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Tu S, Zeng X, Liu T, Zeng J. Emotion Regulation Can Effectively Improve Decision-Making Behaviors of Individuals Who Use Methamphetamine. J Psychosoc Nurs Ment Health Serv 2024:1-8. [PMID: 38950356 DOI: 10.3928/02793695-20240612-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
PURPOSE Negative emotions can cause people to make irrational decisions, and decision-making disorders may lead individuals who use methamphetamine (meth) to relapse. Therefore, the current study was performed to investigate whether emotion regulation (ER) can improve negative emotions and thus improve decision-making behavior of individuals who use meth. METHOD Based on the Iowa Gambling Task, a three-factor mixed experimental design was used to examine the effects of cognitive reappraisal and expressive suppression strategies on negative emotions and decision-making behaviors of 157 individuals who use meth. RESULTS Cognitive reappraisal and expressive suppression were effective in reducing participants' negative emotions and improving decision-making behaviors. Specifically, two types of ER strategies were effective in improving decision-making abilities of participants with negative emotional distress, and cognitive reappraisal was more effective than expressive suppression. CONCLUSION Regarding cognitive reappraisal, female participants showed better decision-making behavior than males, which predicts that females who use meth might be more adept at using cognitive reappraisal. This finding suggests that mental health providers should aid substance users in managing their negative emotions and also pay attention to gender differences during the nursing process. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].
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Molero-Zafra M, Fernández-García O, Mitjans-Lafont MT, Pérez-Marín M, Hernández-Jiménez MJ. Psychological intervention in women victims of childhood sexual abuse: a randomized controlled clinical trial comparing EMDR psychotherapy and trauma-focused cognitive behavioral therapy. Front Psychiatry 2024; 15:1360388. [PMID: 38868491 PMCID: PMC11167727 DOI: 10.3389/fpsyt.2024.1360388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 05/03/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Childhood sexual abuse persists as a painful societal reality, necessitating responses from institutions and healthcare professionals to prevent and address its severe long-term consequences in victims. This study implements an intervention comprising two psychotherapeutic approaches recommended by the WHO and international clinical guidelines for addressing short-, medium-, and long-term posttraumatic symptomatology: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR). Both approaches are adapted from group formats for implementation in small online groups via Zoom. Methods The impact of both therapeutic approaches on trauma improvement was assessed in a sample of 19 women who were victims of childhood sexual abuse through a Randomized Clinical Trial comparing EMDR Psychotherapy and Trauma-Focused Cognitive Behavioral Therapy after a baseline period. Intra and inter comparison were made using statistics appropriate to the sample. Results Both therapeutic approaches significantly reduced symptomatology across various evaluated variables, suggesting their efficacy in improving the quality of life for these individuals. Following CBT-FT treatment, patients exhibited enhanced emotional regulation, reduced reexperiencing, and avoidance. The EMDR group, utilizing the G-TEP group protocol, significantly improved dissociation, along with other crucial clinical variables and the perception of quality of life. Discussion Although the limitations of this study must be taken into account due to the size of the sample and the lack of long-term follow-up, the results align with existing scientific literature, underscoring the benefits of trauma-focused psychological treatments. The online group format appears promising for enhancing the accessibility of psychological treatment for these women. Furthermore, the differential outcomes of each treatment support recent research advocating for the inclusion of both approaches for individuals with trauma-related symptomatology. Ethics and dissemination The study has been approved by the Ethics Committee of the Valencian International University (VIU) (Valencia, Spain) (Ref. CEID2021_07). The results will be submitted for publication in peer-reviewed journals and disseminated to the scientific community. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT04813224, identifier NCT04813224.
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Della Rocca F, Maremmani AGI, Bacciardi S, Pacini M, Lamanna F, Tripodi B, Miccoli M, Maremmani I. Characteristics of Stress Sensitivity in Heroin Use Disorder Patients during Their Opioid Agonist Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4566. [PMID: 36901575 PMCID: PMC10002439 DOI: 10.3390/ijerph20054566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/22/2023] [Accepted: 03/02/2023] [Indexed: 06/18/2023]
Abstract
In the present study, performed on a sample of Heroin Use Disorder (HUD) patients undergoing Opioid Agonist Treatment (OAT), we attempted to explore the relationships between stress sensitivity and heroin addiction-related clinical aspects. HUD patients' stress sensitivity was evaluated with the Heroin/PTSD-Spectrum questionnaire (H/PSTD-S). The Drug Addiction History Questionnaire (DAH-Q), the Symptomatological Check List-90 (SCL-90), and The Behavioural Covariate of Heroin Craving inventory (CRAV-HERO) were all used, as were the Deltito Subjective Wellness Scale (D-SWS), a self-report scale evaluating subjective well-being; the Cocaine Problem Severity Index (CPSI), a questionnaire determining the extent of a cocaine problem; and the Marijuana Craving Questionnaire (MC-Q), an instrument assessing craving for cannabinoids. We checked correlations between stress sensitivity and the extent of HUD clinical features and compared patients with and without problematic stress sensitivity. H/PTSD-S was positively correlated with patients' income, altered mental status, legal problems, the lifetime different treatments index, the current treatment load index, and all SCL-90 indexes and factors. Regarding subjective well-being, stress sensitivity negatively correlated with the contrast best week (last five years) index. Patients with high-stress sensitivity were females with a low income. They exhibited a more severe mental status at treatment entry, greater difficulty in working adaptation, and legal problems during treatment. Additionally, these patients showed a higher level of psychopathology, more impairment in well-being, and more risky behaviours during treatment. Stress sensitivity, as H/PTSD-S, must be considered an outcome of HUD. HUD's addiction history and clinical features are significant risk factors for H/PTSD-S. Therefore, social and behavioural impairment in HUD patients could be considered the clinical expression of the H/PTSD spectrum. In summary, the long-term outcome of HUD is not represented by drug-taking behaviours. Rather, the inability to cope with the contingent environmental conditions is the key feature of such a disorder. H/PTSD-S, therefore, should be seen as a syndrome caused by an acquired inability (increased salience) concerning regular (daily) life events.
