Family study of affective spectrum disorder

Family history study of the familial coaggregation of borderline personality disorder with axis I and nonborderline dramatic cluster axis II disorders

The purpose of this study was to assess the familial coaggregation of borderline personality disorder (BPD) with a full array of axis I disorders and four axis II disorders (antisocial personality disorder, histrionic personality disorder, narcissistic personality disorder, and sadistic personality disorder) in the first-degree relatives of borderline probands and axis II comparison subjects. Four hundred and forty-five inpatients were interviewed about familial psychopathology using the Revised Family History Questionnaire-a semistructured interview of demonstrated reliability. Of these 445 subjects, 341 met both DIB-R and DSM-III-R criteria for BPD and 104 met DSM-III-R criteria for another type of personality disorder (and neither criteria set for BPD). The psychopathology of 1,580 first-degree relatives of borderline probands and 472 relatives of axis II comparison subjects was assessed. Using structural models for familial coaggregation, it was found that BPD coaggregates with major depression, dysthymic disorder, bipolar I disorder, alcohol abuse/dependence, drug abuse/dependence, panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety disorder, posttraumatic stress disorder, somatoform pain disorder, and all four axis II disorders studied. Taken together, the results of this study suggest that common familial factors, particularly in the areas of affective disturbance and impulsivity, contribute to borderline personality disorder.

MOOD IN RELATION TO SUBCLINICAL OBSESSIVE-COMPULSIVE SYMPTOMS

Obsessive-compulsive disorder (OCD) is considered an anxiety disorder, but shows comorbidity with other disorders in the affective and impulsive-compulsive spectra, including anxiety disorders, major depression, and drug addictions. Subclinical OCD symptoms are relatively common in nonclinical populations and share common neurobiological substrates with clinical OCD. In this nonclinical community sample, the relationship between the severity of obsessions and compulsions, as measured by the Yale-Brown Obsessive Compulsive Scale, related to the intensity of negative emotions (anger, depression, tension, confusion, and fatigue) but not positive emotion (vigor), as measured by the Profile of Mood States. These relationships were independent of demographic influences and psychoactive drug use frequency (alcohol, cannabis, opioid, major stimulants, MDMA, and hallucinogens). These likely reflect common neurobiological substrates for emotional and behavioral regulation in prefrontal-subcortical/limbic circuits, which show normal variations in the general population.

Duloxetine in the treatment of irritable bowel syndrome: an open-label pilot study

OBJECTIVE

To assess the efficacy of duloxetine for irritable bowel syndrome (IBS).

METHODS

We conducted an open-label 12-week trial of duloxetine 60 mg daily in 15 patients with IBS without concurrent major depressive disorder. The primary outcome measure was average abdominal pain. Secondary measures included IBS symptoms, Clinical Global Impression-Severity, Hamilton Anxiety Rating Scale, IBS Quality-of-Life Scale, and Sheehan Disability Scale. We analyzed changes using random regression and one-sample t-tests.

RESULTS

Fourteen patients completed at least one post-baseline evaluation; eight completed the study. Duloxetine was associated with significant improvement (p < 0.05) in pain, severity of illness, quality of life, loose stool, work and family disability, and anxiety. However, duloxetine did not improve hard stool. Although we found no evidence of serious duloxetine toxicity, seven participants withdrew over the course of the study because of adverse drug events.

CONCLUSIONS

In this small, open-label study, duloxetine appeared to be effective for many features of IBS, but its adverse effects, most notably constipation, limited its use. Since our study excluded individuals with concurrent major depression, it appears that duloxetine may benefit IBS independently of its antidepressant effects. These encouraging but preliminary open-label findings support further investigation of duloxetine treatment in placebo-controlled trials of IBS.

Estimating disease prevalence using relatives of case and control probands

We introduce a method of estimating disease prevalence from case-control family study data. Case-control family studies are performed to investigate the familial aggregation of disease; families are sampled via either a case or a control proband, and the resulting data contain information on disease status and covariates for the probands and their relatives. Here, we introduce estimators for overall prevalence and for covariate-stratum-specific (e.g., sex-specific) prevalence. These estimators combine the proportion of affected relatives of control probands with the proportion of affected relatives of case probands and are designed to yield approximately unbiased estimates of their population counterparts under certain commonly made assumptions. We also introduce corresponding confidence intervals designed to have good coverage properties even for small prevalences. Next, we describe simulation experiments where our estimators and intervals were applied to case-control family data sampled from fictional populations with various levels of familial aggregation. At all aggregation levels, the resulting estimates varied closely and symmetrically around their population counterparts, and the resulting intervals had good coverage properties, even for small sample sizes. Finally, we discuss the assumptions required for our estimators to be approximately unbiased, highlighting situations where an alternative estimator based only on relatives of control probands may perform better.

Prevalence of functional gastrointestinal disorders in patients with fibromyalgia and the role of psychologic distress

BACKGROUND & AIMS

Fibromyalgia is a rheumatologic disorder associated with somatic and psychologic conditions. Although fibromyalgia is associated with irritable bowel syndrome, its relationship with other functional gastrointestinal disorders (FGID) is unclear. We evaluated the prevalence of FGID in patients with fibromyalgia and the role of psychologic factors in this relationship.

METHODS

From a Spanish population, 100 patients with fibromyalgia and 100 matched controls completed the Rome II Integrative Questionnaire to assess the prevalence of FGID and the Symptom Checklist-90 Revised (SCL-90R) to evaluate psychologic distress. Patients completed the Fibromyalgia Impact Questionnaire to evaluate the overall impact of fibromyalgia and controls filled out the Chronic Widespread Pain Questionnaire to detect potential cases of fibromyalgia.

RESULTS

Ninety-three percent of the total study population was female, with a mean age of 50 years. We identified 6 cases of widespread pain among controls. The average Fibromyalgia Impact Questionnaire score for patients was 67.28 +/- 14.25. All gastrointestinal symptoms except for vomiting were more frequent in patients. Ninety-eight percent of patients with fibromyalgia had at least one FGID, compared with only 39% of controls. Fibromyalgia was correlated most highly with irritable bowel syndrome. Patients presented with significantly higher scores of psychologic distress than controls, especially those with fecal incontinence.

CONCLUSIONS

There is a prevalence of FGID in patients with fibromyalgia and a wider distribution of such symptoms along the gastrointestinal tract compared with controls. We propose that an increased degree of psychologic distress in these patients predisposes them to FGID, especially significant for anorectal syndromes.

Treatment of chronic fatigue syndrome: findings, principles and strategies

Chronic fatigue syndrome (CFS) is a debilitating condition characterized by serious medically unexplained mental and physical fatigue. The high prevalence and both direct and indirect health costs of CFS patients represent a huge problem for contemporary health care. Moreover, the prognosis of CFS, even when treated, is often poor. In this paper, we first critically review current evidence based treatments of CFS. Second, we discuss the growing insights into the etiopathogenesis of CFS, and the need to translate and integrate these insights into future treatments. In particular, we formulate a pragmatic and empirically testable treatment approach, tailored to the individual needs of patients, which aims at restoring the mental and physical equilibrium of CFS patients by trying to bring about sustained life style changes.

Gastrointestinal complaints among subjects with depressive symptoms in the general population

BACKGROUND

Patients with depression have irritable bowel syndrome (IBS) more often than do nondepressed patients, but the comorbidity of depression and gastrointestinal (GI) symptoms in the general population has received little study.

AIM

To study the co-occurrence of depressive and GI symptoms in a general population sample and to assess the rate of health-care utilization particularly for GI reasons among subjects with depressive symptoms.

METHODS

A questionnaire containing the Finnish version of the Beck Depression Inventory Short Form and questions covering GI symptoms according to Rome II criteria was mailed to 5000 randomly selected adults.

