MDMA ("ecstasy") abuse: psychopathological features and craving for chocolate: a case series

Of mice and men on MDMA: A translational comparison of the neuropsychobiological effects of 3,4-methylenedioxymethamphetamine ('Ecstasy')

MDMA (3,4-methylendioxymethamphetamine), also known as Ecstasy, is a stimulant drug recreationally used by young adults usually in dance clubs and raves. Acute MDMA administration increases serotonin, dopamine and noradrenaline by reversing the action of the monoamine transporters. In this work, we review the studies carried out over the last 30 years on the neuropsychobiological effects of MDMA in humans and mice and summarise the current knowledge. The two species differ with respect to the neurochemical consequences of chronic MDMA, since it preferentially induces serotonergic dysfunction in humans and dopaminergic neurotoxicity in mice. However, MDMA alters brain structure and function and induces hormonal, psychomotor, neurocognitive, psychosocial and psychiatric outcomes in both species, as well as physically damaging and teratogen effects. Pharmacological and genetic studies in mice have increased our knowledge of the neurochemical substrate of the multiple effects of MDMA. Future work in this area may contribute to developing pharmacological treatments for MDMA-related disorders.

The spurious relationship between ecstasy use and neurocognitive deficits: A Bradford Hill review

Numerous studies have suggested that MDMA can cause neurocognitive deficits. However, the available data can only suggest an association - rather than a causal relationship - between MDMA use and neurocognitive deficits. The reliability and robustness of this association was evaluated using Bradford Hill's criteria for determining causation in epidemiology research. Several limitations in the literature were found. Studies have recruited people who abuse ecstasy - an illicit drug that does not always contain MDMA. There is inherent risk in consuming impure or falsely identified substances; and using this as a source as for scientific opinion may introduce biases in our understanding the actuals risks associated with MDMA. Importantly, given that ecstasy research is predominately retrospective, baseline functioning cannot be established; which may be influenced by a variety of preexisting factors. Many studies introduce statistical errors by inconsistently dichotomizing and comparing light and heavy ecstasy users, making dose-response relationships inconclusive. When interpreting the ecstasy literature effect sizes are a more meaningful indicator of neurocognitive functioning rather than relying on p-values alone. Most meta-analyses have failed to find clinically relevant differences between ecstasy users and controls. There is also consistent evidence of publication bias in this field of research, which indicates that the literature is both biased and incomplete. Finally, suggestions for improving the ecstasy literature are provided.

Are the neurocognitive deficits associated with 3,4-methylenedioxymethamphetamine caused by statistical deficits in ecstasy research? A systematic review

There is growing concern that the majority of modern research may be comprised of false findings, which is partly attributed to unacceptable flexibility in data analyses. Here this issue is considered in the literature suggesting that MDMA (3,4-methylenedioxymethamphetamine) may be associated with neurocognitive deficits. Research suggests that increased exposure to ecstasy is associated with decreased performance on some neuropsychological tests. This claim is supported by the fact that “heavier” users often perform worse than “light” users on neurocognitive tests. However, most studies use different criteria for defining what is considered a “light” or “heavy” ecstasy user. Here the literature was systematically reviewed to compare the criteria used across studies which compare light and heavy ecstasy users. Out of the 19 studies reviewed nine unique points of dichotomization were found. In many cases, heavy users in one study would have been considered light users in another study and vice versa. Most studies ( n = 11) did not explain how or justify why a particular criterion was chosen. Only eight studies provided justifications for why they chose a particular criterion and the reasons were often misleading. There are many methodological issues which bring into question the validity of research suggesting MDMA is the cause of neurocognitive deficits. Methodologists have demonstrated that it is unacceptably easy for researchers to report significant findings where no relationship exists, which may have been the case in some studies reporting on the neurocognitive deficits found in ecstasy users.

