), D(10) and D(14) in the lorazepam group compared with the control group (except in recognition reaction time). The current study shows that low repeated doses of lorazepam are able to produce small improvements in some aspects of psychomotor and cognitive functions in healthy volunteers. Different points are discussed to explain the performance improvement: training effect, tolerance effect, partial inverse agonist effect and the possible release of cholecystokinin.

Pharmacological comparison of antipsychotic drugs and sigma-antagonists in rodents

We compared antipsychotic drugs (haloperidol, chlorpromazine and clozapine) and sigma antagonists (remoxipride, cinuperone, alpha-(4-fluorophenyl)-4-(-fluoro-2-pyrimidinyl)-1-piperazine butanol (BMY 14802) and rimcazole) in the radio-ligand binding and behavioural experiments in rodents. A good correlation was established between the affinity of compounds at dopamine2-receptors in the striatum and their ability to block apomorphine-, amphetamine- and quipazine-induced behavioural effects in rodents. By contrast, no correlation was found between the behavioural effects of these drugs and their affinity at dopamine1-5-HT2- and sigma receptors. The rank order of potency among the studied antipsychotic drugs in the behavioural tests and at dopamine2-receptors was following: haloperidol >> chlorpromazine > or = clozapine. The effectiveness of chlorpromazine and clozapine was nearly similar against apomorphine-induced aggressiveness and yawning, whereas at 5-HT2-receptors clozapine was more active than chlorpromazine. The weak activity of sigma antagonists at dopamine2 receptors could be a possible reason why these compounds were less effective in the behavioural studies compared to antipsychotic drugs. However, the antagonism of remoxipride against apomorphine-induced stereotypy and aggressiveness is not related to its activity at sigma receptors, because the other sigma antagonists did not block these effects of apomorphine. It is probable that remoxipride exerts its action through blocking of dopamine2 receptors. In conclusion, the present study revealed only weak activity of sigma antagonists in the behavioural models widely used to study the antipsychotic drugs. Therefore, the antipsychotic activity of sigma antagonists is doubtful.

Additive effects of lithium and antidepressants in the forced swimming test: further evidence for involvement of the serotoninergic system

In the mouse forced swimming test (FST) pretreatment with a subactive dose of lithium (1 mEq/kg), given IP 45 min before the test, facilitated the antidepressant activity of iprindole, fluoxetine, and moclobemide (given IP 30 min before the test). These antidepressants (ADS) were not active alone in the FST in this study. Moreover, when subactive lithium was combined with a wide range of ADS, each given at subactive doses, those ADS with serotoninergic properties (e.g. imipramine, citalopram, paroxetine, fluoxetine, trazodone, mianserin, and moclobemide) significantly reduced immobility times. ADS acting primarily on noradrenaline (NA) or dopamine (DA) systems (desipramine, maprotiline, viloxazine, and bupropion) did not significantly decrease immobility when given in combination with lithium. This was also the case for RO 16 6491 [a reversible, B specific monoamine oxidase inhibitor (MAOI)], nialamide, and pargyline (both irreversible, mixed MAOIs). The anti-immobility effect of iprindole in combination with lithium suggests either a direct or indirect action on the serotonin (5HT) system by this ADS whose mechanism of action remains obscure. These results, using an animal behavioral model of depression and combining our present knowledge of the acute action of various ADS, support the hypothesis that the potentiation by lithium of ADS is via direct 5HT mechanisms, indirectly via a NA/5HT link, and/or by second messenger systems. Lithium may also facilitate the expression of antidepressant activity of ADS not active by themselves in the FST.

Evidence for potentiation by CCK antagonists of the effect of cholecystokinin octapeptide in the elevated plus-maze

Systemic treatment with cholecystokinin octapeptide (CCK-8, 2.5-10 micrograms/kg, s.c.), a non-selective CCK agonist, decreased the exploratory activity of mice in an elevated plus-maze. At higher doses (5-10 micrograms/kg) CCK-8 reduced the frequency of rearing, but only 10 micrograms/kg of CCK-8 significantly inhibited the number of line crossings in the open-field test. A preferential CCKB antagonist L-365,260 (1 and 100 micrograms/kg, i.p.) and a non-selective CCK antagonist proglumide (0.1-1 microgram/kg, i.p.) potentiated the anti-exploratory effect of CCK-8 (2.5 micrograms/kg). Devazepide, a preferential CCKA antagonist, only at a high dose (100 micrograms/kg) tended to increase the action of CCK-8 in the plus-maze. However, the concomitant treatment of CCK-8 with L-365,260 and proglumide, differently from devazepide, also suppressed the locomotor activity in the open-field test. Therefore, it is likely that the potentiation by CCK antagonists of the anti-exploratory effect of CCK-8 is related to the suppression of motor activity. This peculiar interaction between CCK-8 and CCK antagonists could be explained in the light of the opposite role of CCKA and CCKB receptors in the regulation of motor activity in mice.

Additive effect of lithium and clonidine with 5-HT1A agonists in the forced swimming test

1. The aim of the present work was to demonstrate the possible additive effect of lithium and clonidine with 5-HT1a agonists in the forced swimming test. 2. Anti-depressant like effects of 5-HT1a agonists was investigated using forced swimming test. When administered alone, only 8-OH-DPAT reduced the immobility time in mice. 3. 5-HT1a agonists were then tested in combination with clonidine or lithium. Only gepirone and ipsapirone pretreated by either lithium or clonidine reduced immobility time in the forced swimming test. 4. The authors conclude that lithium and clonidine might be useful to predict antidepressant-like activity of new compounds.