RESULTS

Response rate was 73%. Prevalence of depressive symptoms was 17% (95% CI: 15.7-18.2). Frequent abdominal pain, diarrhoea, constipation, dyspepsia or IBS were present in 54% of those with depressive symptoms and in 29% of nondepressed controls (P < 0.0001). Of those with depressive symptoms, 24% had visited a physician at least once because of abdominal symptoms during the previous year, compared to 13% of controls (P < 0.0001).

CONCLUSIONS

Depressive symptoms are prevalent in the general population. They are associated with a high rate of GI symptoms, leading to increased use of health-care services and work absenteeism because of abdominal complaints.

Fibromyalgia: harmonizing science with clinical practice considerations

This review summarizes the present and emerging knowledge base on the pathophysiology, diagnosis, and management of fibromyalgia.

EPIDEMIOLOGY

Fibromyalgia is the most common chronic pain syndrome encountered in general medicine and rheumatology. Historically, contemporary concepts of fibromyalgia have evolved in terms of its clinical description and parallel advances in the understanding of its pathophysiology.

PATHOPHYSIOLOGY

A generally accepted paradigm postulates that fibromyalgia is the clinical expression of a rheumatologic disorder in which the associated pain is driven primarily by central sensitization and possibly through changes in several neuronal systems but not necessarily reliant on peripheral processes.

MANAGEMENT

Several agents, including serotonin-norepinephrine reuptake inhibitors (ie, duloxetine and milnacipran), opioids (ie, tramadol), and the alpha2-delta ligand pregabalin, which recently received U.S. regulatory approval for the treatment of fibromyalgia, have been evaluated in clinical trials, demonstrating benefit in terms of pain reduction and improvement in core symptoms (ie, fatigue and sleep disturbance). The European League Against Rheumatism has developed updated guidelines for the management of fibromyalgia.

Prospective associations between depressive symptoms and eating disorder symptoms among adolescent girls

OBJECTIVE

Although eating disorders are frequently associated with depression, evidence regarding which problem predicts the other is conflicting, and little research has addressed the developmental course of this relation. This study examined longitudinal associations between depression and eating pathology across adolescence.

METHOD

Participants were 754 girls participating in the community-based Minnesota Twin Family Study. Depressive symptoms and eating pathology were assessed at approximately ages 11, 14, and 17.

RESULTS

As expected, substantial continuity in both eating pathology and depressive symptoms occurred across time. Analysis of cross-lag paths controlling for earlier levels of symptoms indicated that overall levels of eating pathology predicted later depressive symptoms from 11 to 14 and from 14 to 17.

CONCLUSION

Adolescent girls with high levels of eating-related pathology appear to be at risk for later depression.

Repetitive transcranial magnetic stimulation in bulimia nervosa: preliminary results of a single-centre, randomised, double-blind, sham-controlled trial in female outpatients

BACKGROUND

Bulimia nervosa (BN) is often associated with depressive symptoms and treatment with antidepressants has shown positive effects. A shared deficient serotonergic transmission was postulated for both syndromes. The left dorsolateral prefrontal cortex was argued to regulate eating behaviour and to be dysfunctional in eating disorders.

METHODS

Fourteen women meeting DSM-IV criteria for BN were included in a randomised placebo-controlled double-blind trial. In order to exclude patients highly responsive to placebo, all patients were first submitted to a one-week sham treatment. Randomisation was followed by 3 weeks of active treatment or sham stimulation. As the main outcome criterion we defined the change in binges and purges. Secondary outcome variables were the decrease of the Hamilton Depression Rating Scale (HDRS), the Beck Depression Inventory (BDI) and the Yale-Brown Obsessive Compulsive Scale (YBOCS) over time.

RESULTS

The average number of binges per day declined significantly between baseline and the end of treatment in the two groups. There was no significant difference between sham and active stimulation in terms of purge behaviour, BDI, HDRS and YBOCS over time.

CONCLUSION

These preliminary results indicate that repetitive transcranial magnetic stimulation (rTMS) in the treatment of BN does not exert additional benefit over placebo. A larger number of patients might clarify a further role of rTMS in the treatment of BN.

The role of internalizing and externalizing liability factors in accounting for gender differences in the prevalence of common psychopathological syndromes

BACKGROUND

We hypothesized that gender differences in average levels on the internalizing and externalizing factors that account for co-morbidity among common psychopathological syndromes in both men and women account for gender differences in the prevalence of specific syndromes.

METHOD

The latent structure of 11 syndromes was examined in a middle-aged (mean age=52.66 years, s.d.=5.82) sample of 2992 (37% men) members of the community-based Minnesota Twin Registry (MTR) assessed using 10 scales of the Psychiatric Diagnostic Screening Questionnaire (PDSQ) and an adult antisocial behavior scale. Confirmatory factorial invariance models were applied to a best-fitting, internalizing-externalizing model.

RESULTS

A 'strong gender invariance model' fit best, indicating that gender differences in the means of individual syndromes were well accounted for by gender differences in mean levels of internalizing and externalizing. Women exhibited higher mean levels of internalizing (d=0.23) and lower mean levels of externalizing (d=-0.52) than men.

CONCLUSIONS

These findings suggest that risk factors for common mental disorders exhibiting gender differences may influence prevalence at the latent factor level. Future research may benefit from focusing on both the latent factor and individual syndrome levels in explaining gender differences in psychopathology.

History of depressive and anxiety disorders and paroxetine response in patients with irritable bowel syndrome: post hoc analysis from a placebo-controlled study

OBJECTIVE

Although irritable bowel syndrome (IBS) is highly comorbid with depressive and anxiety disorders, information on the clinical implications of this comorbidity is limited. We investigated whether a history of depressive and/or anxiety disorders was associated with response to treatment in a double-blind, randomized, placebo-controlled trial of paroxetine controlled release (CR) in IBS.

METHOD

Seventy-two IBS subjects (diagnosed using Rome II criteria) were recruited from August 2003 to November 2005 and randomly assigned to receive flexibly dosed paroxetine CR (dose, 12.5-50 mg/day) or placebo for 12 weeks. The Mini-International Neuropsychiatric Interview (MINI-Plus version) was used to ascertain current (exclusionary) or past diagnoses of depressive and anxiety disorders. Subjective depression, anxiety, and stress were assessed at entry and throughout the trial using the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Perceived Stress Scale (PSS). Severity of IBS symptoms was determined by the Composite Pain Score (CPS), administered via Interactive Voice Response System, and the Clinical Global Impressions scale (CGI). The primary outcome was treatment response defined as ≥ 25% reduction in CPS from randomization to end of treatment. A post hoc analysis (multivariate logistic regression) was done to evaluate whether a history of depressive and/or anxiety disorder was associated with response to medication.

RESULTS

Baseline demographic and clinical characteristics (CPS, BDI, BAI, PSS, CGI scores) were similar between groups (history of depressive/anxiety disorder vs. no history). In multivariate logistic regression analysis, treatment response was not predicted by history of depressive and/or anxiety disorder (OR = 0.58, CI = 0.29 to 1.68, p = .32) or drug status (paroxetine CR vs. placebo) (OR = 1.26, CI = 0.68 to 3.21, p = .19). Drug status was significantly associated with the secondary outcome variable of treatment response as defined by a CGI improvement score of 1 to 2 (OR = 12.14, CI = 2.9 to 48.4, p < .001). Paroxetine CR was safe and well tolerated during the study.

CONCLUSIONS

History of depressive and/or anxiety disorder was not associated with response of IBS symptoms to paroxetine CR. Conclusions are limited due to insufficient statistical power. Further research is needed to clarify the role of selective serotonin reuptake inhibitors in the treatment of IBS and to elucidate the treatment ramifications of comorbid psychiatric disorders.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00610909.

