Denosologization of biological psychiatry or the specificity of 5-HT disturbances in psychiatric disorders

Tryptophan depletion alters the decision-making of healthy volunteers through altered processing of reward cues

While accumulating evidence suggests that effective real-life decision-making depends upon the functioning of the orbitofrontal cortex, much less is known about the involvement of the monoamine neurotransmitter systems and, in particular, serotonin. In the present study, we explored the impact of depleting the serotonin precursor, tryptophan, on human decision-making. Eighteen healthy volunteers consumed an amino-acid drink containing tryptophan and 18 healthy volunteers consumed an amino-acid drink without tryptophan, before choosing between simultaneously presented gambles, differing in the magnitude of expected gains (ie reward), the magnitude of expected losses (ie punishment), and the probabilities with which these outcomes were delivered. Volunteers also chose between gambles probing identified non-nomative biases in human decision-making, namely, risk-aversion when choosing between gains and risk-seeking when choosing between losses. Tryptophan-depleted volunteers showed reduced discrimination between magnitudes of expected gains associated with different choices. There was little evidence that tryptophan depletion was associated with altered discrimination between the magnitudes of expected losses, or altered discrimination between the relative probabilities with which these positive or negative outcomes were delivered. Risk-averse and risk-seeking biases were also unchanged. These results suggest that serotonin mediates decision-making in healthy volunteers by modulating the processing of reward cues, perhaps represented within the orbitofrontal cortex. It is possible that such a change in the cognition mediating human choice is one mechanism associated with the onset and maintenance of anhedonia and lowered mood in psychiatric illness.

Neuroendocrine response to meta-chlorophenylpiperazine and ipsapirone in relation to anxiety and aggression

The aim of this study was to establish the association of trait anxiety and anger with hormonal responses to acute challenges with two different 5-HT agonists in a mixed group of patients with depressed mood. Fifteen patients and 16 normal controls received single oral doses of 0.5 mg/kg meta-chlorophenylpiperazine (MCPP), a 5-HT(2C) agonist, and 10 mg of ipsapirone, a 5-HT(1A) agonist, according to a double-blind, placebo-controlled, cross-over design. Dutch-adapted versions of the Spielberger Trait-Anxiety Inventory and the Spielberger Trait-Anger Scale administered assessed at study entry. Hormonal responses, expressed as drug-placebo differences, to MCPP and ipsapirone (changes in cortisol, ACTH and prolactin) were measured. Blood levels of MCPP and ipsapirone were also measured. MCPP and ipsapirone elevated cortisol, ACTH and prolactin. In the patient group, there was a significant correlation between trait anxiety and the cortisol response to MCPP. No significant correlations between the ACTH and prolactin responses to MCPP and levels of anxiety/anger were observed in the patients. No significant correlations could be established between levels of anxiety/anger and hormonal responses to ipsapirone. This study provided evidence for an association between measures of anxiety/aggression and the hormonal response to MCPP. Thus, in subjects with depressed mood, high levels of anxiety suggest a higher probability of 5-HT(2C) disturbances.

A dimensional impulsive-aggressive phenotype is associated with the A218C polymorphism of the tryptophan hydroxylase gene: a pilot study in well-characterized impulsive inpatients

Tryptophan hydroxylase (TPH) is the rate-limiting enzyme in the biosynthesis of serotonin, and association and linkage studies of its variants in suicidal and impulsive-aggressive behavior have brought conflicting results. This pilot study was designed to investigate whether TPH A218C genotypes could be associated with impulsive behavioral tendencies (IBTs) in consecutively admitted nonpsychotic nonorganic inpatients. Patients (20 females and 34 males; age, 38.8 +/- 11.8) did not differ from healthy nonimpulsive controls (16 females and 11 males; age, 35.2 +/- 10.2) regarding TPH genotypes, but in the patients, the number of IBT was related to the presence of the 218C allele. It was concluded that impulsive-aggressive behavior may be associated with the TPH genotype in well-characterized impulsive patients and that the present results stress the importance of considering impulsiveness-aggressiveness in studies investigating the relationship between suicidal behavior and TPH genotypes.

Citalopram treatment for impulsive aggression in children and adolescents: an open pilot study

OBJECTIVE

To assess the short-term effect and safety of citalopram in the reduction of impulsive aggression in children and adolescents.

METHOD

Twelve subjects, aged 7 to 15 years, were attending a psychiatric outpatient clinic and had a profile of impulsive aggression. Subjects were treated in an open trial with citalopram for 6 weeks after a 1-week washout period. Dosage was regulated individually over a period of 4 weeks. The starting dose was 10 mg/day followed by 10 mg increments on a weekly basis. The maximum dose was not to exceed 40 mg/day. Outcome measures included the Modified Overt Aggression Scale (MOAS), the Child Behavioral Checklist (CBCL), and the Clinical Global Impressions (CGI).

RESULTS

Eleven subjects completed the study Citalopram produced clinically and statistically significant reductions on target symptoms of impulsive aggression, independent of other behavioral problems, as measured by the MOAS, the CBCL, and the CGI at doses ranging from 20 to 40 mg/day (mean = 27 mg). No major adverse reactions were associated with citalopram use.

CONCLUSION

Citalopram appears to be effective and well tolerated in this sample of children and adolescents with impulsive aggression.

Are closed-minded people more open to the idea of killing themselves?

This article summarizes the author's work on Openness to Experience (a personality trait) and suicidal behavior. It appears that people who obtain low scores on an inventory measuring Openness to Experience are less likely to report suicidal ideation but more likely to take their own lives. How can this apparent discrepancy be reconciled? Based on the premise that the expression of suicidal ideation can have adaptive consequences (e.g., by mobilizing family and treatment providers), it is hypothesized that people with major depression who are low in Openness may be at increased risk for completed suicide in part because they are less likely to feel, or report feeling, suicidal.

Clinical and neurochemical effect of acute tryptophan depletion in unaffected relatives of patients with bipolar affective disorder

BACKGROUND

The lowering of mood induced by an acute tryptophan depletion (ATD) has been proposed as a candidate endophenotype for the vulnerability to manic-depressive illness. This study tests this hypothesis in relatives of probands from well-characterized multiplex families affected with bipolar affective disorder (BAD).