Designer Drugs of Abuse

Designer drugs of abuse represent a major health risk to those who use them. The toxic effects of these agents are very dangerous when they are correctly identified, but they are especially dangerous because they are often misidentified by emergency room personnel. The three groups of designer drugs are the opiates, amphetamine derivatives and phencyclidine derivatives. Amphetamine derivatives such as MDMA and MDA can cause fatal sequelae including hyperthermia, hypertension, and seizures. No specific antidote exists for these agents. Therefore, their widespread use in certain areas is a major concern. The opiate derivatives M PPP, MPTP and the fentanyl analogues produce a wide range of toxic effects. These agents are much more potent than heroin, and are sometimes sold as heroin unknowingly to the user. The results have been catastrophic, with many fatalities. Arylhexylamines such as phencyclidine and ketamine are becoming more popular as agents of abuse. These drugs may result in fatal toxicity resulting from cardiac arrest, hypertensive emergency, or status epilepticus. Familiarity with the signs and symptoms of toxicity from the designer drugs will expedite the care of these patients.

Human psychobiology of MDMA or 'Ecstasy': an overview of 25 years of empirical research

AIMS

This paper aimed to review how scientific knowledge about the human psychobiology of MDMA has developed over time.

METHODS

In this paper, the empirical findings from earlier and later studies will be reviewed.

RESULTS

When MDMA was a 'novel psychoactive substance', it was not seen as a drug of abuse, as it displayed loss of efficacy. However, recreational users display a unique pattern of increasing doses, deteriorating cost-benefit ratios, and voluntary cessation. MDMA increases body temperature and thermal stress, with cortisol levels increased by 800% in dance clubbers. It can be extremely euphoric, although negative moods are also intensified. MDMA causes apoptosis (programmed cell death) and has been investigated for cancer therapy because of its anti-lymphoma properties. Recreational users show deficits in retrospective memory, prospective memory, higher cognition, problem solving, and social intelligence. Basic cognitive skills remain intact. Neuroimaging studies show reduced serotonin transporter levels across the cerebral cortex, which are associated with neurocognitive impairments. Deficits also occur in sleep architecture, sleep apnoea, complex vision, pain, neurohormones, and psychiatric status. Ecstasy/MDMA use during pregnancy leads to psychomotor impairments in the children.

CONCLUSIONS

The damaging effects of Ecstasy/MDMA are far more widespread than was realized a few years ago, with new neuropsychobiological deficits still emerging.

MDMA, serotonergic neurotoxicity, and the diverse functional deficits of recreational 'Ecstasy' users

Serotonergic neurotoxicity following MDMA is well-established in laboratory animals, and neuroimaging studies have found lower serotonin transporter (SERT) binding in abstinent Ecstasy/MDMA users. Serotonin is a modulator for many different psychobiological functions, and this review will summarize the evidence for equivalent functional deficits in recreational users. Declarative memory, prospective memory, and higher cognitive skills are often impaired. Neurocognitive deficits are associated with reduced SERT in the hippocampus, parietal cortex, and prefrontal cortex. EEG and ERP studies have shown localised reductions in brain activity during neurocognitive performance. Deficits in sleep, mood, vision, pain, psychomotor skill, tremor, neurohormonal activity, and psychiatric status, have also been demonstrated. The children of mothers who take Ecstasy/MDMA during pregnancy have developmental problems. These psychobiological deficits are wide-ranging, and occur in functions known to be modulated by serotonin. They are often related to lifetime dosage, with light users showing slight changes, and heavy users displaying more pronounced problems. In summary, abstinent Ecstasy/MDMA users can show deficits in a wide range of biobehavioral functions with a serotonergic component.

Dance clubbing on MDMA and during abstinence from Ecstasy/MDMA: prospective neuroendocrine and psychobiological changes

BACKGROUND/AIMS

The present study is the first to prospectively compare a group of recreational Ecstasy users when dance clubbing on 3,4-methylenedioxymethamphetamine (MDMA) and when clubbing during abstinence from Ecstasy/MDMA.