Genetic epidemiology, endophenotypes, and eating disorder classification

OBJECTIVE

To explore how genetic epidemiology has informed the identification of endophenotypes and how endophenotypes may inform future classification of eating disorders.

METHOD

Literature review and synthesis.

RESULTS

Although a number of endo- and subphenotypes have been suggested for eating disorders, few reach the rigorous definitions developed for candidate endophenotypes.

CONCLUSION

Further study of endophenotypes and subphenotypes for eating disorders may assist with developing a more homogenous classification system that more closely reflects underlying biological mechanisms, and provides a clearer focus for the development of coherent models and treatments.

The association of anxiety disorders and obsessive compulsive personality disorder with anorexia nervosa: evidence from a family study with discussion of nosological and neurodevelopmental implications

BACKGROUND

To investigate the association of anorexia nervosa with anxiety disorders through use of a case-control family study design.

METHOD

Lifetime prevalence of anxiety disorders and obsessive compulsive personality disorder was determined among 574 first-degree relatives of 152 probands with anorexia nervosa and compared to rates observed among 647 first-degree relatives of 181 never-ill control probands.

RESULTS

Adjusting for comorbidity of the same illness in the proband, relatives of probands with anorexia nervosa, had a significantly higher prevalence of generalized anxiety, obsessive compulsive disorder, separation anxiety disorder, social phobia, panic disorder, and obsessive compulsive personality disorder compared to relatives of never-ill control probands.

CONCLUSION

Anorexia nervosa may share familial liability factors in common with various anxiety phenotypes. In suggesting that a transmitted propensity for anxiety is a key aspect of vulnerability in anorexia nervosa, the findings point to research developments in the affective neurosciences, specifically the neurocircuitry of fear and anxiety, as a heuristic framework in which to interpret aspects of premorbid temperamental anxieties and clinical symptoms.

Genetics of chronic pain states

Chronic pain states are common in the general population. Genetic factors can explain a significant amount of the variability in the perception of pain. Fibromyalgia syndrome (FMS) and related conditions are syndromes characterized by generalized pain sensitivity as well as a constellation of other symptoms. Family studies show a strong familial aggregation of FMS and related conditions, suggesting the importance of genetic factors in the development of these conditions. Recent evidence suggests a role for polymorphisms of genes in the serotoninergic, dopaminergic and catecholaminergic systems in the pathogenesis of FMS and related conditions. Environmental factors may trigger the development of these disorders in genetically predisposed individuals. Future large well-designed studies are needed to further clarify the role of genetic factors in FMS and related conditions. The knowledge of these gene polymorphisms may help with better subgrouping of FMS patients and in designing a more specific pharmacologic treatment approach.

Depression: relationships to sleep paralysis and other sleep disturbances in a community sample

Sleep disturbances are important correlates of depression, with epidemiologic research heretofore focused on insomnia and sleepiness. This epidemiologic study's aim was to investigate, in a community sample, depression's relationships to other sleep disturbances: sleep paralysis (SP), hypnagogic/hypnopompic hallucinations (HH), cataplexy - considered rapid eye movement-related disturbances - and automatic behavior (AB). Although typical of narcolepsy, these disturbances are prevalent, albeit under-studied, in the population. Cross-sectional analyses (1998-2002), based on Wisconsin Sleep Cohort Study population-based data from 866 participants (mean age 54, 53% male), examined: depression (Zung Self-Rating Depression Scale), trait anxiety (Spielberger State-Trait Anxiety Inventory, STAI-T >or= 75th percentile), and self-reported sleep disturbances. Descriptive sleep data were obtained by overnight polysomnography. Adjusted logistic regression models estimated depression's associations with each (>few times ever) outcome - SP, HH, AB, and cataplexy. Depression's associations with self-reported SP and cataplexy were not explained by anxiety. After anxiety adjustment, severe depression (Zung >or=55), vis-à-vis Zung <50, increased SP odds approximately 500% (P = 0.0008). Depression (Zung >or=50), after stratification by anxiety given an interaction (P = 0.02), increased self-reported cataplexy odds in non-anxious (OR 8.9, P = 0.0008) but not anxious (OR 1.1, P = 0.82) participants. Insomnia and sleepiness seemed only partial mediators or confounders for depression's associations with self-reported cataplexy and SP. Anxiety (OR 1.9, P = 0.04) partially explained depression's (Zung >or=55) association with HH (OR 2.2, P = 0.08). Anxiety (OR 1.6, P = 0.02) was also more related than depression to AB. Recognizing depression's relationships to oft-neglected sleep disturbances, most notably SP, might assist in better characterizing depression and the full range of its associated sleep problems in the population. Longitudinal studies are warranted to elucidate mediators and causality.

Migraine comorbidity constellations

OBJECTIVES

To identify distinct constellations of comorbid disorders occurring in migraineurs, and to examine differences in demographics, headache profiles, and psychosocial features between the comorbidity constellations.

METHODS

This is a retrospective electronic chart review of consecutive new female outpatients diagnosed with migraine (n = 223) using International Classification of Headache Disorders (ICHD)-II criteria. Questionnaire collected information on comorbid diagnoses, current depression, somatic symptoms, psychosocial stressors, and antidepressant use, social and abuse history. Cluster analysis, based on nonheadache disorders, was performed and differences between the resulting groups were examined.

RESULTS

We identified 3 groups. Group 1 (n = 55) was defined by hypertension, hyperlipidemia, diabetes mellitus, and hypothyroidism; Group 2 (n = 83) by depression, anxiety, and fibromyalgia; Group 3 (n = 85) by the absence of defining comorbidities. Group 1 had more males (22% vs 5% vs 12%, P < .05), was older (median years: 52 vs 36 vs 32, P < .01), and had later age of headache onset (median years: 22 vs 16 vs 18, P < .05). Group 2 had the greatest disability (P < .05), and the lowest quality of life (P < .001). Persons in Group 2 more commonly reported sexual abuse (OR = 2.7, 95% CI: 1.1 to 6.5), physical abuse (OR = 2.5, 95% CI: 1.2 to 5.1), and emotional abuse (OR = 4.3, 95% CI: 1.9 to 8.9).

CONCLUSION

Within a headache clinic population, we identified 3 different migraine comorbidity constellations, with differing headache and psychosocial profiles, suggesting heterogeneity of genetic and environmental factors. This may have implications for diagnosis and disease management.

Endometriosis Is Associated With Prevalence of Comorbid Conditions in Migraine

OBJECTIVE

To examine the headache characteristics of women with migraine and endometriosis (EM), and differences in the prevalence of comorbid conditions between female migraineurs with EM, without EM and nonheadache controls.

BACKGROUND

Migraine and EM are common conditions in women of reproductive age, and both are influenced by ovarian hormones. The comorbidity of migraine and EM is newly recognized, but reasons for the association are uncertain.

METHODS

This is a cross-sectional study of female headache outpatients and healthy controls conducted at University of Toledo and Duke University in 2005 and 2006. After a headache specialist determined headache frequency and diagnosis (based on criteria of the second International Classification of Headache Disorders), patients completed a self-administered electronic survey with information on demographics, headache-related disability, menstrual disorders, premenstrual dysphoric disorder (PMDD), vascular event risk, and comorbid conditions, including irritable bowel syndrome (IBS), fibromyalgia (FM), chronic fatigue syndrome (CFS), interstitial cystitis (IC), depression, and anxiety.

RESULTS

Study enrolled 171 women with migraine and 104 controls. EM was reported more commonly in migraineurs than in controls (22% vs 9.6%, P < .01). Frequency of chronic headache was higher in migraineurs with EM compared to without EM (P= .002) and median headache-related disability scores were also higher in the EM group (P= .025). Symptoms of PMDD were more common in migraineurs, but frequency did not differ by EM status. Migraineurs with EM reported more menorrhagia, dysmenorrhea, and infertility compared to the migraine cohort without EM and to controls. Depression, anxiety, IBS, FM, CFS, and IC were more common in migraine with EM group than in controls. Anxiety (OR = 2.2, 95% CI 1.0-4.7), IC (OR = 10.6, 95% CI 1.9-56.5), and CFS (OR = 3.6, 95% CI 1.1-11.5) were more common in migraine with EM group, than in the cohort with migraine without EM.