METHODS

In a double-blind, crossover design, 20 unaffected relatives (URs) and 19 control subjects received either a 100-g amino acid (AA) drink devoid of tryptophan or a placebo, respectively. Clinical and biochemical effects of ATD were compared between unaffected relatives of BAD probands and age- and sex-matched control subjects.

RESULTS

At 5 hours after AA drink ingestion, relative to the placebo, ATD resulted in 74% and 84% decreases in total plasma tryptophan concentrations in control subjects and relatives of patients with BAD, respectively. Unlike control subjects unaffected relatives experienced a lowering of mood during ATD but not with the placebo. Furthermore, URs tended to show increased impulsivity in the ATD condition. Measurements obtained before ingestion of the AA drink indicated that, relative to control subjects URs exhibited lower serotonin platelet concentrations, lower affinity, and fewer binding sites of the serotonin transporter for imipramine; these differences were unaffected by ATD.

CONCLUSION

These results replicate and extend previous findings suggesting that URs of patients with BAD are more susceptible to low tryptophan availability. This finding may bear significance in the purported role of serotonergic mechanisms in the vulnerability to depressive syndrome and/or illness.

Anxiety/aggression--driven depression. A paradigm of functionalization and verticalization of psychiatric diagnosis

A new subtype of depression is proposed, named: anxiety/aggression-driven depression. The psychopathological, psychopharmacological and biochemical evidence on which this construct is based, is being discussed. Selective postsynaptic 5-HT1A agonists together with CRH and/or cortisol antagonists are hypothesized to be a specific biological treatment for this depression type, in conjunction with psychological interventions to raise the stressor-threshold and to increase coping skills. The development of this depression construct has been contingent on the introduction of two new diagnostic procedures, called functionalization and verticalization of psychiatric diagnosis. These procedures are explained and it is stressed that they are essential to psychiatric diagnosing, in order to put this process on a scientific footing.

Past expectations, present disappointments, future hopes or psychopathology as the rate-limiting step of progress in psychopharmacology

In 1974 I published a paper in which we predicted that biological depression research would lead to new, innovative antidepressants, to more sophisticated prescription of antidepressants and ultimately to 'functional psychopharmacology'. These expectations have not materialized. The reasons why are discussed and the conclusion is reached that there are reasons to believe that, belated, they will come true. I consider it no bold venture to uphold them. Copyright 2001 John Wiley & sons, Ltd.

Inflationary tendencies in judging the yield of depression research

The mood around mood disorders is one of optimism. Progress in diagnosis and treatment is generally felt to be considerable. Zeitgeist rests on convictions. In this case the main supporting convictions are the following: depression is a very frequent disorder and its diagnosis has improved greatly; we dispose of more or less specific agents to control depression: biological psychiatric research made great strides, particularly in the field of affective disorders; new antidepressants are properly tested before being clinically introduced. Each of these convictions is critically analysed. It is concluded that each of these claims is either a half-truth or not true. Apparently reality awareness and reality testing are out of balance. This harms the prospects of research, particularly biological research. Ways to avoid the stalemate are discussed.

Low cholesterol and violent crime

BACKGROUND

Community cohort studies and meta-analyses of randomized trials have shown a relation between low or lowered cholesterol and death by violence (homicide, suicide, accident); in primates, cholesterol reduction has been linked to increased behavioral acts of aggression (Kaplan J, Manuck S. The effects of fat and cholesterol on aggressive behaviour in monkeys. Psychosom. Med 1990;52:226-7; Kaplan J, Shively C, Fontenot D, Morgan T, Howell S, Manuck S et al. Demonstration of an association among dietary cholesterol, central serotonergic activity, and social behaviour in monkeys. Psychosom. Med 1994;56:479-84.). In this study we test for the first time whether cholesterol level is related to commission of violent crimes against others in a large community cohort.

METHODS

We merged one-time cholesterol measurements on 79,777 subjects enrolled in a health screening project in Varmland, Sweden with subsequent police records for arrests for violent crimes in men and women aged 24-70 at enrollment; and with information on covariates. We performed a nested case control comparison of cholesterol in violent criminals - defined as those with two or more crimes of violence against others - to cholesterol in nonoffenders matched on age, enrollment year, sex, education and alcohol, using variable-ratio matching, with a nonparametric sign test.

RESULTS

One hundred individuals met criteria for criminal violence. Low cholesterol (below the median) was strongly associated with criminal violence in unadjusted analysis (Men: risk ratio 1.94, P=0.002; all subjects risk ratio 2.32, P<0.001). Age emerged as a strong confounder. Adjusting for covariates using a matching procedure, violent criminals had significantly lower cholesterol than others identical in age, sex, alcohol indices and education, using a nonparametric sign test (P=0.012 all subjects; P=0.035 men).

CONCLUSIONS

Adjusting for other factors, low cholesterol is associated with increased subsequent criminal violence.

Nosologomania: a disorder of psychiatry

For many years, psychiatry has been devoted to nosology. This disease model conceives psychiatric conditions as discrete entities, with a particular pathophysiology and predictable relations between phenomenology, course and outcome. This model witnessed a true revival with the introduction of the DSM III. Its foundations, however, are weak. Many of the disorders, so delineated, are of doubtful validity. This is demonstrated, taking major depression as a paradigm. The nosological way of thought, moreover, carries with it harmful side effects, such as proliferation of new diagnoses, magnification of comorbidity, border problems and neglect of the factor psychogenesis. The question is raised of a possible alternative disease model and the reaction form model is considered to be just that. This model is defined and discussed and the conclusion is reached that it fits clinical practice and biological research better than the nosological disease model. A reconstruction of the diagnostic process in psychiatry is proposed, in such a way that it gains in sophistication and at the same time creates opportunities for comparative studies of the merits of the nosological and the reaction form model for psychiatric practice and research.

Relationship between impulsivity and platelet serotonin content in adolescents

The relationship between impulsivity and serotonin function was explored in impulsive and non-depressed adolescents. Platelet serotonin content was chosen as a peripheral indicator of central serotonin function. Impulsivity was assessed with a questionnaire. All measures were performed once a week over a 6-week period for all subjects. Subjects comprised eight adolescent inpatients who were hospitalized as a result of their impulsive acts and eight healthy age- and sex-matched control subjects. Mean platelet serotonin concentration was significantly higher in the impulsive group than in the control group. Platelet serotonin concentration was positively correlated with the intensity of impulsivity in the patient group.