METHODS

Twelve normal healthy volunteers (mean age = 23.2 years) were assessed at a Saturday night dance club under self-administered MDMA. On the other weekend they went to the same dance club without taking MDMA (order counterbalanced). Both conditions involved 5 test sessions conducted at similar times: pre-drug baseline, 1 h post-drug clubbing, 2.5 h post-drug clubbing, and 2 and 4 days later. The assessments included body and ambient temperature, physical activity (pedometer), as well as self-ratings for mood state, physical activity, thermal comfort and thirst. Saliva samples were analyzed for MDMA, cortisol and testosterone.

RESULTS

The cortisol levels increased significantly by 800% when dance clubbing on MDMA, while testosterone increased significantly by 75%; neither neuroendocrine measure was altered during abstinence. Saliva analyses confirmed the presence of MDMA when dancing on Ecstasy and its absence when dancing off Ecstasy. The pedometer values and self-rated levels of dancing were similar at both weekends. Hot and cold flushes and feeling hot increased significantly under MDMA. The mean body temperature did not change significantly, although there was a borderline trend for increased values after MDMA. Feelings of happiness and excitement increased under MDMA, although they were not significantly greater than when clubbing during abstinence.

CONCLUSIONS

Neurohormonal release may be an important part of the acute MDMA experience. The large cortisol increase provides further data on the bioenergetic stress model of recreational Ecstasy/MDMA.

The dark side of ecstasy: neuropsychiatric symptoms after exposure to 3,4-methylenedioxymethamphetamine

3,4-Methylenedioxymethamphetamine (MDMA, ecstasy) is a known neurotoxin in animals. This review discusses the history, pattern of use, pharmacology, acute and long-term effects of MDMA. Emphasis is given to the concern that MDMA may induce long-term cognitive and psychiatric effects. MDMA is an illegal substance, and investigations of the effects of exposure in human beings have limitations and weaknesses. There are numerous studies suggesting a correlation between MDMA exposure and psychopathology, and that the psychotropic effects may be long-lasting or permanent. However, it is not possible to conclude that there is a causal relationship between exposure and the increased psychopathology observed in MDMA users. Longitudinal studies are needed to assess whether MDMA causes persistent cognitive impairment and/or psychiatric symptoms in human beings.

Memory function and serotonin transporter promoter gene polymorphism in ecstasy (MDMA) users

Although 3,4-methylenedioxymethamphetamine (MDMA or ecstasy) has been shown to damage brain serotonin (5-HT) neurons in animals and possibly humans, little is known about the long-term consequences of MDMA-induced 5-HT neurotoxic lesions on functions in which 5-HT is involved, such as cognitive function. Because 5-HT transporters play a key element in the regulation of synaptic 5-HT transmission it may be important to control for the potential covariance effect of a polymorphism in the 5-HT transporter promoter gene region (5-HTTLPR) when studying the effects of MDMA as well as cognitive functioning. The aim of the study was to investigate the effects of moderate and heavy MDMA use on cognitive function, as well as the effects of long-term abstention from MDMA, in subjects genotyped for 5-HTTLPR. A second aim of the study was to determine whether these effects differ for females and males. Fifteen moderate MDMA users (<55 lifetime tablets), 22 heavy MDMA+ users (>55 lifetime tablets), 16 ex-MDMA+ users (last tablet > 1 year ago) and 13 controls were compared on a battery of neuropsychological tests. DNA from peripheral nuclear blood cells was genotyped for 5-HTTLPR using standard polymerase chain reaction methods.A significant group effect was observed only on memory function tasks (p = 0.04) but not on reaction times (p = 0.61) or attention/executive functioning (p = 0.59). Heavy and ex-MDMA+ users performed significantly poorer on memory tasks than controls. In contrast, no evidence of memory impairment was observed in moderate MDMA users. No significant effect of 5-HTTLPR or gender was observed. While the use of MDMA in quantities that may be considered "moderate" is not associated with impaired memory functioning, heavy use of MDMA use may lead to long lasting memory impairments. No effect of 5-HTTLPR or gender on memory function or MDMA use was observed.