CONCLUSION

Prevalence of EM is higher in women with migraine than in nonheadache controls. Migraineurs with EM have more frequent and disabling headaches, and are more likely to have other comorbid conditions affecting mood and pain, compared to migraineurs without EM.

Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes

OBJECTIVES

To discuss fibromyalgia syndrome (FMS) and overlapping conditions, eg, irritable bowel syndrome, headaches, and chronic fatigue syndrome, within the concept of central sensitivity syndromes (CSS).

METHODS

A critical overview of the literature and incorporation of the author's own views.

RESULTS

The concept of CSS seems viable. It is based on mutual associations among the CSS conditions as well as the evidence for central sensitization (CS) among several CSS members. However, such evidence is weak or not available in other members at this time, requiring further studies. The biology of CSS is based on neuroendocrine aberrations, including CS, that interact with psychosocial factors to cause a number of symptoms.

CONCLUSIONS

CSS is an important new concept that embraces the biopsychosocial model of disease. Further critical studies are warranted to fully test this concept. However, it seems to have important significance for new directions for research and patient care involving physician and patient education. Each patient, irrespective of diagnosis, should be treated as an individual considering both the biological and psychosocial contributions to his or her symptoms and suffering.

Biology and therapy of fibromyalgia. Genetic aspects of fibromyalgia syndrome

Genetic and environmental factors may play a role in the etiopathology of fibromyalgia syndrome (FMS) and other related syndromes. There is a high aggregation of FMS in families of FMS patients. The mode of inheritance is unknown but it is most probably polygenic. There is evidence that polymorphisms of genes in the serotoninergic, dopaminergic and catecholaminergic systems play a role in the etiology of FMS. These polymorphisms are not specific for FMS and are associated with other functional somatic disorders and depression. Future genetic studies in the field of FMS and related conditions should be conducted in larger cohorts of patients and ethnically matched control groups.

Mechanisms of Disease: genetics of fibromyalgia

Fibromyalgia is characterized by widespread pain and tenderness, and has a significant familial component. The etiology of fibromyalgia remains unclear, but genetic factors seem to have a significant role, and are influenced by environmental factors. Research over the past two decades has demonstrated that genetic polymorphisms in the serotoninergic, dopaminergic and catecholaminergic systems of pain transmission and processing are involved in the etiology of fibromyalgia, but additional candidates continue to emerge. Fibromyalgia is thought to belong to the group of affective spectrum disorders, which include related psychiatric and medical disorders. As the concept of affective spectrum disorders continues to evolve, progress in the understanding of the genetic basis of related functional disorders, such as irritable bowel syndrome and post-traumatic-stress disorder, is aiding our understanding of the genetic basis of fibromyalgia.

Emotional processing in eating disorders: specific impairment or general distress related deficiency?

The literature on eating disorders emphasizes the relationship between alexithymia and anorexia nervosa on the one hand, and between bulimia nervosa and affect dysregulation on the other. In our study, two questions are addressed: (1) Are there different patterns of emotional processing deficiencies in anorexia and bulimia? and (2) Is there a unique contribution of eating disorders to emotional processing deficiencies? Participants were women with anorexia nervosa (ANs, n=20), bulimia nervosa (BNs, n=20), and normal controls (NCs, n=20). Three hypotheses were examined: (1) Women with eating disorders will exhibit lower emotional awareness and more deficient emotional regulation than will NCs (emotional deficiency); (2) ANs will be less emotionally aware than BNs, whereas BNs will be less capable of effective emotional regulation than ANs (disorder specificity); and (3) emotional distress will mediate the relationships between emotional processing and eating disorders (emotional distress mediation). Results supported the emotional deficiency and distress mediation hypotheses, and partially supported the disorder specificity hypothesis. The need to move beyond alexithymia in understanding the pattern of emotional processing deficiencies in eating disorders is discussed.

A Pilot Study of the Efficacy of Heart Rate Variability (HRV) Biofeedback in Patients with Fibromyalgia

Fibromyalgia (FM) is a non-inflammatory rheumatologic disorder characterized by musculoskeletal pain, fatigue, depression, cognitive dysfunction and sleep disturbance. Research suggests that autonomic dysfunction may account for some of the symptomatology of FM. An open label trial of biofeedback training was conducted to manipulate suboptimal heart rate variability (HRV), a key marker of autonomic dysfunction.

METHODS

Twelve women ages 18-60 with FM completed 10 weekly sessions of HRV biofeedback. They were taught to breathe at their resonant frequency (RF) and asked to practice twice daily. At sessions 1, 10 and 3-month follow-up, physiological and questionnaire data were collected.

RESULTS

There were clinically significant decreases in depression and pain and improvement in functioning from Session 1 to a 3-month follow-up. For depression, the improvement occurred by Session 10. HRV and blood pressure variability (BPV) increased during biofeedback tasks. HRV increased from Sessions 1-10, while BPV decreased from Session 1 to the 3 month follow-up.

CONCLUSIONS

These data suggest that HRV biofeedback may be a useful treatment for FM, perhaps mediated by autonomic changes. While HRV effects were immediate, blood pressure, baroreflex, and therapeutic effects were delayed. This is consistent with data on the relationship among stress, HPA axis activity, and brain function.

The genetics of fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a common chronic widespread pain syndrome mainly affecting women. Although the etiology of FMS is not completely understood, varieties of neuroendocrine disturbances, as well as abnormalities of autonomic function, have been implicated in its pathogenesis. The exposure of a genetically predisposed individual to a host of environmental stressors is presumed to lead to the development of FMS. Fibromyalgia overlaps with several related syndromes, collectively compromising the spectrum of the functional somatic disorder. FMS is characterized by a strong familial aggregation. Recent evidence suggests a role for polymorphisms of genes in the serotoninergic, dopaminergic and catecholaminergic systems in the etiopathogenesis of FMS. These polymorphisms are not specific for FMS and are similarly associated with additional comorbid conditions. The mode of inheritance in FMS is unknown, but it is most probably polygenic. Recognition of these gene polymorphisms may help to better subgroup FMS patients and to guide a more rational pharmacological approach. Future genetic studies conducted in larger cohorts of FMS patients and matched control groups may further illuminate the role of genetics in FMS.

Genetics and diagnostic refinement

For many psychiatric conditions it is speculated that, rather than being single disease entities, they are a set of several disorders sharing clinical features but having (partly) different underlying causes. The possibility of measuring genetic variation on a large scale has given researchers new hope of identifying these disease subtypes that may differ with respect to prognosis, course, and response to treatment. However, although a considerable number of articles have been published suggesting that we may even be on the verge of making genotype-based diagnoses, the reality is that we do not have a good answer to even the most basic question of how measured genes could best be used to refine diagnostic categories. In this article, we show that for common psychiatric disorders, it may not be possible to simply look for similar genetic profiles in groups of patients. Instead, we propose a model assuming that genotypes affect phenotypes through more or less coherent etiological systems or pathogenic processes and argue that these etiological systems may provide a more fruitful basis for defining disease subtypes. Several examples from the literature that support the face validity of different aspects of our model are given. Finally, we argue that, given our limited knowledge of disease etiology, the use of discovery-oriented techniques requiring extensive data collection and (artificial) intelligent computer searches may be imperative, and discuss the prospect of model-based diagnosis to classify etiologically different disease subtypes.

