Magnetic resonance imaging in social phobia

Recent studies have implicated dopamine and the basal ganglia circuits in the pathophysiology of social phobia. Twenty-two patients who met DSM-III-R criteria for social phobia and 22 age- and sex-matched control subjects underwent magnetic resonance imaging (MRI). MRI was performed with a 1.5 Tesla General Electric Signa System. No statistically significant difference was demonstrated between social phobia patients and normal control subjects in respect to total cerebral, caudate, putamen, and thalamic volumes. Although this study failed to demonstrate any specific cerebral structure abnormalities in patients with social phobia, it did reveal an age-related reduction in putamen volumes in patients with social phobia that was greater than that seen in controls. This age-related reduction in putamen volumes in patients with social phobia was not correlated with the severity of their illness.

Wernicke-Korsakoff syndrome caused by psychogenic food refusal: MR findings

A 37-year-old woman developed Wernicke encephalopathy after prolonged psychogenic food refusal. MR revealed characteristic signal abnormalities in the midbrain and dorsal thalamus. Follow-up scans showed atrophy and third ventricular enlargement. Wernicke encephalopathy can occur in nonalcoholics, and MR imaging is useful in both the diagnosis and follow-up.

Bicaudate index on magnetic resonance imaging: effects of normal aging

The bicaudate and bifrontal indices have been used in prior computed tomographic studies to investigate atrophy of the caudate nuclei in patients with Huntington's chorea and cerebral atrophy. However, the relationship between these indices and caudate volume has not been documented previously. In this study, we used high-field magnetic resonance imaging (MRI) to determine the effects of normal aging on the bicaudate and bifrontal indices and to study the relationship between these indices and caudate volume. The subjects were 49 normal volunteers, aged 22 to 82 years, who were without any significant neurologic or psychiatric disorders. Age was positively correlated with bicaudate index (r = .59; P < .0001) and bifrontal index (r = .40; P < .0047). Age was negatively correlated with caudate nuclei volume (r = -.47; P < .0005). Caudate volume was negatively correlated with bicaudate (r = -.27; P < .06) and bifrontal (r = -.31; P < .03) indices. These findings are consistent with prior reports of caudate nuclei degeneration with increasing age. Linear and volumetric caudate measurements with MRI may prove useful in the investigation of caudate nuclei function in the neuromotor decline with normal aging and in disorders such as Huntington's chorea.

Hypercortisolemia and hippocampal changes in depression

Hypercortisolemia is a frequently observed abnormality in patients with major depression. It has been hypothesized that the hippocampus, as a major feedback site for glucocorticoids, is involved in the pathophysiology of hypercortisolemia. Some have in fact posited that the hippocampus is marked by diminished size in depressed patients with hypercortisolemia. We tested this hypothesis by examining the relationship between hippocampal volume, assessed with magnetic resonance imaging, and hypercortisolemia using the dexamethasone suppression test (DST) in a group of 19 depressed patients. No differences in hippocampal volume were observed between patients and control subjects (n = 30). Within the patient group, DST suppressors did not differ from DST nonsuppressors in hippocampal volume. However, a relationship between hippocampal volume and 11 p.m. cortisol concentration was observed after covariance adjustment for age and sex. Furthermore, significant negative correlations were observed between hippocampal volume and both age of depressive onset and number of hospitalizations. The results of this study therefore provide limited support for the hypothesis regarding an essential role of the hippocampus in the neuroendocrine elevation of glucocorticoids in depression.

Interuncal distance measurements in healthy volunteers and in patients with Alzheimer disease

PURPOSE

To evaluate further the clinical utility of the interuncal distance (IUD) measured from axial MR scans as a reflection of hippocampal atrophy.

METHODS

The IUD measured from the axial MR scans of 17 healthy control subjects was correlated with the volume of the amygdala hippocampal complex obtained from coronal MR images. The IUD was also measured on axial MR scans in 12 patients with possible or probable Alzheimer disease.