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Affiliation(s)
- Filippo Della Rocca
- Addiction Research Methods Institute, World Federation for the Treatment of Opioid Dependence, 225 Varick Street, Suite 402, New York, NY 10014, USA
| | - Angelo G. I. Maremmani
- Addiction Research Methods Institute, World Federation for the Treatment of Opioid Dependence, 225 Varick Street, Suite 402, New York, NY 10014, USA
- Department of Psychiatry and Addictions, Section of Psychiatry, North-Western Tuscany Local Health Unit, Tuscany NHS, Versilia Zone, Via Aurelia 335, 55041 Viareggio, Italy
| | - Silvia Bacciardi
- Addiction Research Methods Institute, World Federation for the Treatment of Opioid Dependence, 225 Varick Street, Suite 402, New York, NY 10014, USA
- Department of Psychiatry and Addictions, Section of Psychiatry, North-Western Tuscany Local Health Unit, Tuscany NHS, Versilia Zone, Via Aurelia 335, 55041 Viareggio, Italy
| | - Matteo Pacini
- V.P. Dole Research Group, G. De Lisio Institute of Behavioural Sciences, Via di Pratale 3, 56121 Pisa, Italy
| | - Francesco Lamanna
- Department of Psychiatry and Addictions, Section of Addictions, North-Western Tuscany Local Health Unit, Tuscany NHS, Pisa Zone, Via delle Torri 160, 56124 Pisa, Italy
| | - Beniamino Tripodi
- Department of Mental Health and Addictions, Division of Psychiatry, ASST Crema, Via Largo Dossena 2, 26013 Crema, Italy
| | - Mario Miccoli
- Addiction Research Methods Institute, World Federation for the Treatment of Opioid Dependence, 225 Varick Street, Suite 402, New York, NY 10014, USA
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | - Icro Maremmani
- Addiction Research Methods Institute, World Federation for the Treatment of Opioid Dependence, 225 Varick Street, Suite 402, New York, NY 10014, USA
- V.P. Dole Research Group, G. De Lisio Institute of Behavioural Sciences, Via di Pratale 3, 56121 Pisa, Italy
- Saint Camillus International University of Health Sciences (UniCamillus), Via di Sant’Alessandro 8, 00131 Rome, Italy
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Tsumura H, Fukuda M, Kanda H. Blunted cortisol and normal sympathetic nervous system responses to an acute psychosocial stressor in internet addiction. Heliyon 2022; 8:e12142. [PMID: 36582718 PMCID: PMC9792755 DOI: 10.1016/j.heliyon.2022.e12142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/25/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Studies have demonstrated that addiction leads to blunted responses of cortisol and sympathetic nervous system (SNS) to acute stressors; however, limited studies have examined the neuroendocrine and SNS stress responses in Internet addiction (IA). To examine acute stress responses in IA, the current study recruited a total of 76 Japanese university students and staff members (51 females and 25 males, mean age = 22.4 years, SD = 4.7), and measured the salivary cortisol, salivary alpha-amylase (sAA), and blood pressure (BP) responses to an acute stressor under stress or a nonstress placebo conditions in IA and non-IA groups. The results revealed that patients with IA showed a blunted cortisol response to a stressor. In contrast, no differences were found in the sAA and BP responses between the IA and non-IA groups. These results suggest that IA may be characterized by blunted cortisol responses in acute stress settings.
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Affiliation(s)
- Hideki Tsumura
- Graduate School of Technology, Industrial and Social Sciences, Tokushima University, 1-1, Minamijosanjima, Tokushima, 770-8502, Japan,Corresponding author.
| | - Mari Fukuda
- Department of Public Health, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Hideyuki Kanda
- Department of Public Health, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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Molina G, Whittaker A. Treatment of post-traumatic stress disorder and substance use disorder in adults with a history of adverse childhood experiences: A systematic review of psychological interventions. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 2:100028. [PMID: 36845903 PMCID: PMC9948894 DOI: 10.1016/j.dadr.2022.100028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/12/2021] [Accepted: 01/17/2022] [Indexed: 11/18/2022]
Abstract
Background Adverse childhood experiences (ACEs) have long-term effects on adult health, including unresolved trauma and substance use disorder (SUD). There are hypotheses of a mediating role of emotion regulation. This systematic literature review and narrative synthesis assessed the effectiveness of psychological interventions on emotion regulation, PTSD and SUD symptoms. Methods Searches were conducted using the Cochrane Handbook for Systematic Reviews methodology. Eligible studies were randomised controlled trials (RCTs) and quasi-experimental psychological interventions published between 2009 and 2019. Study characteristics, results and methodological quality were systematically analysed. Results Thirteen studies, including nine RCTs, were selected. Integrated SUD and PTSD treatments consisted of Seeking Safety, exposure-based treatment, Trauma Recovery and Empowerment Model, and integrated cognitive behavioural therapy. Two studies reported emotion regulation. Five studies found a small to medium positive effect size of psychological interventions on PTSD outcomes. Two studies had a small positive effect size on SUD outcomes and two a small negative effect size. Attrition was high across most studies. Characteristics likely to affect the applicability of the review were described. Conclusion The review found some evidence of a small inconsistent positive effect of psychological interventions on PTSD outcomes, and no evidence of effect on SUD outcomes. The range of theoretical models was narrow. Overall quality was low with high clinical heterogeneity and missing key information, particularly on emotion regulation, an important transdiagnostic feature. Further research is required to establish interventions that can treat these multiple conditions with a focus on effectiveness, acceptability, and implementation in real life clinical practice.
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Key Words
- ACEs, adverse childhood experiences
- AEs, adverse events
- ATREM, Attachment-informed TREM
- CBT, Cognitive–Behavioural Therapy
- CI, confidence intervals
- CPTSD, complex PTSD
- DERS, Difficulties in Emotion Regulation Scale
- EMDR, eye movement desensitisation and reprocessing
- ER, emotion regulation
- FSP, family and social problems
- ICBT, Integrated CBT
- M, mean
- OR, odds ratio
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- PTSD, post-traumatic stress disorder
- RCT, randomised control trial
- SD, standard deviation
- SS, Seeking Safety
- SUD, substance use disorder
- SWiM, Synthesis Without Meta-Analysis
- TREM, Trauma Recovery and Empowerment Model
- adverse childhood experiences
- emotion regulation
- posttraumatic stress disorder
- psychological interventions
- substance use disorder
- systematic review
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Affiliation(s)
- Genevieve Molina
- CeGIDD, Pôle Santé Publique et Médecine Sociale, CHU Toulouse, Hôpital La Grave, TSA 60033, 31059 Toulouse Cedex 9, France
- Corresponding author.
| | - Anne Whittaker
- NMAHP Research Unit, Faculty of Health Sciences and Sport, Pathfoot Building, University of Stirling, FK9 4LA, Stirling, Scotland, UK
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Baiden P, Onyeaka HK, Kyeremeh E, Panisch LS, LaBrenz CA, Kim Y, Kunz-Lomelin A. An Association of Adverse Childhood Experiences with Binge Drinking in Adulthood: Findings from a Population-Based Study. Subst Use Misuse 2022; 57:360-372. [PMID: 35023435 DOI: 10.1080/10826084.2021.2012692] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Adverse childhood experiences (ACEs) are a major public health issue linked to negative health outcomes. Yet, few recent studies drawing on national data have examined the association between ACEs and binge drinking. Objective: The objective of this study was to examine the association between ACEs and binge drinking among adults in the United States and whether this association is dependent on sex. Methods: Data for this study were obtained from the 2019 Behavioral Risk Factor Surveillance System survey. An analytic sample of 41,322 adults aged 18-64 years (50.7% male) from 17 states was analyzed using binary logistic regression. The outcome variable was binge drinking, and the main explanatory variable was ACEs. Results: Of the 41,322 respondents, 21.3% engaged in binge drinking. About 30% of the respondents had no ACEs and 23.9% had four or more ACEs. In the multivariable logistic regression, we observed that sex moderated the association between ACEs and binge drinking. Odds were 1.36 times higher for females who experienced two ACEs (aOR = 1.36 p < .05, 95% CI = 1.04-1.77) and 1.58 times higher for females who experienced three ACEs (aOR = 1.58 p < .01, 95% CI = 1.17-2.12) to engage in binge drinking. Other factors associated with binge drinking include younger age, non-Hispanic White, higher income level, higher education, not being married, being overweight, and history of cigarette smoking. Conclusion: The findings of this study underscore the importance of developing sex-appropriate screening and intervention strategies to support individuals exposed to ACEs and potentially mitigate negative health outcomes later in life.