Effects of flumazenil on cholecystokinin-tetrapeptide-induced panic symptoms in healthy volunteers

The neuropeptide cholecystokinin-tetrapeptide (CCK-4) has potent anxiogenic action in human and animal subjects. On the basis of prior work which demonstrated that benzodiazepine (BZD) receptor agonists antagonized CCK-induced excitation of rat hippocampal neurons we studied whether BZD receptors mediated the anxiogenic effect of CCK-4. To examine this possibility we determined whether the BZD receptor antagonist flumazenil could antagonize the effects of CCK-4 (50 micrograms) in healthy volunteers. Thirty subjects (10 females; 20 males) were pretreated with flumazenil (2 mg in saline) or placebo (0.9% NaCl in water) 15 min prior to CCK-4 challenge in a randomized double-blind crossover design. Flumazenil had no impact on the behavioral and cardiovascular effects of CCK-4, suggesting that BZD receptors do not mediate the anxiogenic action of CCK-4. The influence of GABA and non-GABA-related mechanisms on response to CCK-4 remains to be considered.

Subdiaphragmatic vagotomy does not prevent the anti-exploratory effect of caerulein in the elevated plus-maze

We compared the action of subdiaphragmatic vagotomy upon the anti-exploratory and motor depressant effects of caerulein, an agonist of cholecystokinin (CCK) receptors, in male rats. Vagotomized rats entered more frequently into the open arms of elevated plus-maze compared to intact control rats. Caerulein (1 microgram/kg subcutaneously (s.c.)) significantly suppressed the exploratory behaviour in vagotomized rats but not in intact and sham-operated rats. In contrast, subdiaphragmatic vagotomy did not change the locomotor activity of rats in open field compared to intact and sham-operated animals. At a higher dose (10 micrograms/kg s.c.), the caerulein pretreatment markedly decreased the number of line crossings, rearings and head-dippings of intact animals in open field. In sham-operated rats caerulein also suppressed the locomotor activity, whereas in vagotomized rats it only tended to reduce the frequency of rearings. Consequently, the present study revealed the different action of vagotomy upon the motor depressant and anti-exploratory effects of caerulein. These results support the view that CCKA receptors in the gastrointestinal tract are mediating the motor depressant, whereas CCKB receptors in the brainstem are involved into the mediation of anti-exploratory effect of caerulein.

[Iprindole: a functional link between serotonin and noradrenaline systems?]

Iprindole is an active antidepressant in clinical practice but its mechanism of action has never been clearly defined. Serotoninergic regulation of noradrenergic neurons of locus coeruleus depends on 5-HT2 receptors. This regulatory action of the 5-HT system appears to facilitate the down-regulation of beta receptors. In behavioural tests involving the noradrenergic system, the role of iprindole, administered in subactive doses, was evaluated in the presence of subactive doses of fluvoxamine, a serotonin uptake inhibitor. Yohimbine is an alpha2 antagonist, inducing a dose-dependent toxicity. This test allows a rapid and selective screening of antidepressants with direct and indirect beta-agonist properties. Administration of iprindole displayed a toxicity of fluvoxamine in the presence of yohimbine. A 5-day pre-treatment of iprindole antagonized this potentiation unmasked after acute administration of iprindole. The down-regulation of beta receptors induced by a chronic treatment by iprindole could prevent the adrenergic expression of yohimbine's toxicity. But the down-regulation of 5-HT2 receptors also obtained with chronic treatment by iprindole, can explain this antagonism preventing fluvoxamine's action. Hypothermia induced by a high dose of apomorphine, depends on an activation of the noradrenergic system. During the interaction with fluvoxamine, iprindole unmasked an antagonism of this hypothermia due to apomorphine. The activity of a subactive dose of salbutamol, a direct beta-agonist, was evaluated in the presence of fluvoxamine on hypothermia induced by a high dose of apomorphine. The aim of this interaction was to define the beta-adrenergic property of iprindole more precisely.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of low doses of lorazepam on psychometric tests in healthy volunteers

The effects of low oral doses of lorazepam on several cognitive and performance tasks were investigated in 50 healthy students. A double-blind, parallel group design was used to compare five treatments: placebo and lorazepam 0.5, 0.75, 1 mg and progressive doses up to 1.5 mg. After randomization, all subjects received placebo for 3 days in a single-blind procedure followed by five consecutive days of treatment. Subjects completed a battery of tests each day of the 5 days active treatment and the day after stopping the treatment. There were no significant differences between placebo and lorazepam on the free recall test and the critical flicker fusion frequency test, but lorazepam produced significant improvement on the digit symbol substitution test and the choice reaction time test. We suggest that low repeated doses of lorazepam in healthy subjects improve the psychomotor performance without sedation and memory impairment.

Anti-conflict effect of 5-HT1A agonists in rats: a new model for evaluating anxiolytic-like activity

A new conflict procedure was developed to study the potential anti-punishment effects of 5-HT( 1A) agonists as compared to diazepam. In this paradigm, the opportunity existed for rats to choose during punished periods between immediate, punished reinforcement and delayed, non-punished reinforcement. The results confirm that, for non-sedative doses (1 mg/kg), diazepam increases the number of punished responses. Furthermore, the present paradigm seems sensitive for the detection of 5-HT(1A) activity. Buspirone, gepirone, ipsapirone, zalospirone and 8-OH-DPAT increased responding for immediate but punished reinforcement. 1-(2-pyrimidinyl)piperazine, the common metabolite of the azapirones, does not participate in their anti-conflict effect. NAN 190, a 5-HT(1A) antagonist, was shown to block the 5-HT(1A) agonists. The findings of the present study suggest that benzodiazepines and 5-HT( 1A) agonists reduce the capacity to tolerate delays in reward. Abnormality in serotonin systems may be associated with poor impulse control.