RESULTS

The correlation between the total amygdala hippocampal volume and the IUD was insignificant for control subjects (r = -0.38, P = .13). When analysis of covariance was performed with the IUD as the dependent variable and age and diagnosis as the independent variables, overall R2 was 0.25. Age (F = 5.02, df = 1, P = .034), but not diagnosis (F = 0.02, df = 2, P = .88), had a significant effect.

CONCLUSIONS

The IUD has no significant correlation with the amygdala hippocampal volume. The IUD appears to be a better measure of overall brain volume, which changes with age. In our patient population diagnosed with mild to moderate Alzheimer disease, the IUD measurement was not found to be useful in distinguishing their scans from those of the volunteers.

Interuncal distance as a measure of hippocampal atrophy: normative data on axial MR imaging

PURPOSE

To assess the effects of age and gender on the interuncal distance measured from MR images.

METHODS

High-field strength MR images (axial) of 75 volunteers, 21-82 years old and free of neurologic disorders, were used to measure the interuncal distance.

RESULTS

The interuncal distance increased with age (r = 0.66, P < .0001). The mean (SD) interuncal distance for all subjects was 21.4 (4) mm with a range of 12 to 29 mm.

CONCLUSIONS

The interuncal distance in healthy subjects is unlikely to exceed 30 mm. Our data may be of clinical significance in view of a previous report stating that the interuncal distance may be enlarged in pathologic hippocampal degeneration, such as in patients with Alzheimer disease.

In vivo assessment of pituitary volume with magnetic resonance imaging and systematic stereology: relationship to dexamethasone suppression test results in patients

The relationship between dexamethasone suppression test (DST) results and in vivo pituitary volume was studied in 24 psychiatric inpatients. The principles of systematic stereology were used to measure pituitary volume from 3-mm contiguous sagittal spin-echo magnetic resonance (MR) images of the brain. There was no correlation between pituitary volume and 3 p.m. or 10 p.m. postdexamethasone (post-DEX) plasma cortisol concentrations. However, when multiple regression analysis was performed to relate pituitary volume to gender, age, and post-DEX plasma cortisol concentrations, there was a significant relationship between pituitary volume and age, gender, and 10 p.m. post-DEX cortisol plasma concentration. This is the first study to demonstrate a method that directly measures, rather than estimates, in vivo pituitary volume. Furthermore, it suggests that activation of the hypothalamic-pituitary-adrenal axis in psychiatric patients, as manifested by elevated post-DEX cortisol concentrations, may influence pituitary volume.

Magnetic resonance imaging of the caudate nuclei in depression. Preliminary observations

A role of the caudate nucleus in depression has been suggested from relevant clinical conditions, such as patients with Huntington's disease or caudate infarcts, as well as animal studies. Correlations of caudate nucleus disease with depressive symptoms have been limited to autopsy studies and cases of gross pathological disorder, such as large infarcts. We used serial axial high-field magnetic resonance images and an unbiased stereological technique to estimate the volumes of the caudate nuclei in 50 patients who met DSM-III criteria for major depression (23 men, 48.3 +/- 17 years old) in comparison with 50 age- and gender-matched normal controls free of major neurological and psychiatric disorders. Depressed patients had smaller caudate nucleus volumes (5.2 +/- 1.6 cm3) compared with controls (6.2 +/- 1.7 cm3). Right and left caudate nucleus volumes were smaller in depressed patients compared with controls. Age was negatively correlated with caudate nucleus volumes in depressed patients as well as in controls. Caudate nucleus volumes in depressed patients were inversely correlated with the bicaudate and bifrontal indices. These results may be the first demonstration of diminished caudate nucleus volumes in depression and suggest a role for the caudate nucleus in the pathogenesis of major depression.