Prolactin response to D-fenfluramine and suicidal behavior in depressed patients

Previous studies of the prolactin response to D-fenfluramine in depressed patients have yielded inconsistent results. This may be because they did not address the question of suicidality. We carried out this study to test the hypothesis that lower prolactin response to D-fenfluramine is more closely associated with suicidal behavior than with depression itself. A D-fenfluramine test was performed in a sample of 18 healthy control subjects and in 85 drug-free inpatients with a DSM-III-R diagnosis of major depressive episode (49 with a history of suicide attempt, 36 without). Depressed inpatients with a history of suicide attempt showed a significantly lower prolactin response to D-fenfluramine compared to depressed inpatients without such a history and compared to control subjects. Healthy control subjects and depressed inpatients without a history of suicide attempt showed comparable levels of prolactin after D-fenfluramine. Time elapsed since suicide attempt did not influence prolactin level (baseline or post-stimulation). Results show that in our depressed drug-free inpatient sample, prolactin response to D-fenfluramine seems to be a marker of suicidality, but not of depression itself. We suggest that it is a trait marker of suicidality.

Defense mechanisms, negative emotions, and psychopathology in adolescent inpatients

Ego defense mechanisms were compared in adolescent psychiatric inpatients and healthy adolescents to determine their relationship to specific diagnoses and to negative emotions. Seventy-one patients with schizophrenia, 28 with major depressive disorder, and 24 with obsessive-compulsive disorder (OCD) and 87 normal adolescents were assessed for defense mechanisms by the Life Style Index (LSI) and Ego Defense Scale (EDS). The Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and Multidimensional Anger Inventory (MAI) were used to assess depression, anxiety, and anger. Several defenses distinguished all psychiatric patients from controls, and a few defenses characterized different patient groups, especially those with OCD. Projection (on the LSI), displacement, and regression correlated significantly with anger; displacement, reaction formation, and undoing on the EDS correlated with anxiety, and denial was negatively correlated with depression. These findings have some relevance for the evaluation of Plutchik's psychoevolutionary theory of emotions and for the further empirical study of defenses in psychopathology.

Ethological research in clinical psychiatry: the study of nonverbal behavior during interviews

Ethology is relevant to clinical psychiatry for two different reasons. First, ethology may contribute significantly to the development of more accurate and valid methods for measuring the behavior of persons with mental disorders. Second, ethology, as the evolutionary study of behavior, may provide psychiatry with a theoretical framework for integrating a functional perspective into the definition and clinical assessment of mental disorders. This article describes an ethological method for studying the nonverbal behavior of persons with mental disorders during clinical interviews and reviews the results derived from the application of this method in studies of patients who had a diagnosis of schizophrenia or depression. These findings and others that are emerging from current ethological research in psychiatry indicate that the ethological approach is not limited simply to a mere translation into quantitative and objective data of what clinicians already know on the basis of their judgment or the use of rating scales. Rather, it produces new insights on controversial aspects of psychiatric disorders. Although the impact of ethology on clinical psychiatry is still limited, recent developments in the fields of ethological and Darwinian psychiatry can revitalize the interest of clinical psychiatrists for ethology.

Impulsivity as a correlate of suicidal behavior in adolescent psychiatric inpatients

One hundred and eighteen inpatient adolescents in a psychiatric hospital were evaluated to determine the relationship of aggression, self injury, and suicidal behavior to impulsivity. It was hypothesized that all these variables would be significantly and positively correlated with one another. This hypothesis was in part based on the results of psychobiological research that found serotonin dysfunction to be the common denominator of these psychopathological dimensions. As predicted, a significant correlation was found between the measures of suicidal behavior, aggressive behavior, and impulsivity. This correlation between suicidal behavior and impulsivity remained after partialing out the factor of aggression. Furthermore, the correlations between impulsivity and suicidality appeared greater in males than in females. Since male suicide attempters are more likely to eventually commit suicide than female suicide attempters, these findings may have a bearing on suicide prediction.

CSF 5-HIAA levels are lower in impulsive as compared to nonimpulsive violent suicide attempters and control subjects

BACKGROUND

We studied CSF 5-HIAA and HVA concentrations in violent suicide attempters and examined their relationship with depression, anxiety, and impulsivity.

METHODS

CSF 5-HIAA and HVA concentrations were determined very shortly after hospital admission and compared to those of a matched control population. Clinical evaluation was performed concomitantly; the level impulsivity was evaluated by the Impulsivity Rating Scale (IRS).

RESULTS

Twenty-three patients and 23 control subjects were included. According to the IRS, 14 patients were classified as impulsive, including all patients suffering from personality disorders, and 9 as nonimpulsive, with a main DSM-IIIR diagnosis of melancholia. CSF 5-HIAA concentrations in the suicide group were significantly lower than in control subjects. This difference was entirely due to the impulsive suicide attempters. There was an inverse correlation between the IRS score and CSF 5-HIAA (r = -.47, p = .02) and only a trend for HVA (r = -.41, p = .078) levels in the suicide group.

CONCLUSIONS

This study of a group of violent suicide attempters distinguished a subgroup of patients diagnosed with personality disorder with high impulsivity scores and a subgroup of patients with the main diagnosis of severe depression. CSF 5-HIAA was significantly lower in impulsive violent attempters than in nonimpulsive violent attempters, therefore desintangling violence from impulsivity and linking this biologic abnormality to impulsivity.

The platelet intracellular calcium response to serotonin and thrombin in patients with panic disorder

Serotonin is implicated in both the biology of depression and anxiety. The aim of this study was to examine the platelet intracellular calcium response to serotonin and thrombin using spectrofluorometry in 14 patients with DSM-4 panic disorder compared to 14 matched controls. Patients did not show significantly higher baseline platelet intracellular calcium levels and serotonin stimulated levels of intracellular calcium than control subjects. There was a much smaller standard deviation in the control subjects than in the panic patients. The intracellular calcium response to thrombin activation was however greater in panic patients than in control subjects (P<0.001). The failure of this study to find enhanced sensitivity of 5-HT2 receptors in panic disorder is compatible with the findings of previous challenge studies that found no consistent dysregulation of serotonin in panic disorder. The enhanced thrombin sensitivity, nevertheless suggests some receptor mediated second messenger changes independent of serotonin in the disorder.