MDMA in humans: factors which affect the neuropsychobiological profiles of recreational ecstasy users, the integrative role of bioenergetic stress

Many recreational ecstasy/MDMA users display neuropsychobiological deficits, whereas others remain problem free. This review will investigate some of the drug and non-drug factors which influence the occurrence of these deficits. Acute and chronic MDMA usage are both important. Intensive use within a session is often associated with more problems. In term of lifetime usage, novice users generally remain unimpaired, whereas most heavy users report memory or other psychobiological problems which they attribute to ecstasy. These complaints are confirmed by objective deficits in working memory, attention, frontal-executive, and episodic memory tasks. Psychobiological deficits include disturbed sleep, sexual dysfunction, reduced immuno-competence, and increased oxidative stress. Further MDMA-related factors which may contribute to these changes, include acute and chronic tolerance, and drug dependence. Around 90ñ95% of ecstasy/MDMA users also take cannabis, and this can independently contribute to the adverse neuropsychobiological pro.les; although in some situations the acute co-use of these two drugs may be interactive rather than additive, since cannabis has relaxant and hypothermic properties. Alcohol, nicotine, amphetamine, and other drugs, can also affect the psychobiological pro.les of ecstasy polydrug users in complex ways. Pure MDMA users are rare but they have been shown to display significant neurocognitive deficits. Psychiatric aspects are debated in the context of the diathesis-stress model. Here the stressor of ecstasy polydrug drug use, interacts with various predisposition factors (genetic, neurochemical, personality), to determine the psychiatric outcome. Recreational MDMA is typically taken in hot and crowded dances/raves. Prolonged dancing, feeling hot, and raised body temperature, can also be associated with more psychobiological problems. This is consistent with the animal literature, where high ambient temperature and other metabolic stimulants boost the acute effects of MDMA, and cause greater serotonergic neurotoxicity. In conclusion, the neuropsychobiological effects of MDMA are modulated by a wide range of drug and non-drug factors. These multiple influences are integrated within a bioenergetic stress model, where factors which heighten acute metabolic distress lead to more neuropsychobiological problems.

Chronic tolerance to recreational MDMA (3,4-methylenedioxymethamphetamine) or Ecstasy

This review of chronic tolerance to MDMA (3,4-methylenedioxymetamphetamine) covers the empirical data on dosage escalation, reduced subjective efficacy and bingeing in recreational Ecstasy users. Novice users generally take a single Ecstasy tablet, regular users typically take 2-3 tablets, whereas the most experienced users may take 10-25 tablets in a single session. Reduced subjective efficacy following repeated usage is typically described, with many users subjectively reporting the development of tolerance. Intensive self-administration or bingeing is often noted by experienced users. This can comprise 'stacking' on several tablets together, and 'boosting' on successive doses over an extended period. Some experienced users snort Ecstasy powder nasally, whereas a small minority inject MDMA. Chronic tolerance and bingeing are statistically linked to higher rates of drug-related psychobiological problems. In terms of underlying mechanisms, neuroadaptive processes are certainly involved, but there is a paucity of evidence on hepatic and behavioural mechanisms. Further studies specifically designed to investigate chronic tolerance, involving low intermittent dose regimens, are required. Most animal research has involved intensive MDMA dosing regimens designed to engender serotonergic neurotoxicity, and this may comprise another underlying mechanism. If distal serotonin axon terminal loss was also developing in recreational users, it may help to explain why reducing subjective efficacy, dosage escalation and increasing psychobiological problems often develop in parallel. In conclusion, there is extensive evidence for chronic pharmacodynamic tolerance to recreational Ecstasy/MDMA, but the underlying mechanisms are currently unclear. Several traditional processes are probably involved, but one of the possible causes is a novel mechanism largely unique to the ring substituted amphetamine derivatives, namely serotonergic neurotoxicity.