Posterior fossa abnormalities in major depression: a controlled magnetic resonance imaging study

High-field magnetic resonance (MR) images were used to study posterior fossa morphology in 27 patients with major depression and 36 normal control subjects. Depressed patients demonstrated smaller brain stem and cerebellar vermis than controls. These differences were highly significant for the anterior cerebellar vermis and medulla. There was also a striking age-related decline in midbrain size in depressed patients as well as in controls. Our results are consistent with several lines of evidence implicating a role for the cerebellar vermis in affective disorders and, in addition, provide the first MR documentation of the differential effects of aging on posterior fossa morphology in normal subjects compared with patients with major depression.

MR assessment of pituitary gland morphology in healthy volunteers: age- and gender-related differences

PURPOSE AND METHODS

High-field MR images at 1.5 T were used to characterize the effects of age and gender on pituitary size and shape in a sample of 71 adult volunteers (40 females), aged 21 to 82 years.

FINDINGS

For all subjects, age was inversely correlated with pituitary height (r = -.43, P less than .0002) and cross-sectional area (r = -.35, P less than .0028). Age-specific gender differences were also present in pituitary height and area. A convex upper pituitary margin was more common in females (P = .002) and younger subjects (P = .009).

CONCLUSIONS

This study confirms that aging is accompanied by gender-specific changes in pituitary size and shape, and provides normative data that may facilitate evaluation of the pituitary gland in neuroendocrine disorders.

Morphometric changes of the human midbrain with normal aging: MR and stereologic findings

PURPOSE

To determine the effects of age on estimated midbrain volume.

PATIENTS AND METHODS

T2-weighted MR imaging and an unbiased stereologic method were used in 75 volunteers; the subjects ranged in age from 21 to 82 years and were without any significant neurologic or psychiatric disorders.

RESULTS

Age was negatively correlated with estimated midbrain volume (R = -.39, P less than .0005), with the anteroposterior diameter through the substantia nigra (R = -.33, P less than .004) and with the interpeduncular distance (R = -.24, P less than .04). The linear measurements for the right and left side were almost identical. These findings are consistent with prior reports of nigrostriatal degeneration with increasing age. Furthermore, they suggest a close symmetry of age-related changes between the right and left side in normal subjects.

CONCLUSIONS

Volumetric and linear measurements of midbrain morphology with MR may prove useful in the investigation of neurologic disorders such as Parkinson disease.

Simultaneous major depression and panic disorder: treatment with electroconvulsive therapy

BACKGROUND

Major depression and panic disorder commonly occur together. Patients with simultaneous depression and panic disorder may have a higher lifetime rate of suicide attempts and an overall worse prognosis than patients with either depression or panic disorder alone. In addition, preliminary work suggests that some of these patients may not respond satisfactorily to antidepressants. In this report, we describe the clinical courses of eight consecutive patients with simultaneous major depression and panic disorder who were referred for ECT at our institution.

METHOD

Eight consecutive patients who met DSM-III-R criteria for simultaneous major depression and panic disorder received ECT. All eight patients were evaluated by a structured clinical interview and the patients' major depression and panic disorder were evaluated with a 7-point Clinical Global Impressions severity rating scale.

RESULTS

Before ECT was begun, each subject's panic disorder and depression were rated as at least markedly ill. After receiving ECT, all eight showed improvement in their depression. In addition, none of the eight patients reported having a panic attack from the time of their fourth ECT treatment until discharge.

CONCLUSION

In this report, eight consecutive patients with simultaneous major depression and panic disorder improved with ECT. Further work is required which examines the potential utility of ECT in treating these patients.

Occurrence of subcortical hyperintensities in elderly subjects with mania

In a retrospective study, brain magnetic resonance images of 12 patients with the onset of manic symptoms after the age of 50 years were compared to age- and sex-matched control subjects for the incidence, size, and location of subcortical hyperintensities. Compared with controls, the patients demonstrated a significantly greater number of large subcortical hyperintensities, particularly in the middle third of the brain parenchyma. The lesions occurred with equal frequency in the right and left hemisphere. There were no differences between the two groups in the size of the ventricles or the presence of periventricular hyperintensities.