Anxiety and increased aggression as pacemakers of depression

The concept of a serotonin (5-HT)-related, anxiety and/or aggression-driven, stressor-precipitated depression is formulated and discussed. The serotonergic disturbances found in some depressed individuals, particularly those with lowered CSF 5-HIAA, are linked to the anxiety and aggression components of the depressive syndrome. In this type of depression, called 5-HT-related depression, dysregulation of anxiety and/or aggression is hypothesized to be primordial and mood-lowering is a derivative phenomenon. In other words, this is a group of anxiety/aggression-driven depressions. The author submits that the serotonergic impairment in certain types of depression is a trait phenomenon, i.e. it persists during remission. This disturbance makes the individual susceptible to perturbation of anxiety and aggression regulation. Anxiety and (overt or suppressed) anger are core constituents of the stress syndrome. Thus the serotonergic disturbance will induce a heightend sensitivity to stressful events, i.e. the latter will induce stress phenomena, including anxiety and anger, more readily than normal. The latter psychological features induce lowering of mood, and thus 'drive' the patient into a full-blown depression. Furthermore, it is predicted that anxiolytics and serenics (i.e. anti-aggressive drugs) that act via normalization of serotonergic circuits will exert an antidepressant effect in 5-HT related depression, in addition to their therapeutic actions in anxiety disorders and states of increased aggressiveness, respectively. The exact nature of the serotonergic impairment in 5-HT-related depression has yet to be elucidated.

Differential Susceptibility to Comorbid Drug Abuse and Violence

Although many psychoactive substances have been associated with violent behavior, only a subgroup manifests excessively aggressive behavior when sober or intoxicated. Theories to explain addictive behaviors in general may directly relate to the specific proclivity to exhibit excessive aggression in this subset of users. Certain personality traits and cognitive deficits coexist in individuals prone to both drug abuse and violence, suggesting a common origin. Because these excessive and compulsive behaviors have been linked with aberrations in the metabolism and activity of the neurotransmitters dopamine and serotonin, their origins may be partly genetic or biological. Alterations in neurotransmitter function influence activities within the brain's reward center to perturb nervous system arousal levels, thereby increasing stimulation-seeking behaviors. Manifestations of these neurobiological aberrations can be measured in physiological and biochemical processes that serve to mediate these behavioral and psychological outcomes.

Association between multiple suicide attempts and negative affects in adolescents

OBJECTIVE

To compare the level of negative emotions-anxiety, depression, aggression, and impulsivity-in hospitalized adolescents with a history of either a single or multiple suicide attempts.

METHOD

Thirty-two adolescents hospitalized for a first suicide attempt, 19 hospitalized for a repeated attempt (fifth or more), 109 nonsuicidal psychiatric inpatients, and 85 community controls were assessed for level of depression, anxiety, aggression, and impulsivity with the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Multidimensional Anger Inventory, and the Suicide Potential Scale.

RESULTS

Both suicidal groups demonstrated higher levels of most of the negative emotions than both the normal controls and the nonsuicidal inpatients. When the first attempters were compared with the multiple attempters, similarly high levels were noted for most dimensions of anxiety and depression. A trend toward increased aggression was noted among the multiple suicide attempters on all parameters evaluated; some of these differences were significant.

CONCLUSION

In already highly anxious and depressed suicidal inpatients, a high level of aggression might significantly increase the risk of recidivism.

Over the mainstream: diagnostic requirements for biological psychiatric research

Progress in biological psychiatry is contingent on progress in neurobiology and on research into proper characterisation and assessment of abnormal behavior. Advances in neurobiology are rapid and steady; diagnostic research does not keep pace. On the contrary, the diagnostic approach seems solidified, as today's basic premises are uncritically accepted. The diagnostic requirements for meaningful biological psychiatric research are discussed and contrasted with present-day diagnostic practices. Serious reflection on the state of psychiatric diagnosing is urgently needed.

Psychopathology and personality of young women who experience food cravings

The objective of the present study was to investigate the psychopathology and personality characteristics of women who experience food cravings. A total of 101 young women selected at random from the community completed the Diagnostic Interview for Genetic Studies with a trained interviewer. The interview included a section about food-craving experiences and associated factors. Subjects also completed a self-report questionnaire booklet containing the Temperament and Character Inventory (TCI) and the Eating Disorder Inventory (EDI). Compared to noncravers, women who reported food cravings were significantly more likely to report a history of alcohol abuse/dependence (p = .003), significant weight changes (p = .003), and to have undertaken dieting (p = .02), bingeing (p = .05), vomiting (p = .02), exercise (p = .04), diet pill (p = .03), and laxative use (p = .01) to control weight. There was a trend for the cravers to have higher novelty-seeking scores on the TCI (p = .06). Our findings suggest that women who experience food cravings are more likely to have met criteria for alcohol abuse/dependence and tend to have temperament characterized by higher levels of novelty seeking. In addition the high rates of eating-disorder symptomatology implies overconcern with body weight and shape in the women who experienced food cravings.

Anchorpoints: an introspective

This, then, is what it has been all about. Today I mark the end of an academic career that ranged over 45 years. 1952 was the starting point. In that year, as a medical student, I was accepted as a research assistent by Prof. G.G.J. Rademaker, a neurophysiologist and at the time head of the Department of Neurology at the Academic Hospital in Leiden. The neurological research period was followed by a mycological one. Having received my MD degree and doing my military service, I was asked to carry out a study into the prevalence, prevention and treatment of mycological infections in military personel. For this reason I worked for more than 1, 5 years in Baarn at the section Medical Mycology of the Phytopathological Laboratory, an interacademic institution of the Universities of Amsterdam and Utrecht (1956-1958). Immediately after the military service I became a resident in psychiatry and started - together with the biochemist Prof. B. Leijnse - a research program into the biological determinants of depression. The period of psychiatric investigation lasted until this very day, albeit in different locations, i.e. Rotterdam, Groningen, Utrecht, New York and Maastricht respectively.