Human psychopharmacology of Ecstasy (MDMA): a review of 15 years of empirical research

MDMA (3,4-methylenedioxymethamphetamine) or 'Ecstasy' was scheduled as an illegal drug in 1986, but since then its recreational use has increased dramatically. This review covers 15 years of research into patterns of use, its acute psychological and physiological effects, and the long-term consequences of repeated use. MDMA is an indirect monoaminergic agonist, stimulating the release and inhibiting the reuptake of serotonin (5-HT) and, to a lesser extent, other neurotransmitters. Single doses of MDMA have been administered to human volunteers in double-blind placebo-controlled trials, although most findings are based upon recreational MDMA users. The 'massive' boost in neurotransmitter activity can generate intense feelings of elation and pleasure, also hyperactivity and hyperthermia. This psychophysiological arousal may be exacerbated by high ambient temperatures, overcrowding, prolonged dancing and other stimulant drugs. Occasionally the 'serotonin syndrome' reactions may prove fatal. In the days after Ecstasy use, around 80% of users report rebound depression and lethargy, due probably to monoaminergic depletion. Dosage escalation and chronic pharmacodynamic tolerance typically occur in regular users. Repeated doses of MDMA cause serotonergic neurotoxicity in laboratory animals, and there is extensive evidence for long-term neuropsychopharmacological damage in humans. Abstinent regular Ecstasy users often display reduced levels of 5-HT, 5-HIAA, tryptophan hydroxylase and serotonin transporter density; functional deficits in learning/memory, higher cognitive processing, sleep, appetite and psychiatric well-being, and, most paradoxically, 'loss of sexual interest/pleasure'. These psychobiological deficits are greatest in heavy Ecstasy users and may reflect serotonergic axonal loss in the higher brain regions, especially the frontal lobes, temporal lobes and hippocampus. These problems seem to remain long after the recreational use of Ecstasy has ceased, suggesting that the neuropharmacological damage may be permament. Copyright 2001 John Wiley & Sons, Ltd.

Effects of dose, sex, and long-term abstention from use on toxic effects of MDMA (ecstasy) on brain serotonin neurons

BACKGROUND

3,4-methylenedioxymethamphetamine (MDMA or ecstasy) is a popular recreational drug that has been shown to damage brain serotonin neurons in high doses. However, effects of moderate MDMA use on serotonin neurons have not been studied, and sex differences and the long-term effects of MDMA use on serotonin neurons have not been identified. We investigated the effects of moderate and heavy MDMA use, sex differences, and long-term effects of MDMA use on serotonin neurons in different brain regions.

METHODS

By means of flyers posted in "rave" venues in Amsterdam, the Netherlands, we recruited 15 moderate MDMA users, 23 heavy MDMA users, 16 ex-MDMA users who had stopped using MDMA for more than 1 year, and 15 controls who claimed never to have used MDMA. We studied the effects of MDMA on brain serotonin neurons using 123iodine-2beta-carbomethoxy-3beta-(4-iodophenyl) tropane ([123I]beta-CIT)-a radioligand that binds with high affinity to serotonin transporters. Density of binding (expressed as a ratio of region-of-interest binding over binding in the cerebellum) was calculated by single-photon-emission computed tomography (SPECT).

FINDINGS

We saw significant effects of group and group by sex (p=0.041 and p=0.022, respectively) on overall [123I]beta-CIT binding ratios. In heavy MDMA users, significant decreases in overall binding ratios were seen in women (p<0.01) but not men (p=0.587). In female ex-MDMA users, overall densities of serotonin transporters were significantly higher than in heavy MDMA users (p=0.004), but not higher than in controls (p=0.524).

INTERPRETATION

Our results indicate that heavy use of MDMA is associated with neurotoxic effects on serotonin neurons, that women might be more susceptible than men, and that MDMA-induced neurotoxic changes in several brain regions of female ex-MDMA users are reversible.