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Affiliation(s)
- Philip Baiden
- School of Social Work, The University of Texas at Arlington, Arlington, Texas, USA
| | - Henry K Onyeaka
- Harvard Medical School, Department of Psychiatry, Massachusetts General Hospital/McLean Hospital, Boston, Massachusetts, USA
| | - Emmanuel Kyeremeh
- Department of Sociology, University of Toronto, Toronto, Ontario, Canada
| | - Lisa S Panisch
- School of Social Work, Wayne State University, Detroit, Michigan, USA
| | - Catherine A LaBrenz
- School of Social Work, The University of Texas at Arlington, Arlington, Texas, USA
| | - Yeonwoo Kim
- College of Nursing and Health Innovation, Department of Kinesiology, The University of Texas at Arlington, Arlington, Texas, USA
| | - Alan Kunz-Lomelin
- School of Social Work, The University of Texas at Arlington, Arlington, Texas, USA
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Emotional reactivity and difficulties in emotional regulation in drug users: a study in adolescents undergoing treatment in a therapeutic community. THERAPEUTIC COMMUNITIES 2021. [DOI: 10.1108/tc-08-2021-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this study is to investigate which emotions and difficulties in the emotional regulation of adolescents with illicit substance consumption.
Design/methodology/approach
In total, 41 adolescents undergoing treatment for the use of alcohol and drugs were recruited. The instruments used were the emotional rating scale and the difficulties in the regulation of emotions scale.
Findings
Emotional reactivity showed significant differences in the sadness dimension in relation to the number of cannabis cigarettes smoked daily and length of stay, and in the surprise dimension in relation to the number of cannabis cigarettes smoked daily. There was a significant correlation between happiness and age, surprise and number of siblings, sadness and school absenteeism and fear, school absenteeism and number of substances consumed. In regard to difficulties in emotional regulation, there were significant differences between the groups, in strategies regarding the gender of the participants and the number of substances consumed, in non-acceptance and impulses and in the number of substances consumed and in the awareness of the type and number of substances consumed. There was a significant correlation between strategies, non-acceptance, awareness and impulses and the number of substances consumed.
Originality/value
This study demonstrated that the emotional problems of adolescents admitted to a therapeutic community are predictors of illicit substance use.
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Gerra ML, Gerra MC, Tadonio L, Pellegrini P, Marchesi C, Mattfeld E, Gerra G, Ossola P. Early parent-child interactions and substance use disorder: An attachment perspective on a biopsychosocial entanglement. Neurosci Biobehav Rev 2021; 131:560-580. [PMID: 34606823 DOI: 10.1016/j.neubiorev.2021.09.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 12/19/2022]
Abstract
This review aims to elucidate environmental and genetic factors, as well as their epigenetic and neuroendocrine moderators, that may underlie the association between early childhood experiences and Substance Use Disorders (SUD), through the lens of parental attachment. Here we review those attachment-related studies that examined the monoaminergic systems, the hypothalamic pituitary adrenal stress response system, the oxytoninergic system, and the endogenous opioid system from a genetic, epigenetic, and neuroendocrine perspective. Overall, the selected studies point to a moderating effect of insecure attachment between genetic vulnerability and SUD, reasonably through epigenetic modifications. Preliminary evidence suggests that vulnerability to SUDs is related with hypo-methylation (e.g. hyper-expression) of high-risk polymorphisms on the monoaminergic and hypothalamic pituitary adrenal system and hyper-methylation (e.g. hypo-expressions) of protective polymorphisms on the opioid and oxytocin system. These epigenetic modifications may induce a cascade of neuroendocrine changes contributing to the subclinical and behavioural manifestations that precede the clinical onset of SUD. Protective and supportive parenting could hence represent a key therapeutic target to prevent addiction and moderate insecure attachment.
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Affiliation(s)
| | - Maria Carla Gerra
- Center for Neuroplasticity and Pain (CNAP), SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
| | | | | | - Carlo Marchesi
- Psychiatry Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Elizabeth Mattfeld
- Drug Prevention and Health Branch, Prevention Treatment and Rehabilitation Section, United Nations Office on Drugs and Crime, Vienna, Austria.
| | - Gilberto Gerra
- Department of Mental Health, AUSL of Parma, Parma, Italy.
| | - Paolo Ossola
- Center for Neuroplasticity and Pain (CNAP), SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
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Ossola P, Gerra MC, Gerra ML, Milano G, Zatti M, Zavan V, Volpi R, Marchesi C, Donnini C, Gerra G, Di Gennaro C. Alcohol use disorders among adult children of alcoholics (ACOAs): Gene-environment resilience factors. Prog Neuropsychopharmacol Biol Psychiatry 2021; 108:110167. [PMID: 33166669 DOI: 10.1016/j.pnpbp.2020.110167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/03/2020] [Accepted: 11/02/2020] [Indexed: 11/17/2022]
Abstract
Both genetic and early environmental factors contribute to the pathogenesis of Alcohol Use Disorder (AUD). Gender and psychopathology symptoms might further moderate this association, resulting in an impairment of both the dopaminergic and serotoninergic pathways that sustain the binge, withdrawal and craving cycle. In a sample of of adult children of alcoholic parents (ACOAs) (n = 107) we compared those with and without an AUD, on socio-demographic variables, adverse childhood experiences, psychopathology symptoms and two polymorphisms associated with an impaired serotoninergic and dopaminergic neurotransmission (5HTTLPR and Taq1A/DRD2). A logistic regression revealed that an early caring environment might lower the risk of developing an AUD. When controlling for the actual psychopathology symptoms, being male and having the genotype associated with an impaired dopaminergic neurotransmission were still associated with AUD. Results were confirmed by an unsupervised approach that showed how the clusters characterised by being male and having the high risk genotypes were still associated with AUD compared to being female without the unfavourable dopamine genotype.Our results point to the need for implementing prevention strategies aimed at creating a caring environment especially in those families with an alcoholic parent. We further suggest that psycho-education as a symptom recognition and avoiding self-medication could improve the outcome in those subjects at higher risk, especially males.
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Affiliation(s)
- Paolo Ossola
- Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Maria Carla Gerra
- Center for Neuroplasticity and Pain (CNAP), SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
| | - Maria Lidia Gerra
- Department of Mental Health, Local Health Agency Parma, Parma, Italy
| | - Giulia Milano
- Department of Laboratory Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marta Zatti
- Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Valeria Zavan
- Department of Addiction Pathology, Local Health Agency Alessandria, Alessandria, Italy
| | - Riccardo Volpi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Carlo Marchesi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Claudia Donnini
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy.
| | - Gilberto Gerra
- Drug Prevention and Health Branch, Division for Operations, United Nation Office on Drugs and Crime, Vienna, Austria.