Recent life stressors and biological markers in newly admitted psychotic patients

The association of recent life stressor severity to putative biological markers of stress was examined in 34 newly admitted patients with acute psychosis. Of the biological variables examined, only pretreatment admission serum cortisol was correlated with stressor severity. Pretreatment serum prolactin, plasma homovanillic acid (HVA), and methoxyhydroxyphen-ethylglycol were not associated with severity of recent life stressors. We controlled for clinical and psychosocial variables that might affect the relationship of stressor severity to biological markers, and found that duration of psychotic symptoms was negatively correlated with stressor severity; however, when both cortisol and duration were entered in a stepwise multiple regression analysis, only pretreatment admission cortisol remained significantly and positively correlated with stressor severity. These findings suggest that serum cortisol may be a useful biological marker when investigating the relationship of life stress to episode onset. In addition, pretreatment HVA was correlated with early neuroleptic response but not with stressor severity, suggesting that HVA has value as a predictor of response independent of recent life stressors.

Plasma free 3-methoxy-4-hydroxyphenylglycol predicts response to fluoxetine

This study was designed to investigate the relationship between platelet serotonin (5-HT) and plasma free 3-methoxy-4-hydroxyphenylglycol (MHPG) measures in depressed outpatients obtained from the same patient with unipolar depression during the pretreatment period and subsequent response to 6 weeks of treatment with either fluoxetine or maprotiline. Compared to the nonresponder group, the fluoxetine responders showed significantly higher pretreatment levels of MHPG, but no difference in pretreatment 5-HT levels. There were no significant differences in either 5-HT or MHPG levels between maprotiline responders and nonresponders. As to posttreatment levels, there were no between-group differences in 5-HT or MHPG between responders and nonresponders to either fluoxetine or maprotiline. When the relationships between changes in 5-HT or MHPG levels and treatment response were examined, 5-HT values showed a marked decrease in both fluoxetine responders and nonresponders, but no significant changes were found in the maprotiline treatment groups. On the other hand, MHPG levels in the fluoxetine nonresponders tended to increase (borderline significance), whereas the MHPG levels for fluoxetine responders and maprotiline responders and nonresponders were unaffected from pre- to posttreatment. Pretreatment levels of plasma free MHPG appear to predict response to fluoxetine.

Faulty cortisol/serotonin interplay. Psychopathological and biological characterisation of a new, hypothetical depression subtype (SeCA depression)

The hypothesis is proposed of a new subtype of depression named: stressor-precipitated, cortisol-induced, serotonin-related, anxiety/aggression-driven depression (SeCA depression). Biologically, these patients are characterized by impaired 5-HT synthesis and reduced 5-HT1A receptor sensitivity. Under normal conditions these functions proceed marginally; in times of stress they easily fail, due to sustained overproduction of cortisol. Psychopathologically this depression type shows the following characteristics: anxiety and aggression, not mood lowering, heralding a depressive episode; the personality structure shows 'character neurotic' impairments and tolerance for (certain) traumatic life events is low. As specific therapeutic agents selective 5-HT1A agonists and cortisol or CRH antagonists are proposed. Prophylactically, maintenance treatment with 5-HT1A agonists seems indicated as well as psychological interventions to increase the stressor threshold.

Affective disturbances in Alzheimer's disease

OBJECTIVE

To evaluate the emotional disturbances in patients with Alzheimer's disease (AD) using both a categorical and a dimensional approach.

DESIGN

Prospective study.

SETTING

Outpatient clinic in a neurological department from a general University Teaching Hospital.

MEASURES

A semi-structured interview was used to fill in the Hamilton Depression Rating Scale, the Retardation Rating Scale for depression, the Tyrer and Covi scales for anxiety, and the Depressive Mood Scale for emotional disturbances. The cognitive status was assessed by the Mini-Mental State Examination and the Mattis Dementia Rating Scale.

PATIENTS

One hundred eighteen consecutive AD outpatients fitting the criteria for probable or possible AD, according to the National Institute of Neurological and Communication Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association, were compared with 34 community-dwelling healthy older controls and with 20 inpatients meeting the diagnostic criteria for depression according to the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition-Revised.

RESULTS

No AD patient met the criteria for Major Depressive Episode or Generalized Anxiety Disorder, but 10 (8%) met the criteria for Dysthymic Disorder. AD patients scored significantly higher than the control group but lower than the depressed group for depressive and anxious symptomatology. Depressive symptomatology was correlated negatively to the cognitive status and positively to anxious symptomatology. Two main dimensions in emotional disturbances were described using the Depressive Mood Scale: Emotional Deficit (anhedonia, hypoexpressiveness) and Loss of Control (felt irritability, hyperexpressiveness). Emotional Deficit was correlated positively to the depressive symptomatology and correlated negatively to the cognitive status and the Loss of Control dimension. Loss of Control was correlated positively to the severity of the depressive and anxious symptomatology and weakly to cognitive performance.

CONCLUSION

Affective changes were found frequently in AD patients, but no major affective disorder was found. The dimensional approach seems to be more appropriate than the categorical approach to describe the emotional disturbances in these patients.

Serotonergic modulation of striatal D2 dopamine receptor binding in humans measured with positron emission tomography

The modulating effect of serotonergic drugs on the striatal dopamine neurotransmission has remained controversial, and there are no published data on serotonin-dopamine interaction obtained from living human brain. Citalopram is a selective serotonin reuptake inhibitor widely used in the treatment of depression (20-40 mg/day). We measured the effects of acute (20 mg, per os) and chronic (20 mg/day for 14 days) doses of citalopram and placebo intake on [11C]-raclopride binding to striatal D2-receptors in eight healthy volunteers by using positron emission tomography. Although the effect magnitude was not large, the results indicate that chronic citalopram intake slightly decreases the raclopride binding which may reflect increased dopamine release in the striatum. In addition, after 14 days there was a high correlation between the citalopam plasma levels and the decrease in the [11C]-raclopride binding in both the caudate and the putamen, although statistically significant effect in the raclopride binding potential was more pronounced in the putamen. This report suggests functional interaction of brain dopaminergic and serotonergic systems in vivo in man.