Former chronic methylenedioxymethamphetamine (MDMA or ecstasy) users report mild depressive symptoms

Previous work has indicated recreational use of methylenedioxymethamphetamine (MDMA or ecstasy) is associated with elevated scores on self-report measures of depression. We sought to examine the long-term effects of consumption on depression in a group of individuals who had consumed large quantities of the drug in the past, but were now leading relatively drug free lives. Respondents to this study (n = 29) had consumed an average of 1.5 ecstasy tablets in the last month, 8.4 in the last 6 months and 23.3 in the last 12 months. The estimated total consumed was 527 tablets, indicating that these respondents were indeed former chronic users of the drug. None of the respondents had consumed ecstasy in the last 14 days. Levels of depression (Beck's Depression Inventory) were significantly (p < 0.01) elevated compared to a matched non-drug using control group. Within the group of former chronic users, these levels of depression were not significantly affected by current use of alcohol, cannabis or amphetamine, but were positively correlated with an external locus of control (p < 0.05), infrequent but severe- (p < 0.05) and frequent but mild- (p < 0.005) self-report measures of life stress. Multiple regression indicated that levels of frequent but mild life stress (p < 0.005) and the quantity of ecstasy tablets respondents consumed over a 12-h period (p < 0.05) were the only variables that were significant predictors of self-reported levels of depression. The results of this study indicate that former chronic ecstasy users report higher levels of depression than their matched controls.

3,4-methylenedioxymethamphetamine (ecstasy)-induced learning and memory impairments depend on the age of exposure during early development

Use of 3,4-methylenedioxymethamphetamine (MDMA; ecstasy) has increased dramatically in recent years, yet little is known about its effects on the developing brain. Neonatal rats were administered MDMA on days 1-10 or 11-20 (analogous to early and late human third trimester brain development). MDMA exposure had no effect on survival but did affect body weight gain during treatment. After treatment, body weight largely recovered to 90-95% of controls. MDMA exposure on days 11-20 resulted in dose-related impairments of sequential learning and spatial learning and memory, whereas neonatal rats exposed on days 1-10 showed almost no effects. At neither stage of exposure did MDMA-treated offspring show effects on swimming ability or cued learning. Brain region-specific dopamine, serotonin, and norepinephrine changes were small and were not correlated to learning changes. These findings suggest that MDMA may pose a previously unrecognized risk to the developing brain by inducing long-term deleterious effects on learning and memory.

No difference in brain activation during cognitive performance between ecstasy (3,4-methylenedioxymethamphetamine) users and control subjects: a [H2(15)O]-positron emission tomography study

The long-term use of the serotonin-releaser and uptake-inhibitor 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy") has been associated with memory impairments and increased liability to depressive mood and anxiety attacks. It is unclear, however, whether these psychologic deviations are reflected in alterations of the underlying neurophysiologic substrate. The authors compared mood and regional cerebral blood flow (rCBF) profiles between regular polytoxic Ecstasy users and Ecstasy-naive controls. Brain activity as indexed by rCBF was measured during cognitive activation by an attentional task using positron emission tomography and [H2(15)O]. Mood was assessed by means of the Hamilton Rating Scale for Depression (HAM-D) and the EWL Mood Rating Scale. Statistical parametric mapping revealed that brain activity did not differ between the two groups. Both groups also performed equally on the cognitive task requiring sustained attention. However, significantly higher levels of depressiveness as determined by the HAM-D and EWL scales were found in Ecstasy-using subjects. These data indicate that, despite differences in mood, polytoxic Ecstasy users do not differ from Ecstasy-naive controls in terms of local brain activity. Heightened depressiveness in the Ecstasy group was consistent with results from previous studies and could be related to serotonergic hypofunction resulting from repeated MDMA consumption. However, this study cannot exclude the possibility that the observed differences are preexisting rather than a result of Ecstasy use.