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Oswald LM, Dunn KE, Seminowicz DA, Storr CL. Early Life Stress and Risks for Opioid Misuse: Review of Data Supporting Neurobiological Underpinnings. J Pers Med 2021; 11:315. [PMID: 33921642 PMCID: PMC8072718 DOI: 10.3390/jpm11040315] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 01/02/2023] Open
Abstract
A robust body of research has shown that traumatic experiences occurring during critical developmental periods of childhood when neuronal plasticity is high increase risks for a spectrum of physical and mental health problems in adulthood, including substance use disorders. However, until recently, relatively few studies had specifically examined the relationships between early life stress (ELS) and opioid use disorder (OUD). Associations with opioid use initiation, injection drug use, overdose, and poor treatment outcome have now been demonstrated. In rodents, ELS has also been shown to increase the euphoric and decrease antinociceptive effects of opioids, but little is known about these processes in humans or about the neurobiological mechanisms that may underlie these relationships. This review aims to establish a theoretical model that highlights the mechanisms by which ELS may alter opioid sensitivity, thereby contributing to future risks for OUD. Alterations induced by ELS in mesocorticolimbic brain circuits, and endogenous opioid and dopamine neurotransmitter systems are described. The limited but provocative evidence linking these alterations with opioid sensitivity and risks for OUD is presented. Overall, the findings suggest that better understanding of these mechanisms holds promise for reducing vulnerability, improving prevention strategies, and prescribing guidelines for high-risk individuals.
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Affiliation(s)
- Lynn M. Oswald
- Department of Family and Community Health, University of Maryland School of Nursing, Baltimore, MD 21201, USA;
| | - Kelly E. Dunn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21230, USA;
| | - David A. Seminowicz
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland, Baltimore, MD 21201, USA;
- Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD 21201, USA
| | - Carla L. Storr
- Department of Family and Community Health, University of Maryland School of Nursing, Baltimore, MD 21201, USA;
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Flykt MS, Lindblom J, Belt R, Punamäki R. The role of mother's prenatal substance use disorder and early parenting on child social cognition at school age. INFANT AND CHILD DEVELOPMENT 2021. [DOI: 10.1002/icd.2221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Marjo Susanna Flykt
- Faculty of Social Sciences Tampere University Tampere Finland
- Faculty of Medicine University of Helsinki Helsinki Finland
| | - Jallu Lindblom
- Faculty of Social Sciences Tampere University Tampere Finland
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12
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Swedo EA, Sumner SA, de Fijter S, Werhan L, Norris K, Beauregard JL, Montgomery MP, Rose EB, Hillis SD, Massetti GM. Adolescent Opioid Misuse Attributable to Adverse Childhood Experiences. J Pediatr 2020; 224:102-109.e3. [PMID: 32437756 PMCID: PMC8253221 DOI: 10.1016/j.jpeds.2020.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/20/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To estimate the proportion of opioid misuse attributable to adverse childhood experiences (ACEs) among adolescents. STUDY DESIGN A cross-sectional survey was administered to 10 546 seventh-to twelfth-grade students in northeastern Ohio in Spring 2018. Study measures included self-reported lifetime exposure to 10 ACEs and past 30-day use of nonmedical prescription opioid or heroin. Using generalized estimating equations, we evaluated associations between recent opioid misuse, individual ACEs, and cumulative number of ACEs. We calculated population attributable fractions to determine the proportion of adolescents' recent opioid misuse attributable to ACEs. RESULTS Nearly 1 in 50 adolescents reported opioid misuse within 30 days (1.9%); approximately 60% of youth experienced ≥1 ACE; 10.2% experienced ≥5 ACEs. Cumulative ACE exposure demonstrated a significant graded relationship with opioid misuse. Compared with youth with zero ACEs, youth with 1 ACE (aOR 1.9, 95% CI, 0.9-3.9), 2 ACEs (aOR, 3.8; 95% CI, 1.9-7.9), 3 ACEs (aOR, 3.7; 95% CI, 2.2-6.5), 4 ACEs (aOR, 5.8; 95% CI, 3.1-11.2), and ≥5 ACEs (aOR, 15.3; 95% CI, 8.8-26.6) had higher odds of recent opioid misuse. The population attributable fraction of recent opioid misuse associated with experiencing ≥1 ACE was 71.6% (95% CI, 59.8-83.5). CONCLUSIONS There was a significant graded relationship between number of ACEs and recent opioid misuse among adolescents. More than 70% of recent adolescent opioid misuse in our study population was attributable to ACEs. Efforts to decrease opioid misuse could include programmatic, policy, and clinical practice interventions to prevent and mitigate the negative effects of ACEs.
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Affiliation(s)
- Elizabeth A Swedo
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA; Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Steven A Sumner
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | - Jennifer L Beauregard
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA; Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA; Division of Congenital and Developmental Disorders, National Center on Birth Defects & Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Martha P Montgomery
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA; Ohio Department of Health, Columbus, OH; Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Erica B Rose
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA; Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA; Division of Foodborne, Waterborne & Environmental Diseases, National Center for Emerging & Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Susan D Hillis
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; Office of the Global AIDS Coordinator
| | - Greta M Massetti
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
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13
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Welsch L, Bailly J, Darcq E, Kieffer BL. The Negative Affect of Protracted Opioid Abstinence: Progress and Perspectives From Rodent Models. Biol Psychiatry 2020; 87:54-63. [PMID: 31521334 PMCID: PMC6898775 DOI: 10.1016/j.biopsych.2019.07.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/04/2019] [Accepted: 07/30/2019] [Indexed: 12/20/2022]
Abstract
Opioid use disorder (OUD) is characterized by the development of a negative emotional state that develops after a history of long-term exposure to opioids. OUD represents a true challenge for treatment and relapse prevention. Human research has amply documented emotional disruption in individuals with an opioid substance use disorder, at both behavioral and brain activity levels; however, brain mechanisms underlying this particular facet of OUD are only partially understood. Animal research has been instrumental in elucidating genes and circuits that adapt to long-term opioid use or are modified by acute withdrawal, but research on long-term consequences of opioid exposure and their relevance to the negative affect of OUD remains scarce. In this article, we review the literature with a focus on two questions: 1) Do we have behavioral models in rodents, and what do they tell us? and 2) What do we know about the neuronal populations involved? Behavioral rodent models have successfully recapitulated behavioral signs of the OUD-related negative affect, and several neurotransmitter systems were identified (i.e., serotonin, dynorphin, corticotropin-releasing factor, oxytocin). Circuit mechanisms driving the negative mood of prolonged abstinence likely involve the 5 main reward-aversion brain centers (i.e., nucleus accumbens, bed nucleus of the stria terminalis, amygdala, habenula, and raphe nucleus), all of which express mu opioid receptors and directly respond to opioids. Future work will identify the nature of these mu opioid receptor-expressing neurons throughout reward-aversion networks, characterize their adapted phenotype in opioid abstinent animals, and hopefully position these primary events in the broader picture of mu opioid receptor-associated brain aversion networks.