Heterogeneity of information-processing alterations according to dimensions of depression: an event-related potentials study

To identify alterations in elementary cognitive operations according to dimensions of depression, two stages of information processing, namely the response choice and the motor preparation stages, were explored using an event-related potential paradigm in two subgroups of depressed patients (retarded and blunted affect versus anxious-agitated and impulsive) compared to controls. Two results are common to all depressed patients: a slow encoding of stimuli (P1 wave) and a prolonged processing of stimulus-response compatibility (after P3b). This is compensated by a global velocity increase in stimulus evaluation or decision making (P3b) in anxious-agitated patients or, on the contrary, cumulated with its velocity decrease in retarded-blunted-affect patients. Such results could provide an explanation for the massive retardation observed in blunted-affect patients, contrary to anxious-agitated patients, whose normal reaction times may come from a very high energetical involvement at the P3b level. Results as a whole suggest that impairments in blunted-affect patients concern effort mechanisms, whereas those in anxious-agitated patients concern perceptual processes.

The relationship between fibromyalgia and major depressive disorder

Looking at the results of the seven types of studies discussed previously, it appears that there is strong evidence for an association between fibromyalgia and major depressive disorder on the basis of (1) overlapping symptomatology, (2) similar pattern of comorbid disorders, and (3) high rates of major depressive disorder among relatives of patients with fibromyalgia. There is additional support for an association on the basis of responses to psychological tests and rating scales and the high lifetime rates of mood disorders in fibromyalgia. Two lines of evidence, (1) response to antidepressant medications and (2) response to biologic tests, offer little evidence either for or against an association. On balance, then the weight of the evidence favors an association between fibromyalgia and major depressive disorder. We therefore turn to an analysis of the nature of the association.

The hormonal response to intravenous 5-hydroxytryptophan in bulimia nervosa

In recent years evidence has accumulated to implicate a disturbance in serotonin function in the eating disorder bulimia nervosa. This study employs a neuroendocrine technique to assess the effect of intravenous 5-hydroxytryptophan, the immediate precursor to serotonin, on peripheral hormones in bulimia nervosa subjects and controls. Blunted prolactin and growth hormone responses were observed among bulimia nervosa subjects; the possible pathophysiology and implications of the findings are discussed.

Phenomenology and neurobiology of cocaine withdrawal: are they related?

1. The presence of mood disturbances and platelet 3H-imipramine binding, a putative peripheral serotonergic marker, were evaluated in a group of 27 cocaine users three days after drug withdrawal. 2. Parameters of cocaine use and the linkage between cocaine withdrawal and "post-cocaine depression" were also investigated. In a subgroup of 10 patients, both psychopathological and biological measurements were repeated after 5 or 6 weeks. 3. Interpretation of the data by Pearson's analysis showed a statistically significant and positive correlation between Hamilton Rating Scale for Depression (HAM-D) scores and period of use. A trend towards a negative correlation, which however did not reach the statistical significance, was found between 3H-Imipramine binding and period of cocaine use, number of days of abstinence and HAM-D scores 4. When compared with normal volunteers at baseline, patients had significantly lower Bmax and Kd values which returned towards normal values after 5 or 6 weeks of cocaine withdrawal. 5. These results indicate the presence of a decreased platelet imipramine binding during cocaine withdrawal which may be due to the effect of the drug or alternatively, a result of concomitant depression which may be primary or secondary in origin. The decreased imipramine binding is a reversible phenomenon, since it increases with the time, in parallel with the improvement of depressive symptoms.

Association of biogenic amine metabolites with symptomatology in delusional (psychotic) and nondelusional depressed patients

1. The levels of the main norepinephrine, serotonin, and dopamine metabolite excretion in the urine, MHPG, 5HIAA and HVA respectively, were measured in 84 patients with major depressive disorder, 34 delusional (psychotic) and 50 nondelusional (DSM-III-R criteria). 2. Associations with the 17 items of the HDRS were evaluated using the multiple regression analysis model. In the delusional group, MHPG excretion was positively related to the scores in the items of depressed mood (p = 0.04), middle insomnia (p = 0.008) and genital symptoms (p = 0.001). 5HIAA excretion was negatively associated with late insomnia (p = 0.02), work and interests (p = 0.001) and genital symptoms (p = 0.007). HVA was positively related to agitation (p = 0.043). In the nondelusional group the only association found was between agitation and HVA excretion (p = 0.03).

Cholesterol and psychological well-being

The debate about possible adverse effects associated with low or lowered serum cholesterol has raised important scientific questions concerning the links between lipids and behaviour. One of the most unexpected findings has been an association between cholesterol-lowering treatment and accidental death. A similar association has also emerged among the prospective cohort studies, with higher-than-expected numbers of suicide deaths in the lowest cholesterol groups. These observations have prompted speculation that behavioural or emotional disturbances could be part of the process linking lipids and accidental death. In this paper, the epidemiological literature is reviewed briefly, then the evidence for depression as a mediating condition is discussed. Two conclusions are drawn from this review of the literature. One is that understanding the relationship between the biology of lipids and the psychobiology of mood is demonstrably an important scientific and public health issue. The second is that the introduction of new treatments or preventive programmes should include a careful evaluation of the psychological as well as the physical effects.

Dimensional classification and behavioral pharmacology of personality disorders; a review and hypothesis

Nosological orientation in psychiatry has severely hampered the progress of research in biological psychiatry, especially in the case of personality disorders. Dimensional approaches have redefined the characteristics of these disorders and their possible pathogenetic factors. The significance of arousal and stress, so far relatively neglected in clinical research, and its important function in adaptive and coping strategies has to be included in the study of the behavioral pharmacology of personality disorders. Some preliminary clinical data are available suggesting the potential therapeutic use of serotonin modulating agents in the key symptomatology of certain personality disorders such as disturbed impulsive regulation and increased stress reactivity.

Beyond specificity: effects of serotonin and serotonergic treatments on psychobiological dysfunction

Serotonin is a ubiquitous neurotransmitter with widespread projections that provide for the involvement of serotonin in the regulation of many biological and psychological functions. A variety of serotonin receptor subtypes exist that mediate overlapping psychobiological functions and that are targets for a new generation of medications. Although these new generation medications appear to possess great biochemical specificity, their actions extend to many psychiatric disorders, reflecting the many interactions of serotonergic subsystems.