Potential human neurotoxicity of MDMA ('Ecstasy'): subjective self-reports, evidence from an Italian drug addiction centre and clinical case studies

The present paper attempts to give an updated overview of the magnitude of the phenomenon of ecstasy abuse in Italy and other European countries. It gives an account of some clinical case studies and of a larger-scale report on polydrug (including MDMA) consumers attending our Public Health Addiction Treatment Unit in recent years, with a view to clarifying the characteristics and psychopathological consequences (mainly depression, psychotic disorders, cognitive disturbances, bulimic episodes, impulse control disorders, panic disorders, social phobia) of MDMA consumption. Longer-term, larger-dose (acute or cumulative) MDMA consumers were found to be at high risk of developing these psychopathological disturbances. A tentative description of certain personological dimensions of ecstasy consumers is also given (the novelty-seeking dimension was characteristic of those who occasionally experimented with the drug) while those who ingested larger quantities revealed low harm avoidance scores). Results are discussed in the light of the complex and different methodological issues arising from this kind of study, in which MDMA is far from being the only drug of abuse.

Mood state and brain electric activity in ecstasy users

Resting EEG during open and closed eyes and subsequent mood ratings were obtained from 15 Ecstasy users and 14 Ecstasy-naive controls. Absolute spectral power on the scalp, and the three-dimensional, intracerebral distribution of neuroelectric activity using low resolution brain electromagnetic tomography (LORETA) were computed. LORETA revealed global increases of theta, alpha 1 and beta 2/3 power during eyes open in Ecstasy users, and spectral analyses revealed a right-posterior increase of alpha 2 power (confirmed by LORETA) and increased beta band activity during open eyes. Ecstasy users had higher levels of state depressiveness, emotional excitability and a trend-level increase in state anxiety. The observed differences may be related to regular exposure to Ecstasy or other illicit drugs, or may be pre-existing.

Chocolate: food or drug?

Although addictive behavior is generally associated with drug and alcohol abuse or compulsive sexual activity, chocolate may evoke similar psychopharmacologic and behavioral reactions in susceptible persons. A review of the literature on chocolate cravings indicates that the hedonic appeal of chocolate (fat, sugar, texture, and aroma) is likely to be a predominant factor in such cravings. Other characteristics of chocolate, however, may be equally as important contributors to the phenomena of chocolate cravings. Chocolate may be used by some as a form of self-medication for dietary deficiencies (eg, magnesium) or to balance low levels of neurotransmitters involved in the regulation of mood, food intake, and compulsive behaviors (eg, serotonin and dopamine). Chocolate cravings are often episodic and fluctuate with hormonal changes just before and during the menses, which suggests a hormonal link and confirms the assumed gender-specific nature of chocolate cravings. Chocolate contains several biologically active constituents (methylxanthines, biogenic amines, and cannabinoid-like fatty acids), all of which potentially cause abnormal behaviors and psychological sensations that parallel those of other addictive substances. Most likely, a combination of chocolate's sensory characteristics, nutrient composition, and psychoactive ingredients, compounded with monthly hormonal fluctuations and mood swings among women, will ultimately form the model of chocolate cravings. Dietetics professionals must be aware that chocolate cravings are real. The psychopharmacologic and chemosensory effects of chocolate must be considered when formulating recommendations for overall healthful eating and for treatment of nutritionally related health issues.

Fatal multi-organ failure after suicidal overdose with MDMA, 'ecstasy': case report and review of the literature

A 53-year-old prisoner died of multiorgan failure after a suicidal overdose with 3,4-methylenedeoxymethamphetamine (MDMA, 'Ecstasy'). Twelve hours after ingestion of MDMA, the patient became severely hyperthermic (107.2 degrees F) with evidence of rhabdomyolysis. He subsequently developed acute respiratory distress syndrome (ARDS), disseminated intravascular coagulopathy (DIC) and acute renal failure. At autopsy, plasma concentration of MDMA was 3.05 mg/L. This case shows that MDMA is still abused in our community and clinicians should know the symptoms of MDMA intoxication. In particular, MDMA should be considered when patients have symptoms or signs of increased sympathetic activity. The pathophysiology and treatment of MDMA-induced hyperthermia are discussed.