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Affiliation(s)
- Lola Welsch
- Douglas Mental Health Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Julie Bailly
- Douglas Mental Health Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Emmanuel Darcq
- Douglas Mental Health Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Brigitte Lina Kieffer
- Douglas Mental Health Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada.
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Carlyle M, Rowley M, Stevens T, Karl A, Morgan CJA. Impaired empathy and increased anger following social exclusion in non-intoxicated opioid users. Psychopharmacology (Berl) 2020; 237:419-430. [PMID: 31686176 PMCID: PMC7018792 DOI: 10.1007/s00213-019-05378-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/05/2019] [Indexed: 12/25/2022]
Abstract
RATIONALE Social functioning is modulated by the endogenous opioid system. In opioid use disorder, social functioning appears disrupted, but little research has delineated the nature of these deficits and their relationship to acute opioid use. OBJECTIVES The current study aimed to assess both emotional and cognitive empathy, along with subjective and physiological responses to social exclusion in opioid users who were either acutely intoxicated or non-intoxicated from using opioids. METHODS Individuals on an opioid substitution medication (OSM) were divided into 'intoxicated users' (had taken their OSM the same day as testing, n = 20) and 'non-intoxicated users' (had taken their OSM > 12 h ago, n = 20) and compared with opioid-naïve controls (n = 24). Empathy was assessed using the multifaceted empathy test and self-report questionnaire. Participants also underwent a period of social exclusion (Cyberball Game) and completed measures of mood and physiological responses (salivary cortisol and heart rate). RESULTS Non-intoxicated users had significantly lower emotional empathy (the ability to experience others' emotions), as well as greater anger after social exclusion when compared with the intoxicated users and controls. Anger did not change with social exclusion in the intoxicated user group and cortisol levels were lower overall. CONCLUSIONS Reduced ability to spontaneously share the emotions of others was reported in non-intoxicated users, particularly regarding positive emotions. There was some support for the idea of hyperalgesia to social pain, but this was restricted to an enhanced anger response in non-intoxicated users. Equivalent rates of empathy between the intoxicated users and controls could indicate some remediating effects of acute opioids.
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Affiliation(s)
- Molly Carlyle
- Psychopharmacology and Addiction Research Centre (PARC), University of Exeter, Washington Singer Building, Perry Road, Exeter, EX4 4QG, UK.
| | - Megan Rowley
- Psychopharmacology and Addiction Research Centre (PARC), University of Exeter, Washington Singer Building, Perry Road, Exeter, EX4 4QG, UK
| | - Tobias Stevens
- Psychopharmacology and Addiction Research Centre (PARC), University of Exeter, Washington Singer Building, Perry Road, Exeter, EX4 4QG, UK
| | - Anke Karl
- Psychopharmacology and Addiction Research Centre (PARC), University of Exeter, Washington Singer Building, Perry Road, Exeter, EX4 4QG, UK
| | - Celia J A Morgan
- Psychopharmacology and Addiction Research Centre (PARC), University of Exeter, Washington Singer Building, Perry Road, Exeter, EX4 4QG, UK
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15
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Khosravani V, Samimi Ardestani SM, Sharifi Bastan F, Mohammadzadeh A, Amirinezhad A. Childhood maltreatment, cognitive emotion regulation strategies, and alcohol craving and dependence in alcohol-dependent males: Direct and indirect pathways. CHILD ABUSE & NEGLECT 2019; 98:104197. [PMID: 31600610 DOI: 10.1016/j.chiabu.2019.104197] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 09/14/2019] [Accepted: 09/17/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Childhood maltreatment (CM) and cognitive emotion regulation strategies (CERSs) may be important in alcohol craving and dependence in alcohol-dependent individuals. The aim of this study was to evaluate direct effects of CM on the subscales of alcohol craving and alcohol dependence and its indirect effects via CERSs in individuals with a diagnosis of alcohol dependence. METHODS In a cross-sectional design, 329 alcohol-dependent males completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Cognitive Emotion Regulation Questionnaire-Short version (CERQ-Short), the Alcohol Dependence Scale (ADS), the Obsessive Compulsive Drinking Scale (OCDS), and the Beck Depression Inventory-II (BDI-II). RESULTS Participants with alcohol dependence had early age of onset of alcohol use (mean = 20.78 years), relatively long duration of alcohol use (mean = 11.14 years), and low education (mean = 9.55 years). Indirect effects were observed from CM to the subscales of alcohol craving and dependence only through maladaptive CERSs after adjusting for demographic and clinical factors. No direct effect was observed through CM on the subscales of alcohol craving and dependence. CONCLUSIONS Although drawing causal conclusions from the current research is impossible, the findings suggest that maladaptive CERSs may be a possible mechanism relating CM to alcohol craving and dependence in treatment-seeking alcohol-dependent individuals, while adaptive CERSs may be less important regarding this relation. However, the findings of the current study need longitudinal research.
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Affiliation(s)
- Vahid Khosravani
- Behavioral Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Seyed Mehdi Samimi Ardestani
- Departments of Psychiatry, Behavioral Sciences Research Center, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | | | - Ali Amirinezhad
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
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16
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Direct and indirect associations between perception of childhood trauma and suicidal ideation through emotion dysregulation in males who use heroin. Addict Behav 2019; 98:106011. [PMID: 31233952 DOI: 10.1016/j.addbeh.2019.05.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/17/2022]
Abstract
Emotion dysregulation is considered as one of the factors related to suicide in individuals with childhood trauma (CT). However, no research has been performed on the role of emotion dysregulation in the relationship between perception of CT and suicidal ideation in individuals who use heroin. This study aimed to evaluate direct and indirect relationships between perception of CT and suicidal ideation through emotion regulation difficulties (ERD) and cognitive emotion regulation strategies (CERSs) in males with a DSM diagnosis of heroin dependence. In a cross-sectional design, 310 males with a DSM diagnosis of heroin dependence completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Difficulties in Emotion Regulation Scale (DERS), the Cognitive Emotion Regulation Questionnaire-Short version (CERQ-Short), the Obsessive-Compulsive Drug Use Scale-Form Heroin (OCDUS-Form Heroin), and the Depression Anxiety Stress Scales (DASS). The results revealed that perception of CT had no direct relation to suicidal ideation. Perception of CT was indirectly associated with suicidal ideation through some ERD dimensions [e.g., non-acceptance of emotional responses (Non-acceptance), limited access to emotion regulation strategies (Strategies), lack of emotional awareness (Awareness)] and the CERS of positive reappraisal. The findings suggest that high suicidal ideation may stem from a perception of CT and subsequently emotion dysregulation in individuals who use heroin. Also, the findings of this research may have implications for the prevention and treatment of suicidal ideation in individuals using heroin with a perception of CT. The results of the present study require further examination through longitudinal studies.