Structure of internalising symptoms in early adulthood

BACKGROUND

Debate surrounds the underlying structure of internalising disorders including major depression, generalised anxiety disorder, phobias and panic disorders.

AIMS

To model the within-time and across-time relationships of internalising symptoms, incorporating effects from generalised internalising and disorder-specific components of continuity.

METHOD

Data were gathered from a 25-year longitudinal study of a birth cohort of 953 New Zealand children. Outcome measures included DSM-IV symptom scores for major depression, generalised anxiety disorder, phobia and panic disorder at the ages of 18, 21 and 25 years.

RESULTS

Structural equation modelling showed that, within-times, a common underlying measure of generalised internalising explained symptom score comorbidities. Across-time correlation of symptom scores was primarily accounted for by continuity over time in generalised internalising. However, for major depression and phobia there was also evidence of across-time continuity in the disorder-specific components of symptoms.

CONCLUSIONS

Internalising symptoms can be partitioned into components reflecting both a generalised tendency to internalising and disorder-specific components.

Migraine, fibromyalgia, and depression among people with IBS: a prevalence study

Background

Case descriptions suggest IBS patients are more likely to have other disorders, including migraine, fibromyalgia, and depression. We sought to examine the prevalence of these conditions in cohorts of people with and without IBS.

Methods

The source of data was a large U.S. health plan from January 1, 1996 though June 30, 2002. We identified all people with a medical claim associated with an ICD-9 code for IBS. A non-IBS cohort was a random sample of people with an ICD-9 code for routine medical care. In the cohorts, we identified all claims for migraine, depression, and fibromyalgia. We estimated the prevalence odds ratios (PORs) of each of the three conditions using the Mantel-Haenszel method. We conducted quantitative sensitivity analyses to quantify the impact of residual confounding and in differential outcome identification.

Results

We identified 97,593 people in the IBS cohort, and a random sample of 27,402 people to compose the non-IBS comparison cohort. With adjustment, there was a 60% higher odds in the IBS cohort of having any one of the three disorders relative to the comparison cohort (POR 1.6, 95% CI 1.5 – 1.7). There was a 40% higher odds of depression in the IBS cohort (POR 1.4, 95% CI 1.3 – 1.4). The PORs for fibromyalgia and migraine were similar (POR for fibromyalgia 1.8, 95% CI 1.7 – 1.9; POR for migraine 1.6, 95% CI 1.4 – 1.7). Differential prevalence of an unmeasured confounder, or imperfect sensitivity or specificity of outcome detection would have impacted the observed results.

Conclusion

People in the IBS cohort had a 40% to 80% higher prevalence odds of migraine, fibromyalgia, and depression.

Somatic symptoms in depression

Both painful and nonpainful somatic symptoms essentially characterize clinical states of depressive mood. So far, this well-established psychopathological knowledge has been appreciated only insufficiently by the official diagnostic sys-terms of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IVTR) and the ICD-10 Classification of Mental and Behavioral Disorders. Clinical Descriptions and Diagnostic Guidelines (ICD-10). From a perspective of primary care services, this unmet diagnostic need is deplorable, as the main mode of presenting a depression is by reporting somatic symptoms. This somatic form of presentation, however, significantly contributes to low rates of recognition in primary care. A diagnostic challenge may be seen in the differentiation of a depression with prevailing somatic symptoms from anxiety, somatoform disorders, and medical conditions. When somatic symptoms, particularly painful physical conditions, accompany the already debilitating psychiatric and behavioral symptoms of depression, the course of the illness may be more severe, implying a higher risk of early relapse, chronicity suicide, or mortality due to other natural causes, the economic burden increases considerably, the functional status may be hampered heavily, and health-related quality of life may be lowered dramatically. The neurobiological underpinnings of somatic symptoms in depression may guide more promising treatment approaches.

Gastrointestinal complaints in patients with eating disorders

BACKGROUND

Patients with eating disorders (EDs) typically have numerous somatic and gastrointestinal complaints. Early referral to treatment may result in improved outcomes. We sought to determine whether patients with EDs were presenting to gastroenterologists or primary care physicians with gastrointestinal complaints early in the disease course, when referral for specialized, comprehensive treatment would be most beneficial.

STUDY

Over a 1-year period, we administered a structured interview to a cohort of patients presenting for inpatient ED treatment. We also conducted the same interview on an age-matched cohort of medical students to determine baseline incidences of various gastrointestinal healthcare behaviors.

RESULTS

Patients with bulimia nervosa were significantly more likely to seek healthcare for a gastrointestinal complaint before seeking treatment for an ED than were controls. Patients with EDs were significantly more likely to be prescribed medication for the gastrointestinal tract than were controls.

CONCLUSION

Gastroenterologists and primary care physicians should employ available instruments to screen young women of low to normal weight with gastrointestinal complaints for possible EDs. Referral to specialized treatment programs should be made promptly when an ED is identified.

Human brain evolution and the "Neuroevolutionary Time-depth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder

The DSM-III, DSM-IV, DSM-IV-TR and ICD-10 have judiciously minimized discussion of etiologies to distance clinical psychiatry from Freudian psychoanalysis. With this goal mostly achieved, discussion of etiological factors should be reintroduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). A research agenda for the DSM-V advocated the "development of a pathophysiologically based classification system". The author critically reviews the neuroevolutionary literature on stress-induced and fear circuitry disorders and related amygdala-driven, species-atypical fear behaviors of clinical severity in adult humans. Over 30 empirically testable/falsifiable predictions are presented. It is noted that in DSM-IV-TR and ICD-10, the classification of stress and fear circuitry disorders is neither mode-of-acquisition-based nor brain-evolution-based. For example, snake phobia (innate) and dog phobia (overconsolidational) are clustered together. Similarly, research on blood-injection-injury-type-specific phobia clusters two fears different in their innateness: 1) an arguably ontogenetic memory-trace-overconsolidation-based fear (hospital phobia) and 2) a hardwired (innate) fear of the sight of one's blood or a sharp object penetrating one's skin. Genetic architecture-charting of fear-circuitry-related traits has been challenging. Various, non-phenotype-based architectures can serve as targets for research. In this article, the author will propose one such alternative genetic architecture. This article was inspired by the following: A) Nesse's "Smoke-Detector Principle", B) the increasing suspicion that the "smooth" rather than "lumpy" distribution of complex psychiatric phenotypes (including fear-circuitry disorders) may in some cases be accounted for by oligogenic (and not necessarily polygenic) transmission, and C) insights from the initial sequence of the chimpanzee genome and comparison with the human genome by the Chimpanzee Sequencing and Analysis Consortium published in late 2005. Neuroevolutionary insights relevant to fear circuitry symptoms that primarily emerge overconsolidationally (especially Combat related Posttraumatic Stress Disorder) are presented. Also introduced is a human-evolution-based principle for clustering innate fear traits. The "Neuroevolutionary Time-depth Principle" of innate fears proposed in this article may be useful in the development of a neuroevolution-based taxonomic re-clustering of stress-triggered and fear-circuitry disorders in DSM-V. Four broad clusters of evolved fear circuits are proposed based on their time-depths: 1) Mesozoic (mammalian-wide) circuits hardwired by wild-type alleles driven to fixation by Mesozoic selective sweeps; 2) Cenozoic (simian-wide) circuits relevant to many specific phobias; 3) mid Paleolithic and upper Paleolithic (Homo sapiens-specific) circuits (arguably resulting mostly from mate-choice-driven stabilizing selection); 4) Neolithic circuits (arguably mostly related to stabilizing selection driven by gene-culture co-evolution). More importantly, the author presents evolutionary perspectives on warzone-related PTSD, Combat-Stress Reaction, Combat-related Stress, Operational-Stress, and other deployment-stress-induced symptoms. The Neuroevolutionary Time-depth Principle presented in this article may help explain the dissimilar stress-resilience levels following different types of acute threat to survival of oneself or one's progency (aka DSM-III and DSM-V PTSD Criterion-A events). PTSD rates following exposure to lethal inter-group violence (combat, warzone exposure or intentionally caused disasters such as terrorism) are usually 5-10 times higher than rates following large-scale natural disasters such as forest fires, floods, hurricanes, volcanic eruptions, and earthquakes. The author predicts that both intentionally-caused large-scale bioevent-disasters, as well as natural bioevents such as SARS and avian flu pandemics will be an exception and are likely to be followed by PTSD rates approaching those that follow warzone exposure. During bioevents, Amygdala-driven and locus-coeruleus-driven epidemic pseudosomatic symptoms may be an order of magnitude more common than infection-caused cytokine-driven symptoms. Implications for the red cross and FEMA are discussed. It is also argued that hospital phobia as well as dog phobia, bird phobia and bat phobia require re-taxonomization in DSM-V in a new "overconsolidational disorders" category anchored around PTSD. The overconsolidational spectrum category may be conceptualized as straddling the fear circuitry spectrum disorders and the affective spectrum disorders categories, and may be a category for which Pitman's secondary prevention propranolol regimen may be specifically indicated as a "morning after pill" intervention. Predictions are presented regarding obsessive-compulsive disorder (OCD) (e.g., female-pattern hoarding vs. male-pattern hoarding) and "culture-bound" acute anxiety symptoms (taijin-kyofusho, koro, shuk yang, shook yong, suo yang, rok-joo, jinjinia-bemar, karoshi, gwarosa, Voodoo death). Also discussed are insights relevant to pseudoneurological symptoms and to the forthcoming Dissociative-Conversive disorders category in DSM-V, including what the author terms fright-triggered acute pseudo-localized symptoms (i.e., pseudoparalysis, pseudocerebellar imbalance, psychogenic blindness, pseudoseizures, and epidemic sociogenic illness). Speculations based on studies of the human abnormal-spindle-like, microcephaly-associated (ASPM) gene, the microcephaly primary autosomal recessive (MCPH) gene, and the forkhead box p2 (FOXP2) gene are made and incorporated into what is termed "The pre-FOXP2 Hypothesis of Blood-Injection-Injury Phobia." Finally, the author argues for a non-reductionistic fusion of "distal (evolutionary) neurobiology" with clinical "proximal neurobiology," utilizing neurological heuristics. It is noted that the value of re-clustering fear traits based on behavioral ethology, human-phylogenomics-derived endophenotypes and on ontogenomics (gene-environment interactions) can be confirmed or disconfirmed using epidemiological or twin studies and psychiatric genomics.