[Ecstasy: a pharmacological review]

A literature review on 3,4 methylenedioxymethanphetaneine (MDMA), known as ecstasy, a drug with increased use among youngsters is presented. The history from its synthesis, up to its use as an adjunct to psychotherapy and, more recently, as a drug of abuse, is described. The possible pattern of abuse in several countries is reviewed with the objective of predicting what might happen in Brazil, where some reports of abuse have already appeared. The pharmacokinetics of MDMA is also reviewed to explain the consequences for pharmacological activity, toxicology and adverse effects. The clinical outcome of both short and middle-term intoxication is summarized and the clinical symptoms of severe intoxication with ecstasy, are described. The studies undertaken on its mechanism of action are detailed to explain its toxic psychiatric and physical side effects, to explain the mechanism of self-administration of the drug and to propose a therapeutic possibility of treating intoxication.

MDMA ('ecstasy') consumption in the context of polydrug abuse: a report on 150 patients

The present study examined the characteristics and the possible psychopathological consequences of ecstasy (MDMA, 3,4-methylenedioxymethamphetamine) use. One hundred and fifty consecutive patients, presenting to the Padova (Italy) Addiction Treatment Unit and who had taken ecstasy on at least one occasion, were examined and studied using a semi-structured interview. Ninety-five percent of the patients had experimented with another drug of abuse at least once in their lifetime. Ecstasy was mainly self-administered at disco clubs, and reported acute psychoactive effects confirmed previous reports. Fifty-three percent of the total sample were found to be affected by one or more psychopathological problems; the most frequent were depression, psychotic disorders, cognitive disturbances, bulimic episodes, impulse control disorders, panic disorders, social phobia. Those who were free from any psychopathological problem, compared to the others, had taken a smaller number of MDMA tablets in their lifetime, for a shorter duration and with a lower frequency. Again, they were less likely to have used alcohol together with ecstasy but more likely to have used opiates. Longer-term, larger dosage (acute or cumulative) MDMA consumers were found to be at high risk of developing psychopathological disturbances. The results are discussed, taking into account both the ecstasy suggested serotonin (5-hydroxytryptamine) neurotoxicity and the various methodological issues pertaining to this kind of large-scale clinical study describing people for whom MDMA is far from being the only drug of abuse.

Is the use of ecstasy and hallucinogens increasing? Results from a community study

This report presents findings of a community survey of 3,021 adolescents and young adults aged 14-24 years in Munich, Germany, carried out to determine the prevalence of use and abuse of and dependence on ecstasy, amphetamines and hallucinogens. The response rate was 71%.

RESULTS

(1) In 1995, 4% of the male and 2.3% of the female respondents aged 14-24 reported the use of ecstasy. Ecstasy-related substances (amphetamines and chemically related substances) were reported by 3.6% of men and 1.6% of women. Hallucinogens were reported slightly less frequently by 3% of men and about 2% of women (LSD combined with others). (2) Compared to findings from a 1990 survey this constitutes a substantial, at least twofold, increase in consumption rate of both types of substances. (3) Among lifetime users of both ecstasy and related substances as well as hallucinogens about two thirds could be regarded as regular users. (4) The prevalence of DSM-IV abuse and dependence on ecstasy and related substances is about 1%, identical to rates of hallucinogen abuse and dependence. Findings also point to a significant dependence potential for both substances. (5) Furthermore, considerable overlap between the two substances was found.

CONCLUSION

Our study suggests a substantial increase in both the use of ecstasy and related substances as well as hallucinogens. The data further suggest that the increase is strongest in younger age groups, but the risk of first use of these substances continues to be present up to the age of 24 years. The higher proportion of women contributing to this increase is noteworthy.

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.

Women, food, and mood

Associations between food intake and mood greatly interest both lay and scientific audiences, although scientific support for many observed associations is sparse. Of particular interest are issues surrounding food intake, food cravings, and mood in women throughout the menstrual cycle. Further research is necessary to support or disprove current hypotheses about the relationship between food intake and mood. Meanwhile, health professionals should be prepared to inform the public about the complexity of factors that influence the relationship between food intake and mood.