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Khosravani V, Messman-Moore TL, Mohammadzadeh A, Ghorbani F, Amirinezhad A. Effects of childhood emotional maltreatment on depressive symptoms through emotion dysregulation in treatment-seeking patients with heroin-dependence. J Affect Disord 2019; 256:448-457. [PMID: 31252238 DOI: 10.1016/j.jad.2019.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/05/2019] [Accepted: 06/21/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although individuals who experience childhood emotional maltreatment (CEM) are more likely to use maladaptive emotion regulation strategies, resulting in vulnerability to depression, no research has examined whether emotion dysregulation may explain the association between CEM and current depressive symptoms in a clinical sample of heroin-dependent individuals. OBJECTIVES The current study aimed to assess the direct effect of CEM on current depressive symptoms and its indirect effect via emotion dysregulation in a treatment-seeking sample of males with heroin dependence. In a cross-sectional design, participants (N = 350) completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Difficulties in Emotion Regulation Scale (DERS), the Obsessive-Compulsive Drug Use Scale (OCDUS), and the Beck Depression Inventory-II (BDI-II). RESULTS Emotional abuse and neglect severity had significant direct effects on current depressive symptoms and significant indirect effects through emotion dysregulation after controlling for clinical factors related to heroin use. LIMITATIONS Study limitations include the cross-sectional design and use of self-report scales. CONCLUSIONS Findings suggest emotion dysregulation may increase depressive symptoms in heroin users who experienced CEM. Training in emotion regulation strategies may decrease depressive symptoms in heroin-dependent individuals with CEM. Additional research with a longitudinal design to confirm these results is warranted.
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Affiliation(s)
- Vahid Khosravani
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran.
| | | | | | - Fatemeh Ghorbani
- Clinical Research Development Center of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Amirinezhad
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
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18
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The role of emotion dysregulation in the relation of childhood trauma to heroin craving in individuals with heroin dependence. Drug Alcohol Depend 2019; 195:132-139. [PMID: 30634108 DOI: 10.1016/j.drugalcdep.2018.12.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/02/2018] [Accepted: 12/11/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Difficulties in emotion regulation (DER) may be important in heroin craving in individuals with heroin dependence who have experienced childhood trauma (CT). However, no research has been performed on DER in the context of heroin dependence. The aim of this study was to evaluate direct and indirect relations of CT to the subscales of heroin craving (i.e., heroin thoughts and interference, intention to use heroin and control of its consumption, and resistance to thoughts and decisions to use heroin) via DER dimensions in individuals with a DSM diagnosis of heroin dependence. METHODS In a cross-sectional design, 330 males with heroin dependence completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Difficulties in Emotion Regulation Scale (DERS), the Obsessive-Compulsive Drug Use Scale-Form Heroin (OCDUS-Form Heroin), and the Depression Anxiety Stress Scales (DASS). RESULTS The results revealed that CT had no direct relations to the subscales of heroin craving, but it indirectly was related to all three subscales of heroin craving via one of the DER dimensions named limited access to emotion regulation strategies (Strategies) after adjusting for demographic and clinical factors. CONCLUSIONS The findings suggest that Strategies may be related to heroin craving in individuals with heroin dependence who have CT. This proposes that treatment and prevention attempts focused on training the use of effective emotion regulation strategies may be useful to reduce heroin craving in individuals with heroin dependence who have experienced a history of CT.
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Wemm SE, Sinha R. Drug-induced stress responses and addiction risk and relapse. Neurobiol Stress 2019; 10:100148. [PMID: 30937354 PMCID: PMC6430516 DOI: 10.1016/j.ynstr.2019.100148] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/07/2018] [Accepted: 01/30/2019] [Indexed: 12/21/2022] Open
Abstract
A number of studies have assessed the effects of psychoactive drugs on stress biology, the neuroadaptations resulting from chronic drug use on stress biology, and their effects on addiction risk and relapse. This review mainly covers human research on the acute effects of different drugs of abuse (i.e., nicotine, cannabis, psychostimulants, alcohol, and opioids) on the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system (ANS) responses. We review the literature on acute peripheral stress responses in naïve or light recreational users and binge/heavy or chronic drug users. We also discuss evidence of alterations in tonic levels, or tolerance, in the latter relative to the former and associated changes in the phasic stress responses. We discuss the impact of the stress system tolerance in heavy users on their response to drug- and stress-related cue responses and craving as compared to control subjects. A summary is provided of the effects of glucocorticoid responses and their adaptations on brain striatal and prefrontal cortices involved in the regulation of drug seeking and relapse risk. Finally, we summarize important considerations, including individual difference factors such as gender, co-occurring drug use, early trauma and adversity and drug use history and variation in methodologies, that may further influence the effects of these drugs on stress biology.
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Affiliation(s)
- Stephanie E. Wemm
- Yale Stress Center, Yale School of Medicine, 2 Church St South Suite 209, New Haven, CT, 06519, USA
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20
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Naal H, El Jalkh T, Haddad R. Adverse childhood experiences in substance use disorder outpatients of a Lebanese addiction center. PSYCHOL HEALTH MED 2018; 23:1137-1144. [DOI: 10.1080/13548506.2018.1469781] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Hady Naal
- Department of Psychology, Haigazian University, Beirut, Lebanon
| | - Tatiana El Jalkh
- Department of Life and Earth Sciences, Faculty of Sciences, Lebanese University, Beirut, Lebanon
| | - Ramzi Haddad
- Department of Psychiatry, Saint Joseph University, Beirut, Lebanon
- Department of Psychiatry, Lebanese University, Beirut, Lebanon
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Stein MD, Conti MT, Kenney S, Anderson BJ, Flori JN, Risi MM, Bailey GL. Adverse childhood experience effects on opioid use initiation, injection drug use, and overdose among persons with opioid use disorder. Drug Alcohol Depend 2017; 179:325-329. [PMID: 28841495 PMCID: PMC5599365 DOI: 10.1016/j.drugalcdep.2017.07.007] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 07/12/2017] [Accepted: 07/13/2017] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Adverse childhood experiences are associated with the development of substance use disorders. With opioid use disorder, a growing concern in the United States, we were interested in examining the relationship between adverse experiences and three landmarks of opioid use: age of opioid initiation, injection drug use, and lifetime overdose. METHODS Between May and December 2015, we interviewed consecutive persons seeking inpatient opioid detoxification. Participants were asked about age of opioid initiation, last month injection drug use, and lifetime history of overdose, and completed the ten-item Adverse Childhood Experience (ACE) questionnaire. RESULTS Participants (n=457) averaged 32.2 (±8.64) years of age, 71.3% were male, and 82.5% were non-Hispanic White. The mean score on the ACE scale was 3.64 (±2.75). Mean age at time of initiating opioid use was 21.7 (±7.1) years, 68.7% had injected drugs within the past month, and 39.0% had overdosed. After adjusting for age, gender, and ethnicity, the ACE score was inversely associated with age of initiating opioid use (b=-0.50, 95% CI -0.70; -0.29, p<.001), and positively associated with recent injection drug use (OR=1.11, 95% CI 1.02; 1.20, p=0.014) and the likelihood of experiencing an overdose (OR=1.10, 95% CI 1.02; 1.20, p=0.015) in a graded dose response manner. CONCLUSION Greater adverse childhood experiences are associated with three landmarks of opioid use risk. ACE screening may be useful in identifying high-risk subsets of opioid-using populations.