Affective disorder in the parents of a clinic sample of children with anxiety disorders

BACKGROUND

Family history studies in adults reveal strong familiality for the anxiety disorders with some specificity. The aim of the current study was to establish whether there was an elevated rate of anxiety disorders in the parents of children with anxiety disorders, and whether there was intergenerational specificity in the form of disorder.

METHODS

The mental state of a clinic sample of 85 children with anxiety disorder and their parents was systematically assessed, together with a comparison sample of 45 children with no current disorder and their parents.

RESULTS

Compared to the rate of anxiety disorder amongst parents of comparison children, the rate of current anxiety disorder in mothers of anxious children was significantly raised, as was the lifetime rate of anxiety disorder for both mothers and fathers. The mothers of children with generalised anxiety disorder, social phobia, specific phobia and separation anxiety disorder all had raised lifetime rates of the corresponding disorder, but also raised rates of others disorders.

LIMITATIONS

Only 60% of the fathers of the anxious children were assessed.

CONCLUSIONS

Strong familiality of anxiety disorders was confirmed, especially between child and maternal anxiety disorder. All child anxiety disorders were associated with several forms of anxiety disorder in the mother. Some specificity in the form of anxiety disorder in the child and the mother was apparent for social phobia and separation anxiety disorder. The findings have implications for the management of child anxiety.

Relationship between serotonin transporter gene polymorphism and irritable bowel syndrome

AIM: To investigate the relationship between serotonin transporter gene polymorphism and irritable bowel syndrome (IBS).

METHODS: Polymerase chain reaction (PCR) was used to comparatively analyze the polymorphisms of serotonin transporter gene 5-HTTLPR and VNTRs within intron 2 in patients with diarrhea-predominant IBS (D-IBS, n = 51), constipation-predominant IBS (C-IBS, n = 58), and alternating diarrhea and constipation IBC (A-IBS, n = 38) and healthy controls (n = 48).

RESULTS: The frequencies of L/L genotype and L allele in C-IBS patients were significantly higher than those in the controls (31.0% vs 8.3%, χ² = 8.229, P < 0.05; 47.4% vs 29.2%, χ² = 7.342, P < 0.05). The frequencies of S/S genotype and S allele in D-IBS patients were significantly higher than those in C-IBS and A-IBS patients (S/S: 56.9% vs 36.2%, 36.8%, P < 0.05; S: 71.6% vs 52.6%, 56.6%, P < 0.05), but the frequency of L/L genotype was markedly lower (9.8% vs 31.0%, 23.7%, P < 0.05). However, no significant difference was found in VNTRs polymorphism between the subgroups of IBS and controls (P > 0.05).

CONCLUSION: The presence of L/L genotype and L allele probably increases the susceptibility of individuals to C-IBS, while S/S genotype and S allele probably increases that to D-IBS. L/L genotype may be a protective factor against D-IBS.

The Incidence of Fibromyalgia and Its Associated Comorbidities

BACKGROUND

The epidemiology of fibromyalgia is poorly defined. The incidence of fibromyalgia has not been determined using a large population base. Previous studies based on prevalence data demonstrated that females are 7 times more likely to have fibromyalgia than males and that the peak age for females is during the childbearing years.

OBJECTIVE

We have calculated the incidence rate of fibromyalgia in a large, stable population and determined the strength of association between fibromyalgia and 7 comorbid conditions.

METHODS

We conducted a retrospective cohort study of a large, stable health insurance claims database (62,000 nationwide enrollees per year). Claims from 1997 to 2002 were examined using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify fibromyalgia cases (ICD code 729.1) and 7 predetermined comorbid conditions.

RESULTS

A total of 2595 incident cases of fibromyalgia were identified between 1997 and 2002. Age-adjusted incidence rates were 6.88 cases per 1000 person-years for males and 11.28 cases per 1000 person-years for females. Females were 1.64 times (95% confidence interval = 1.59-1.69) more likely than males to have fibromyalgia. Patients with fibromyalgia were 2.14 to 7.05 times more likely to have one or more of the following comorbid conditions: depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, and rheumatoid arthritis.

CONCLUSION

Females are more likely to be diagnosed with fibromyalgia than males, although to a substantially smaller degree than previously reported, and there are strong associations for comorbid conditions that are commonly thought to be associated with fibromyalgia.

Where do eating disorders lie on the diagnostic spectrum and what does it mean?

The aim of this paper is to review the concept of comorbidity as it pertains to eating disorders. The historical framing of eating disorders within medicine and psychiatry is described and then we move to what is understood by comorbidity in the current context of diagnostic compendiums. The issue of comorbidity highlights the unsatisfactory nature of the current description of illness phenotypes. There is a move to look for broader and more specific concepts such as that of endophenotypes, for example, in relationship to neuropsychology, and the response to reward and emotion. Finally, we consider how this approach may map onto treatment. For example, it may be necessary to have specific modules tailored to the relevant moderating and mediating factors.