Levels of urinary free cortisol in social phobia

Levels of urinary free cortisol were measured in 10 patients with social phobias and in 15 age- and sex-matched normal controls. No differences were found either in cortisol levels or in the ratio of free cortisol to creatinine. These nonsignificant differences between groups do not necessarily rule out the possibility that the hypothalamic-pituitary-adrenal axis may be altered in individuals with social phobia.

A magnetic resonance imaging study of putamen nuclei in major depression

The basal ganglia are recognized as putative mediators of certain cognitive and behavioral symptoms of major depression. Moreover, patients with basal ganglia lesions have repeatedly exhibited significant affective symptomatology, including apathy, depressive mood, and psychosis. Using high resolution, axial T2 intermediate magnetic resonance images, and a systematic sampling stereologic method, we assessed putamen nuclei volumes in 41 patients with major depression (DSM-III) and 44 healthy volunteer controls of similar age. Depressed patients had significantly smaller putamen nuclei compared with controls. Age was negatively correlated with putamen size in both groups. These results are the first demonstration of diminished putamen volumes in depression and further support a role for basal ganglia structures in the etiopathogenesis of depression.

Assessment of posterior fossa structures with midsagittal MRI: the effects of age

Midsagittal magnetic resonance (MR) images of 36 normal volunteers, ranging in age from 26 to 79 years, were used to evaluate the effects of age on the size of posterior fossa structures (cerebellar vermis, midbrain, pons, medulla and fourth ventricle). Our results demonstrate a highly statistically significant age-related decline in the cross-sectional area of the midbrain (r = -.44, p less than 0.007), a less prominent decline in the area of the anterior cerebellar vermis (r = -.33, p less than 0.05) and striking intercorrelations between the dimensions of the pons, medulla and cerebellar vermis. To the best of our knowledge, this is the first MRI demonstration of midbrain atrophy during aging in normal adults.

Subcortical hyperintensities on brain magnetic resonance imaging: a comparison between late age onset and early onset elderly depressed subjects

Subcortical structural changes have been reported to occur in some elderly subjects with late age onset depression. Given the association between diseases affecting subcortical structures and affective disorders, this suggests that these structural changes may be involved in the etiology of late age onset depression in some patients. With the advent of Brain Magnetic Resonance Imaging (MRI), "in vivo" analysis of these subcortical structures is now possible. The authors report a higher occurrence of caudate (60% vs. 11%) and large deep white matter hyperintensities (60% vs. 11%) in late age onset elderly depressed subjects compared with early onset elderly depressed subjects. These results suggest that late age onset depression may be mediated by caudate and white matter structural changes in some patients.

Magnetic resonance findings in patients with early-onset Alzheimer's disease

The magnetic resonance scans of 22 patients with early-onset Alzheimer's disease (AD) were compared to 16 age-matched neurologically normal controls for the presence of white matter subcortical hyperintensities (SCH) and periventricular hyperintensities (PVH). Patients with AD were significantly more likely to have evidence of PVH (p less than 0.01) than age-matched controls. There was no significant difference between the two groups in either the frequency of SCH or the size of the largest lesion. Within the AD group, there was no difference demonstrated in the location of the SCH, either in the anterior-posterior plane or between the two hemispheres. Patients with AD more frequently demonstrated ventriculomegaly (p less than 0.001) and sulcal widening (p less than 0.05) compared with controls. This study suggests that the SCH seen in early-onset AD patients on MRI are related more to the aging process than to the AD process and that the increased frequency of PVH may have a relationship to the disease process.

Caudate hyperintensities in elderly depressed patients with neuroleptic-induced parkinsonism

Elderly patients are particularly sensitive to the neurologic side effects of psychotropic medications. This increased sensitivity may be related to brain structural changes associated with aging. In this pilot study, the authors report on the occurrence of caudate hyperintensities, using brain magnetic resonance imaging, in seven elderly depressed subjects who developed neuroleptic-induced parkinsonism. Caudate hyperintensities were not observed in any of the seven healthy elderly controls examined. These results suggest that caudate hyperintensities may render some elderly depressed patients susceptible to neuroleptic-induced parkinsonism.