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Affiliation(s)
- Michael D. Stein
- Behavioral Medicine, Butler Hospital, Providence, RI, 02906,Boston University School of Public Health, Boston, MA 02118
| | - Micah T. Conti
- Behavioral Medicine, Butler Hospital, Providence, RI, 02906,Stanley Street Treatment and Resources, Inc., Fall River, Massachusetts 02720
| | - Shannon Kenney
- Behavioral Medicine, Butler Hospital, Providence, RI, 02906, USA; Warren Alpert Medical School of Brown University, Providence, RI, 02912, USA.
| | | | - Jessica N. Flori
- Behavioral Medicine, Butler Hospital, Providence, RI, 02906,Stanley Street Treatment and Resources, Inc., Fall River, Massachusetts 02720
| | - Megan M. Risi
- Behavioral Medicine, Butler Hospital, Providence, RI, 02906,Stanley Street Treatment and Resources, Inc., Fall River, Massachusetts 02720
| | - Genie L. Bailey
- Stanley Street Treatment and Resources, Inc., Fall River, Massachusetts 02720,Warren Alpert Medical School of Brown University, Providence, RI, 02912
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Montagud-Romero S, Nuñez C, Blanco-Gandia MC, Martínez-Laorden E, Aguilar MA, Navarro-Zaragoza J, Almela P, Milanés MV, Laorden ML, Miñarro J, Rodríguez-Arias M. Repeated social defeat and the rewarding effects of cocaine in adult and adolescent mice: dopamine transcription factors, proBDNF signaling pathways, and the TrkB receptor in the mesolimbic system. Psychopharmacology (Berl) 2017; 234:2063-2075. [PMID: 28466092 DOI: 10.1007/s00213-017-4612-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 03/25/2017] [Indexed: 02/07/2023]
Abstract
RATIONALE Repeated social defeat (RSD) increases the rewarding effects of cocaine in adolescent and adult rodents. OBJECTIVE The aim of the present study was to compare the long-term effects of RSD on the conditioned rewarding effects of cocaine and levels of the transcription factors Pitx3 and Nurr1 in the ventral tegmental area (VTA), the dopamine transporter (DAT), the D2 dopamine receptor (D2DR) and precursor of brain-derived neurotrophic factor (proBDNF) signaling pathways, and the tropomyosin-related kinase B (TrkB) receptor in the nucleus accumbens (NAc) in adult and adolescent mice. METHODS Male adolescent and young adult OF1 mice were exposed to four episodes of social defeat and were conditioned 3 weeks later with 1 mg/kg of cocaine. In a second set of mice, the expressions of the abovementioned dopaminergic and proBDNF and TrkB receptor were measured in VTA and NAc, respectively. RESULTS Adolescent mice experienced social defeats less intensely than their adult counterparts and produced lower levels of corticosterone. However, both adult and adolescent defeated mice developed conditioned place preference for the compartment associated with this low dose of cocaine. Furthermore, only adolescent defeated mice displayed diminished levels of the transcription factors Pitx3 in the VTA, without changes in the expression of DAT and D2DR in the NAc. In addition, stressed adult mice showed a decreased expression of proBDNF and the TrkB receptor, while stressed adolescent mice exhibited increased expression of latter without changes in the former. CONCLUSION Our findings suggest that dopaminergic pathways and proBDNF signaling and TrkB receptors play different roles in social defeat-stressed mice exposed to cocaine.
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Affiliation(s)
- Sandra Montagud-Romero
- Department of Psychobiology, Facultad de Psicología, Universitat de Valencia, Avda. Blasco Ibáñez, 21, 46010, Valencia, Spain
| | - Cristina Nuñez
- Murcia Research Institute of Health Sciences (IMIB) and Faculty of Medicine, University of Murcia, Murcia, Spain
| | - M Carmen Blanco-Gandia
- Department of Psychobiology, Facultad de Psicología, Universitat de Valencia, Avda. Blasco Ibáñez, 21, 46010, Valencia, Spain
| | - Elena Martínez-Laorden
- Murcia Research Institute of Health Sciences (IMIB) and Faculty of Medicine, University of Murcia, Murcia, Spain
| | - María A Aguilar
- Department of Psychobiology, Facultad de Psicología, Universitat de Valencia, Avda. Blasco Ibáñez, 21, 46010, Valencia, Spain.,Red Tematica de Investigacion Cooperativa en Salud (RETICS-Trastornos Adictivos), Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain
| | - Javier Navarro-Zaragoza
- Murcia Research Institute of Health Sciences (IMIB) and Faculty of Medicine, University of Murcia, Murcia, Spain
| | - Pilar Almela
- Murcia Research Institute of Health Sciences (IMIB) and Faculty of Medicine, University of Murcia, Murcia, Spain
| | - Maria-Victoria Milanés
- Murcia Research Institute of Health Sciences (IMIB) and Faculty of Medicine, University of Murcia, Murcia, Spain.,Red Tematica de Investigacion Cooperativa en Salud (RETICS-Trastornos Adictivos), Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain
| | - María-Luisa Laorden
- Murcia Research Institute of Health Sciences (IMIB) and Faculty of Medicine, University of Murcia, Murcia, Spain.,Red Tematica de Investigacion Cooperativa en Salud (RETICS-Trastornos Adictivos), Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain
| | - José Miñarro
- Department of Psychobiology, Facultad de Psicología, Universitat de Valencia, Avda. Blasco Ibáñez, 21, 46010, Valencia, Spain.,Red Tematica de Investigacion Cooperativa en Salud (RETICS-Trastornos Adictivos), Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain
| | - Marta Rodríguez-Arias
- Department of Psychobiology, Facultad de Psicología, Universitat de Valencia, Avda. Blasco Ibáñez, 21, 46010, Valencia, Spain. .,Red Tematica de Investigacion Cooperativa en Salud (RETICS-Trastornos Adictivos), Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain.