Genetics of fibromyalgia

The pathogenesis of fibromyalgia (FM) and related conditions is not entirely understood. Recent evidence suggests that these syndromes may share heritable pathophysiologic features. Familial studies suggest that genetic and familial factors may play a role in the etiopathogenesis of these conditions. There is evidence that polymorphisms of genes in the serotoninergic and catecholaminergic systems are linked to the pathophysiology of FM and related conditions and are associated with personality traits. The precise role of genetic factors in the etiopathology of FM remains unknown, but it is likely that several genes are operating together to initiate this syndrome. Larger longitudinal studies are needed to better clarify the role of genetics in the development of FM.

Increased prevalence of functional gastrointestinal disorders in panic disorder: clinical and theoretical implications

BACKGROUND

Functional gastrointestinal disorders (FGID) are a group of disorders characterized by recurrent gastrointestinal distress for which no structural or biochemical cause can be discerned. Irritable bowel syndrome (IBS) is an FGID estimated to affect 10% to 25% of the United States population. IBS occurs in over 40% of individuals with panic disorder, and in patients with IBS, 25% to 30% have panic disorder, which has led to speculation about possible shared pathophysiology between the two. Less is known about the prevalence of other FGID in individuals with panic disorder.

OBJECTIVE

The purpose of this study was to examine the prevalence of IBS and all the other FGID in patients with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) panic disorder.

INTRODUCTION

We assessed FGIDs in 73 treatment-seeking DSM-IV panic disorder patients via the Diagnostic Interview Questions for Functional Gastrointestinal Disorders and made descriptive comparisons with a large convenience sample from an already-completed United States Household Survey (USHS), which employed the same diagnostic criteria.

RESULTS

The prevalence of IBS and other FGIDs in both men and women with panic disorder were substantially higher than in the USHS respondents. Women with panic disorder had significantly more functional chest pain than men, but there was no gender difference in IBS. With the exception of functional anorectal and biliary disorders, the FGID prevalences were comparatively higher in panic disorder versus the USHS respondents.

DISCUSSION

This survey supports earlier reports of a high prevalence of IBS in individuals with panic disorder and also suggests that the prevalence of several other FGIDs were comparatively high as well. Methodological limitations precluded direct statistical analysis. It may be that commonly overlapping psychiatric and often-painful FGIDs, and extra-intestinal disorders increase the risk for comorbidity in already-affected individuals via shared pathophysiology. One potential model for which there is some evidence for a role in stress, panic disorder, FGIDs and several extra-intestinal functional conditions is dysregulation of corticotropin-releasing factor function.

CONCLUSION

The prevalence of FGIDs in DSM-IV panic disorder was comparatively higher than in USHS respondent community sample, which used similar FGID diagnostic criteria. The cause for the apparent close association of panic disorder with FGID may represent shared pathophysiology. Increased understanding of the mechanism of the overlap may allow for improved treatment of the significant proportion of the population suffering from comorbid psychiatric and functional medical conditions.

Childhood body-focused behaviors and social behaviors as risk factors of eating disorders

BACKGROUND

The risk factors for adolescent eating disorders are poorly understood. It is generally agreed, however, that interactions with one's body and interactions with others are two important features in the development of anorexia and bulimia nervosa. Therefore, we assessed a variety of childhood body-focused behaviors and childhood social behaviors in eating-disordered patients as compared to non-eating-disordered subjects.

METHOD

We compared 50 female inpatients with eating disorders (anorexia or bulimia nervosa), 50 female inpatients with polysubstance dependence, and 50 nonpatient female control subjects with no history of eating or substance abuse disorders (all defined by DSM-IV criteria), using a semi-structured interview of our own design. We asked questions about (1) childhood body-focused behaviors (e.g. thumb-sucking) and body-focused family experiences (e.g. bodily caresses), and (2) childhood social behaviors (e.g. numbers of close friends) and family social styles (e.g. authoritarian upbringing).

RESULTS

Many body-focused measures, such as feeding problems, auto-aggressive behavior, lack of maternal caresses, and family taboos regarding nudity and sexuality, characterized eating-disordered patients as opposed to both comparison groups, as did several social behaviors, such as adjustment problems at school and lack of close friends. However, nail-biting, insecure parental bonding, and childhood physical and sexual abuse were equally elevated in both psychiatric groups.

CONCLUSION

It appears that eating-disordered patients, as compared to substance-dependent patients and healthy controls, show a distinct pattern of body-focused and social behaviors during childhood, characterized by self-harm, a rigid and 'body-denying' family climate, and lack of intimacy.

Repeated sound stress enhances inflammatory pain in the rat

While it is well established that acute stress can produce antinociception, a phenomenon referred to as stress-induced analgesia, repeated exposure to stress can have the opposite effect. Since, chronic pain syndromes, such as fibromyalgia and rheumatoid arthritis, may be triggered and/or exacerbated by chronic stress, we have evaluated the effect of repeated stress on mechanical nociceptive threshold and inflammatory hyperalgesia. Using the Randall-Selitto paw pressure test to quantify nociceptive threshold in the rat, we found that repeated non-habituating sound stress enhanced the mechanical hyperalgesia induced by the potent inflammatory mediator, bradykinin, which, in normal rats, produces hyperalgesia indirectly by stimulating the release of prostaglandin E2 from sympathetic nerve terminals. Hyperalgesia induced by the direct-acting inflammatory mediator, prostaglandin E2 as well as the baseline nociceptive threshold, were not affected. Adrenal medullectomy or denervation, reversed the effect of sound stress. In sound stressed animals, bradykinin-hyperalgesia had a more rapid latency to onset and was no longer inhibited by sympathectomy, compatible with a direct effect of bradykinin on primary afferent nociceptors. In addition, implants of epinephrine restored bradykinin-hyperalgesia in sympathectomized non-stressed rats, lending further support to the suggestion that increased plasma levels of epinephrine can sensitize primary afferents to bradykinin. These results suggest that stress-induced enhancement of inflammatory hyperalgesia is associated with a change in mechanism by which bradykinin induces hyperalgesia, from being sympathetically mediated to being sympathetically independent. This sympathetic-independent enhancement of mechanical hyperalgesia is mediated by the stress-induced release of epinephrine from the adrenal medulla.

Maternal inheritance in cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS), characterized by severe discrete episodes of nausea, vomiting, and lethargy, is a fairly common, disabling, predominately-childhood condition most often associated with migraine and dysautonomic features. Our group recently reported that children with CVS and additional neuromuscular disease manifestations demonstrate strong maternal inheritance of multiple disease manifestations and abnormal urine organic acids, suggesting the presence of predisposing mitochondrial DNA (mtDNA) sequence variants. In order to determine if maternal inheritance is present in CVS in general, a clinical interview was administered regarding 80 unrelated individuals with CVS ascertained randomly from the database of the Cyclic Vomiting Syndrome Association (CVSA). Disease manifestations consistent with potential mitochondrial dysfunction were far more common in matrilineal (sharing the same mtDNA sequence) versus in non-matrilineal relatives, including mothers versus fathers (P = 3 x 10(-9)) and maternal versus paternal grandmothers (P = 2 x 10(-6)). Maternal inheritance is suggested in 52% of the 23 subjects with two or more neuromuscular abnormalities ("CVS+") and in 54% of the 44 subjects without any neuromuscular abnormalities ("CVS-"). In both the CVS+ and CVS- sub-groups, subjects, and affected matrilineal relatives of all ages suffer at a far higher incidence from several dysautonomic-related conditions, including migraine and irritable bowel, as well as depression and hypothyroidism, while neuromuscular and cognitive disorders such as hypotonia and ADHD are common only in affected children. We conclude that mtDNA sequences predispose towards the development of protean disease manifestations in CVS patients ascertained through a disease-specific association, as well as among their matrilineal relatives, whether or not neuromuscular disease is present in the proband. Since CVS was absent in all but one matrilineal relative of our probands, CVS is apparently a rare clinical presentation in individuals carrying the predisposing mtDNA sequences. The four conditions reported most frequently among the matrilineal relatives of our cases, migraine, depression, irritable bowel, and hypothyroidism, are known to segregate together in families, and our findings suggest that a common predisposing genetic factor is likely present on the mtDNA.