Platelet [3H]-imipramine binding and leukoencephalopathy in geriatric depression

We examined the relationship between platelet [3H]-imipramine binding and leukoencephalopathy as assessed by 1.5 Tesla Magnetic Resonance Imaging (MRI) in 21 elderly depressed patients who satisfied DSM-III criteria for major depression. Both drug-free platelet [3H]-imipramine binding and brain MRI studies were obtained during the same episode of depression. Our findings show a significant inverse relationship between frequency of subcortical hyperintensity (SCH) and the number (Bmax) of platelet [3H]-imipramine binding sites. Patients with Bmax less than 850 fmol/mg protein had significantly larger SCH compared with patients with a higher Bmax. These data provide further support to the potential use of platelet [3H]-imipramine binding studies and brain MR imaging as diagnostic adjuncts in geriatric depression and suggest, moreover, that these two biological markers may be linked in geriatric patients with depression.

Pituitary size in depression

Magnetic resonance images centered at the pituitary stalk were used to measure pituitary gland size in 19 patients with major depression compared with that in age- and sex-matched controls. Depressed patients had significantly greater pituitary cross-sectional area (P = 0.0009) and volume (P = 0.007) than the controls. This difference was particularly prominent in elderly depressed patients compared to elderly controls. These results provide the first demonstration of structural alterations in the pituitary gland in major depression.

In vivo stereological assessment of human cerebellar volume: effects of gender and age

Intermediate T2-weighted MR images and a systematic sampling stereological method were used in 37 normal volunteers, 24 to 79 years old, to assess the effects of age and sex on cerebellar volume. Female subjects (n = 21) had significantly smaller cerebellar volumes compared with males (n = 16) of similar age (t = -3.9, p less than .0008, two-tail t test). Using straight-line, univariate regression, we determined that age was not a significant predictor of cerebellar volume (R2 = 0.07, t = -1.66, p = 0.11), whereas gender did appear to account for a significant amount of variability in cerebellar volume (R2 = 0.33, t = -4.13, p = .0002). The mean absolute cerebellar volume in this study was 112 ml (SD +/- 16) for all subjects, 104 ml (SD +/- 10) for females, and 122 ml (SD +/- 16) for males. This study demonstrates the feasibility of using MR images along with a systematic stereological method to assess in vivo human cerebellar volume, thereby providing a research tool to correlate cerebellar morphology with cognitive and neuromotor function.

Magnetic resonance imaging in biological psychiatry

1. Although clinicians have been quick to adopt magnetic resonance imaging (MRI) in the search for brain pathology in psychiatric disorders, the clinical utility of MRI is only now being well defined. 2. Numerous past computerized tomography or post-mortem tissue reports in patients with schizophrenia, affective disorders, dementia, autism, and many other psychiatric illnesses have suggested neuroanatomical substrates for these disorders. However, these techniques have several limitations. 3. The advent of MRI has allowed a high resolution method for examining the brain in vivo. It is important for psychiatrists to know the clinical utility, and the advantages/disadvantages of MR compared with CT. 4. In this article, the authors review the relevant MR literature with some illustrative cases where MRI provided clinically useful information. Recent advances in MRI technology that will have future applications in psychiatry are also discussed.

A magnetic resonance image study of age-related changes in human putamen nuclei

Putamen nuclei were assessed in 36 normal volunteers using magnetic resonance imaging and a systematic sampling method. There was a significant decrease in the volume of the putamen nuclei with advancing age (r = -0.74, p less than 0.0001), and an associated decline in the volume of the caudate nuclei (r = 0.60, p less than 0.0001). The implications of these findings in age-associated motor abnormalities are discussed.