Citalopram, a selective serotonin reuptake inhibitor, in the treatment of aggression in schizophrenia

The aim of this double-blind cross-over study was to investigate whether treatment with the selective serotonin reuptake inhibitor, citalopram reduces aggressiveness in chronically violent schizophrenic inpatients. Initially 19 patients were enrolled into this double-blind cross-over study in which the patients were treated for 24 weeks with placebo and 24 weeks with citalopram (20-60 mg/day) as a supplement to their previous neuroleptic medication. Fourteen patients completed the entire study, but sufficient data on 15 patients could be used in the end-point analysis of efficacy. Psychiatric assessments (Brief Psychiatric Rating Scale, Clinical Global Impression Scale for Severity of Illness, Social Dysfunction and Aggression Scale and the Global Aggression Scale) and side effects (UKU Side Effect Scale) were recorded at baseline and 4 times during both periods. Aggressive incidents (Staff Observation Aggression Scale) were recorded throughout the study. During citalopram treatment, the frequency of aggressive incidents was significantly lower and the mental state did not deteriorate. Patients either experienced no side effects or else side effects were equally mild during both periods.

Platelet markers in suicide attempters

1. The authors measured 3H-imipramine (3H-IMI) binding and serotonin (5HT) uptake parameters as well as sulphotransferase activity in platelets of suicide attempters. 2. Platelet 3H-IMI binding sites and 5HT uptake are related to similar sites and processes present in the brain, and sulphotransferase (ST) is an enzyme involved in the catabolism of cathecholamines. 3. The results showed the presence of a decreased density of both 3H-IMI binding and of 5HT uptake sites, with no change in ST activity in suicide attempters, as compared with healthy controls. 4. The reduced 3H-IMI binding and 5HT uptake may be related to a hypofunction of presynaptic serotonergic mechanisms which might be altered in suicidal behavior.

Pharmacotherapy of the eating disorders: a commentary

During the last 10 yr, evidence has accumulated which indicates that the eating disorders of bulimia and anorexia nervosa (BN and AN) may be differentially affected by pharmacological treatment. Although the efficacy of drug treatment alone (relative to nonpharmacological approaches) has been debated, there is support for the generalization that all types of antidepressant medications have proven efficacious for bulimia but not for anorexia. These clinical observations are consistent with an extensive body of research concerning the regulation of ingestion, which indicates that the neurotransmitter serotonin plays an important role in mediating satiety. Such considerations have led to the "serotonin-hypothesis of bulimia," which postulates that BN represents an underlying "hyposerotonergic" condition and, conversely, that AN represents a "hyperserotonergic" state. Recently, however, two independent studies have shown that the antidepressant fluoxetine, which selectively blocks the synaptic re-uptake of serotonin, provided significant therapeutic benefit for anorexic patients. The implications of these apparently anomalous results for the "serotonin-hypothesis of BN" are discussed in an attempt to gain insight into the present pharmacotherapy of the eating disorders.

Recent developments in the psychopharmacology of social phobia

The past 2 decades have witnessed an upsurge in the interest in anxiety disorders. Much research effort has been dedicated to panic disorder and obsessive-compulsive disorder. However, it is only very recently that we have begun to understand some of the basic principles about the psychopharmacology of social phobia. Drug classes thus far studied include beta-blockers, nonselective and irreversible monoamine oxidase inhibitors (MAOIs), and benzodiazepines. Beta blockers appear to be of use in specific social phobias, such as public speaking, whereas they are of little use in generalized social phobia. There is considerable evidence suggesting that MAOIs are effective in reducing both social anxiety as well as social avoidance in generalized social phobia. A disadvantage of the conventional irreversible MAOIs is their risk for hypertensive crises when combined with dietary tyramine. Thus far only a small number of studies with selective MAO-A inhibitors, such as moclobemide and brofaromine, have been conducted in social phobia, and the results indicate that both compounds are effective. Drugs exerting selective and specific actions on certain components of, for example, the serotonergic system, can now be studied, and it is hoped that the role of 5-hydroxytryptamine) and other neuronal systems in social phobia can be elucidated. In order to gain more information about selective serotonergic drugs, the first double-blind placebo-controlled study with fluvoxamine was recently published. Preliminary results indicate a reduction in social anxiety after a prolonged treatment period. Finally, the role of peptides in the treatment of social phobia is critically reviewed. The MSH/ACTH analog Org 2766 was investigated in patients suffering from social phobia.(ABSTRACT TRUNCATED AT 250 WORDS)

Loss of control of pre-motor activation in anxious agitated and impulsive depressives. A clinical and ERP study

1. Current research uses a variety of traditional validation methods in order to test the clinical expression of biological models in psychiatry. The application of these methods has resulted in a paradoxical situation which requires the definition of new objectives in biological and pharmacoclinical research: the biological specificity of new psychotropic drugs does not assume any congruence between their pharmacological and their therapeutic effects, but raises the question of the relationship between biological systems and clinical symptomatology. The dimensional description of psychopathological disorders may be more appropriate to biological studies in psychiatry. 2. A study was undertaken on a population of twenty-one in-patients fulfilling the DSM III-R criteria for major depressive episode. They were divided into two groups on the basis of contrasting clinical dimensions: anxious-agitation and impulsiveness versus retardation and affective blunting. 3. Significant clinical differences between the two groups on mood profiles were echoed by contrasts in event-related potentials during a go-nogo task: only anxious agitated and impulsive patients developed an abnormal cortical activity, as measured by contingent negative variation (CNV), in the nogo condition. 4. This paper suggests how a paradigm with control of motor action leads to specify premotor activation abnormalities in the agitated impulsive depression subtype.