Bulimia Nervosa and Attention Deficit Hyperactivity Disorder: A Possible Role for Stimulant Medication

BACKGROUND

Bulimia nervosa and attention deficit hyperactivity disorder (ADHD) share several key features, including impulsivity and low self-esteem. Stimulant medications have been highly effective in the treatment of ADHD. However, medication management of bulimia with antidepressants has demonstrated only partial resolution of bulimic symptoms. To date, there are no published reports of controlled trials evaluating the efficacy of stimulants for bulimia. The purpose of this paper is to report 6 patients with comorbid bulimia and ADHD who were treated with the stimulant medication, dextroamphetamine.

RESULTS

All 6 patients described reported complete abstinence from binge eating and purging after treatment with psychostimulants, and none of the patients discontinued taking the medication because of side effects. The side effect of decreased appetite proved beneficial in decreasing the desire to binge eat. However, all 6 patients remained within a healthy weight range.

CONCLUSIONS

Data from these case reports suggest a possible benefit of screening for ADHD as part of the overall evaluation of bulimia. In addition, these cases suggest the potential role of psychostimulants in the management of bulimia because of the high rate of abstinence from bulimic symptoms and the low rate of adverse side effects. Clinical trials are needed to fully evaluate the efficacy and tolerability of psychostimulants in the treatment of bulimia nervosa.

Genetic factors in neuromuscular pain

Recent evidence suggests that fibromyalgia, a chronic widespread pain condition and related syndromes (chronic fatigue syndrome, irritable bowel syndrome, etc.) may share heritable pathophysiologic features. We review the recent literature on genetic and familial factors found to participate in the pathogenesis of these syndromes, specifically fibromyalgia, including evidence suggesting that serotonin- and dopamine-related genes may play a role in the pathogenesis of these illnesses. The importance of environmental factors triggering these conditions in predisposed individuals is also discussed.

Family study of fibromyalgia and affective spectrum disorder

BACKGROUND

Fibromyalgia is one member of a proposed group of psychiatric and medical disorders, collectively termed affective spectrum disorder (ASD), hypothesized to share possibly heritable pathophysiologic features. Two predictions of the ASD hypothesis were tested: ASD, taken as a single entity, aggregates in families; and fibromyalgia coaggregates with other forms of ASD in families.

METHODS

Probands with and without fibromyalgia, together with their first-degree relatives, were administered structured diagnostic interviews. Noninterviewed relatives were diagnosed according to information provided by interviewed relatives. Aggregation and coaggregation of disorders were analyzed with proband predictive logistic and linear regression models.

RESULTS

In 533 relatives of 78 probands with fibromyalgia and 272 relatives of 40 probands without fibromyalgia, the estimated odds ratio (OR) (95% confidence interval) for the familial aggregation of ASD was 1.8 (.97, 3.2), p = .065, and the increase in number of forms of ASD in a relative for each additional form of ASD in a proband was .076 (.027, .1240), p = .002. The OR for the coaggregation of fibromyalgia with other forms of ASD was 2.0 (1.2, 3.2), p = .004; this remained significant even after excluding all mood-disorder diagnoses: 1.8 (1.1, 3.0), p = .012.

CONCLUSIONS

These findings support familial aggregation of ASD collectively and familial coaggregation of fibromyalgia with other forms of ASD.

Understanding pain in depression

A dysfunction of the serotonergic and noradrenergic pathways is commonly accepted as playing a major role in the aetiology of depression. Serotonergic cell bodies, located in the raphe nucleus, send projections to various parts of the brain where they are involved in the control of mood, movement, emotions such as anxiety and regulate behaviours such as eating, sexual activity and the feeling of pleasure. Similarly, the noradrenergic neurons, located in the locus coeruleus, project to the same regions where they regulate, in addition, attention and cognition. A further projection to the cerebellum regulates motor control. A dysfunction at the level of the monoamine neurons thus results in the classical symptoms of depression. In addition to these ascending pathways, however, the neurons in the raphe nucleus and the locus ceruleus also project to the spinal cord. These descending pathways serve to inhibit input from the intestines, the skeletal muscles and other sensory inputs. Under normal conditions, these inhibitory effects are modest, but in times of stress, in the interests of the survival of the individual, they can completely inhibit the input from painful stimuli. A dysfunction at the level of the serotonergic and noradrenergic neurons can thus affect both the ascending and descending pathways resulting in the psychological and somatic symptoms of depression but also in physical painful symptoms.

Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together

Fibromyalgia (FM) is a controversial syndrome, characterised by persistent widespread pain, abnormal pain sensitivity and additional symptoms such as fatigue and sleep disturbance. The syndrome largely overlaps with other functional somatic disorders, particularly chronic fatigue syndrome (CFS). Although the exact aetiology and pathogenesis of FM are still unknown, it has been suggested that stress may play a key role in the syndrome. This article first reviews the function of the stress response system, placing special emphasis on the relationships between adverse life experiences, stress regulation and pain-processing mechanisms, and summarising the evidence for a possible aetiopathogenetic role of stress in FM. Finally, an integrative biopsychosocial model that conceptualizes FM as a stress disorder is proposed, and the clinical and research implications of the model are discussed.

Genetics of anxiety disorders

There is considerable evidence that genetic determinants play a major role in the etiology of anxiety. Investigations into susceptibility genes for anxiety are well underway, particularly for panic disorder and obsessive-compulsive disorder and more broadly defined anxiety-related traits, such as neuroticism and harm avoidance. This review will discuss some of the core issues related to diagnosis and molecular genetic methodology, followed by a review of recent molecular genetic findings for anxiety. The authors will attempt to highlight the numerous convergent and exciting findings. Given the rapid acceleration in knowledge of the human genome, a more definitive understanding of the genetic roots of these complex conditions may be anticipated in the relatively near future.

Pharmaceutical treatment options for fibromyalgia

Fibromyalgia syndrome (FMS) is a chronic multisymptom illness characterized by widespread pain and associated with neuropsychological symptoms including fatigue, unrefreshing sleep, cognitive dysfunction, anxiety, and depression. A discreet cause of FMS has not been identified. It is likely that multiple mechanisms give rise to symptom expression. Understanding specific etiologic factors and pathogenic mechanisms in individual patients will allow clinicians to determine treatments that are most effective for a given patient. Available evidence implicates the central nervous system as key in maintaining pain and other core symptoms of FMS. The approach to treatment of pain will typically address these central mechanisms. Nonpain symptoms may be treated by drugs affecting similar central neurochemicals. This paper will review the rationale for the different types of pharmaceutical treatments that may be useful for the treatment of FMS and issues regarding new drug development for this indication.

Generalized anxiety disorder and major depressive disorder comorbidity: an example of genetic pleiotropy?

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) are the most common type of anxiety-mood comorbidity. Up to 80% of subjects with lifetime GAD also have a comorbid mood disorder during their lifetime. Many hypotheses have been raised to explain such high comorbidity. Pleiotropy, i.e. a single genetic mutation explains (apparently) different disorders, is one of them and is hereby reviewed. Importance and reliability of GAD and MDD comorbidity (1); Evidence in favour of co-aggregation of GAD and MDD within families (the risk of one disorder in a proband increasing the risk for the other in relatives) (2); substantial heredity for both disorders according to twin studies with evidence for genetic correlation of unity between the two disorders (3); existence of numerous mechanisms (4) potentially linking the two disorders to common vulnerability genes, are all in accordance with such a hypothesis. Some examples of potentially shared mechanisms (such as CRF dysregulation or abnormal transcription factors) and possible common vulnerability genes (for example, the serotonin transporter gene) are given to highlight the pleiotropy hypothesis.