Pituitary abnormalities in eating disorders: further evidence from MRI studies

1. The frequent occurrence of hypothalamo-pituitary dysfunction in patients with eating disorders as well as prior reports that nutritional and endocrine status influence pituitary morphology, led us to hypothesize that pituitary size and shape may be altered in patients with eating disorders. 2. Magnetic resonance imaging (MRI) does not use ionizing radiation and is currently one of the most feasible modalities available to study the pituitary gland in vivo. Using MRI, we have previously reported in a preliminary study that female patients with eating disorders had significantly smaller pituitary glands than controls. In addition MRI excluded any pituitary mass lesions. 3. In this report, we confirm our previous MRI findings and provide further evidence of pituitary abnormalities in an expanded sample of eating disorder patients. Preliminary data on pituitary volume estimates from MRI scans are provided for a subset of patients and controls.

ECT-induced delirium in depressed patients with Parkinson's disease

In this pilot study, a prolonged (interictal) delirium was induced by electroconvulsive therapy (ECT) in seven out of seven depressed patients with Parkinson's disease. This occurrence of delirium appears much higher than what has been reported in other patient populations. These findings are consistent with several lines of data that have implicated the basal ganglia in the development of delirium from other causes, and they suggest that structural changes in these areas may predispose individuals to develop an interictal delirium during a course of ECT.

In vivo assessment of pituitary gland volume with magnetic resonance imaging: the effect of age

We used sagittal and coronal T1 weighted magnetic resonance images, at 1.5 Tesla, to measure the height, width, length, and cross-sectional area and to generate two estimates of pituitary gland volume in 35 normal volunteers aged 26-79 yr (19 females and 16 males). Subjects over 50 yr of age had significantly smaller pituitary gland height (P = 0.03), area (P = 0.04), and volume (P = 0.04) than those under 50 yr (by two-tailed t test). Overall, age was negatively correlated with pituitary volume (V1: r = -0.51; P = 0.003; V2: r = -0.47; P = 0.008), area (r = -0.43; P = 0.009), and height (r = -0.46; P = 0.005), but not with pituitary length or width. There were no statistically significant differences in pituitary size between men and women (by two-tailed t test). These findings suggest that pituitary gland height provides a good single measure for the assessment of pituitary gland size and that age must be controlled for in studies of pituitary gland size.

A brain magnetic resonance imaging study of pituitary gland morphology in anorexia nervosa and bulimia

Magnetic resonance imaging (MRI) of the brain was used to examine the morphology and dimensions of the pituitary gland in 18 patients with eating disorders (8 anorectics and 10 bulimics), in comparison with 13 healthy volunteers. None of the 18 patients with anorexia or bulimia had any radiological evidence suggestive of pituitary macroadenoma, cyst, or empty sella. Measurements revealed that the anorectics and bulimics had smaller pituitary gland cross-sectional areas (p less than 0.05) and smaller pituitary gland heights, compared with healthy controls. These preliminary findings in anorectics and bulimics are suggestive of pituitary atrophy secondary to nutritional or endocrine alterations, rather than a primary pituitary pathology.

Subcortical structural changes in ECT-induced delirium

A prolonged (interictal) delirium was induced by electroconvulsive therapy (ECT) in 6/36 (17%) elderly depressed patients. Brain magnetic resonance imaging or brain computerized axial tomography revealed structural changes in the basal ganglia and white matter in all six patients who developed delirium. These findings are consistent with our previous work and with several lines of data that have implicated the basal ganglia and subcortical white matter in the development of delirium from other causes. These result suggest that lesions in these areas may predispose one to developing an interictal delirium during a course of ECT.

In vivo stereological assessment of caudate volume in man: effect of normal aging

Using intermediate weighted magnetic resonance imaging (MRI) and a systematic sampling stereological method in 39 normal volunteers aged 24-79 years old, we demonstrated a marked age-associated decline in caudate nuclei volume (r = -0.69, p less than 0.0001). The mean absolute volume of the caudate nuclei in this study (9.4 cm3) was almost identical to that reported in a previous autopsy study and further confirms the validity of this stereological technique for use with MR images. This technique will provide a method for measuring the caudate and other nuclei in vivo, from brain images and, as such, a research tool to correlate age-associated changes in cognitive, sensory and motor function with caudate nucleus volume and other brain regions.