Biological markers as classifiers for depression: a multivariate study

1. Delta TSH, REM latency, 4 pm and 11 pm post-dexamethasone cortisol values were determined after a wash-out period in a group of 74 non-selected depressed patients who were diagnosed (according to RDC with the SADS) as follows: 46 definite and 10 probable MD, 4 minor and 14 intermittent depression. 2. These biological variables, as well as gender, age and basal TSH were introduced in a principal component analysis. The four first PC scores explaining up to 77% of the data set were further calculated for each patients and used in a cluster analysis. A three clusters solution was retained. 3. DST escape and increased TSH response to TRH each identified subgroups of depressed patients. Conversely, blunted TSH response or REM latency were inefficient to classify patients. 4. Thus, HPA hyperactivity characterized CL-I patients (n = 29). These were more severely depressed, displayed more endogenous features and were reported as being more anxious. 5. Increased TSH response to TRH identified CL-III, exclusively composed of female patients (n = 10) that displayed more apparent sadness and tended to be older. 6. In CL-II, the usual sex-ratio for depressive illness was reversed and patients (n = 35) exhibited the least HPA axis disturbances and the same rate of blunted TSH response than in CL-I. They were also less severely depressed, displayed less endogenous characteristics and were rated as more mood reactive. 7. These results suggest heterogeneity in biological disturbances in depression and further stress the importance for controlling age, gender and severity of illness in studies investigating biological markers in depression.

Recent advances in the psychopharmacology of social phobia

1. The last two decades have witnessed an upsurge in the interest in anxiety disorders. Much research effort has been dedicated to panic disorder and obsessive compulsive disorder. However, it is only very recently that we have begun to understand some of the basic principles about the psychopharmacology of social phobia. 2. Drug classes sofar studied include beta-blockers, nonselective and irreversible MAO-inhibitors (MAOI's) and benzodiazepines. 3. Beta blockers appear to be of use in specific social phobias, like public speaking. There is considerable evidence suggesting that MAOI's are effective in reducing both social anxiety as well as social avoidance. A disadvantage of the conventional irreversible MAOI's is their risk for hypertensive crises when combined with dietary tyramine. So far only a small number of studies with selective MAOI-A inhibitors such as moclobemide and brofaromine have been conducted in social phobia, and the results indicate that both compounds are effective. 4. Drugs exerting selective and specific actions on certain compounds of e.g. the serotonergic system can now be studied and it is hoped that the role of 5-HT and other neuronal systems in social phobia can be elucidated. 5. In order to gain more information about selective serotonergic drugs the first double blind placebo controlled study with fluvoxamine in social phobia is here reported. Preliminary results indicate a reduction of social anxiety. 6. Finally the role of peptides in the treatment of social phobia is critically reviewed. The MSH/ACTH analog Org 2766 was investigated in patients suffering from social phobia. No anxiolytic effects of this peptide could be observed.

Correlates of violence risk in hospitalized adolescents

Forty adolescent inpatients with histories of frequent interpersonal violent behavior were compared with 36 hospitalized adolescents without histories of overt violence using self-report questionnaires that measured violence risk, depression, impulsivity, and suicide risk. The two groups did not differ in terms of their demographic characteristics, but the violent patients had a higher prevalence of substance abuse and borderline personality disorder diagnoses. Violent adolescents were more impulsive and at higher suicide risk than nonviolent adolescents. In addition, violent adolescents had more positive histories of suicide attempts and had significantly higher family histories of attempted and completed suicide. In the total sample of adolescents, violence risk was significantly correlated with impulsivity and suicide risk, but not with depression.

Genetic factors in substance abuse based on studies of Tourette syndrome and ADHD probands and relatives. I. Drug abuse

There have been relatively few studies of genetic factors in drug abuse. Childhood Attention Deficit Hyperactivity Disorder (ADHD) has been implicated as a risk factor, and pedigree studies of Tourette Syndrome (TS), a hereditary impulse disorder closely related to ADHD, show an increased prevalence of substance abuse in relatives. These observations suggest the genes for TS and ADHD may play an important role in the development of drug abuse. To examine this hypothesis 217 TS probands and 328 of their relatives, 58 ADHD probands and 35 of their relatives, and 50 controls were prospectively studied using a structured questionnaire based on the Diagnostic Interview Schedule. All subjects were Caucasians 16 to 49 years of age. The responses concerning the use of 8 different drugs and 8 different symptoms of drug abuse were compared. The results showed a highly significant increase in positive responses with increased loading for the TS and ADHD genes for 6 of the 8 drugs and all of the drug abuse symptoms. The percentage of positive responses in TS probands was markedly influenced by the presence of comorbid ADHD, as well as discipline, obsessive-compulsive, or alcohol problems. These results suggest that the genes responsible for TS and ADHD play an important role in drug abuse/dependence. The dopamine D2 receptor gene (DRD2) appears to be one of these genes since variants at this locus are significantly increased in frequency in TS, ADHD, conduct disorder and drug abuse.

Fluvoxamine open-label treatment of adolescent inpatients with obsessive-compulsive disorder or depression

OBJECTIVE

Fluvoxamine, a monocyclic, specific serotonin uptake inhibitor with demonstrated efficacy in obsessive-compulsive disorder (OCD) and depression in adults, is marketed in more than 30 countries worldwide, including Israel. In the United States, where fluvoxamine is available only on an investigational basis, marketing appears imminent. This study evaluates the safety and efficacy of fluvoxamine in adolescents.

METHOD

In an 8-week, open-label trial of fluvoxamine, 20 adolescent inpatients, ages 13 to 18 years, were treated for OCD (n = 14) or major depressive disorder (MDD)(n = 6) with daily doses ranging from 100 to 300 mg. Target symptoms were rated at regular intervals with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS); Suicide Potential Scales (SPS); Beck Depression Inventory (BDI); the Overt Aggression Scale (OAS); and the Children's Global Adjustment Scale (CGAS).

RESULTS

Fluvoxamine proved relatively safe and was especially effective in the patients with OCD; mean Y-BOCS scores decreased significantly (p < .0001) from 28.0 to 19.8 on medication. Although fluvoxamine also appeared effective in decreasing depression and bulimic symptoms, its impact on impulsive, suicidal, and anorectic symptoms was less clear. The commonest side effects (n > or = 3) were dermatitis, insomnia, hyperactivity, excitement, anxiety, tremor, and nausea. Fluvoxamine was discontinued in four patients because of side effects; the most serious side effect occurred in two debilitated anorexic patients, of whom one became delirious and the other developed hallucinations.

CONCLUSION

Preliminary evidence suggests that short-term treatment of adolescents with fluvoxamine is relatively safe and may be effective for OCD and some affective spectrum symptoms.