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Ieong HFH, Yuan Z. Resting-State Neuroimaging and Neuropsychological Findings in Opioid Use Disorder during Abstinence: A Review. Front Hum Neurosci 2017; 11:169. [PMID: 28428748 PMCID: PMC5382168 DOI: 10.3389/fnhum.2017.00169] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 03/22/2017] [Indexed: 01/07/2023] Open
Abstract
Dependence to opiates, including illicit heroin and prescription pain killers, and treatment of the opioid use disorder (OUD) have been longstanding problems over the world. Despite intense efforts to scientific investigation and public health care, treatment outcomes have not significantly improved for the past 50 years. One reason behind the continuing use of heroin worldwide despite such efforts is its highly addictive nature. Brain imaging studies over the past two decades have made significant contribution to the understanding of the addictive properties as to be due in part to biological processes, specifically those in the brain structure and function. Moreover, traditional clinical neuropsychology studies also contribute to the account in part for the treatment-refractory nature of the drug abuse. However, there is a gap between those studies, and the rates of relapse are still high. Thus, a multidisciplinary approach is needed to understand the fundamental neural mechanism of OUD. How does the brain of an OUD patient functionally and cognitively differ from others? This brief review is to compare and contrast the current literature on non-invasive resting state neuroimaging and clinical neuropsychological studies with the focus on the abstinence stage in OUD. The results show as follow:
Brain connectivity strength in the reward system, dysregulation of circuits associated with emotion and stress, enhanced beta and alpha power activity, and high impulsivity are induced by OUD. Some recovery signs in cognition are demonstrated in OUD subjects after prolonged abstinence, but not in the subjects undergoing methadone treatment. Normalization in the composition of brain oscillations especially in the temporal region is induced and restored by methadone treatment in roughly 6 months in mean duration for OUDs having a mean opioid-use history of 10 years.
We hope that the review provides valuable implications for clinical research and practice and paves a new insight into the future path to the identification of potential biomarkers and clinical outcome predictors in OUD in the domains of brain regions, functions, and behaviors.
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Affiliation(s)
- Hada Fong-Ha Ieong
- Bioimaging Core, Faculty of Health Sciences, University of MacauTaipa, Macau
| | - Zhen Yuan
- Bioimaging Core, Faculty of Health Sciences, University of MacauTaipa, Macau
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Abstract
Medical yoga is defined as the use of yoga practices for the prevention and treatment of medical conditions. Beyond the physical elements of yoga, which are important and effective for strengthening the body, medical yoga also incorporates appropriate breathing techniques, mindfulness, and meditation in order to achieve the maximum benefits. Multiple studies have shown that yoga can positively impact the body in many ways, including helping to regulate blood glucose levels, improve musculoskeletal ailments and keeping the cardiovascular system in tune. It also has been shown to have important psychological benefits, as the practice of yoga can help to increase mental energy and positive feelings, and decrease negative feelings of aggressiveness, depression and anxiety.
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25
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Laviolette SR. Cannabinoid regulation of opiate motivational processing in the mesolimbic system: the integrative roles of amygdala, prefrontal cortical and ventral hippocampal input pathways. Curr Opin Behav Sci 2017. [DOI: 10.1016/j.cobeha.2016.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Biseul I, Icick R, Seguin P, Bellivier F, Scott J. Feasibility and Acceptability of the 'HABIT' Group Programme for Comorbid Bipolar and Alcohol and Substance use Disorders. Clin Psychol Psychother 2016; 24:887-898. [PMID: 27761983 DOI: 10.1002/cpp.2053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/03/2016] [Accepted: 10/04/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVES We investigated the feasibility and acceptability of an integrated group therapy (called HABIT) for comorbid bipolar disorder (BD) and alcohol and substance use disorders (ASUD) (BD-ASUD), a disabling clinical presentation for which no specific treatment has been validated. The 14-session HABIT programme employs psychoeducation-oriented cognitive-behaviour therapy (CBT) followed by mindfulness-based relapse prevention (MBRP) therapy. METHOD Potential group participants were recruited from adult clients with a DSM-IV diagnosis of BD and an ASUD who were referred by their treating clinician. Observer-rated changes in mood symptoms and ASUD, attendance rates and subjective feedback are reported. RESULTS Eight of 12 clients referred to the programme initially agreed to join the group, six attended the first group session and five clients completed the programme. Group mean scores for mood symptoms improved over time, with slightly greater reductions in depression during the first module. About 50% of individuals showed clinically significant improvement (≥30% reduction) in alcohol and substance use. Attendance rates showed some variability between individuals and across sessions, but the average attendance rate of the group was marginally higher for the first module (86%) as compared with the second module (77%). Most clients reported high levels of general satisfaction with a group specifically targeted at individuals with BD-ASUD. CONCLUSION This small pilot study suggests our intensive group therapy is acceptable and feasible. If findings are replicated, we may have identified a therapy that, for the first time, leads to improvement in both mood and substance use outcomes in clients with difficult-to-treat comorbid BD-ASUD. Copyright © 2016 John Wiley & Sons, Ltd. Key Practitioner Message Comorbidity between bipolar and alcohol and substance use disorders (BD-ASUD) is frequent and highly disabling; Therapeutic research on approaches that can simultaneously help BD and ASUD is lacking; Previous research highlights the need for integrated treatment of both conditions but showed improvements limited to either element of the comorbid disorder; This pilot study supports the feasibility and acceptability of an intensive, 14-session group therapy programme that integrates CBT and mindfulness approaches.
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Affiliation(s)
- Isabelle Biseul
- Assistance Publique-Hôpitaux de Paris, GH Saint-Louis-Lariboisière-Fernand Widal, Département de Psychiatrie et de Médecine Addictologique, Paris, France.,Fondation FondaMental, Créteil, France
| | - Romain Icick
- Assistance Publique-Hôpitaux de Paris, GH Saint-Louis-Lariboisière-Fernand Widal, Département de Psychiatrie et de Médecine Addictologique, Paris, France.,Fondation FondaMental, Créteil, France.,Inserm, U1144, Paris, France.,Université Paris Descartes, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, UMR-S 1144, Paris, France
| | - Perrine Seguin
- Assistance Publique-Hôpitaux de Paris, GH Saint-Louis-Lariboisière-Fernand Widal, Département de Psychiatrie et de Médecine Addictologique, Paris, France.,Fondation FondaMental, Créteil, France
| | - Frank Bellivier
- Assistance Publique-Hôpitaux de Paris, GH Saint-Louis-Lariboisière-Fernand Widal, Département de Psychiatrie et de Médecine Addictologique, Paris, France.,Fondation FondaMental, Créteil, France.,Inserm, U1144, Paris, France.,Université Paris Descartes, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, UMR-S 1144, Paris, France
| | - Jan Scott
- Academic Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Centre for Affective Disorders, IPPN, London, UK
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Phillips TJ, Reed C, Pastor R. Preclinical evidence implicating corticotropin-releasing factor signaling in ethanol consumption and neuroadaptation. GENES BRAIN AND BEHAVIOR 2015; 14:98-135. [PMID: 25565358 DOI: 10.1111/gbb.12189] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 11/22/2014] [Accepted: 11/25/2014] [Indexed: 12/15/2022]
Abstract
The results of many studies support the influence of the corticotropin-releasing factor (CRF) system on ethanol (EtOH) consumption and EtOH-induced neuroadaptations that are critical in the addiction process. This review summarizes the preclinical data in this area after first providing an overview of the components of the CRF system. This complex system involves hypothalamic and extra-hypothalamic mechanisms that play a role in the central and peripheral consequences of stressors, including EtOH and other drugs of abuse. In addition, several endogenous ligands and targets make up this system and show differences in their involvement in EtOH drinking and in the effects of chronic or repeated EtOH treatment. In general, genetic and pharmacological approaches paint a consistent picture of the importance of CRF signaling via type 1 CRF receptors (CRF(1)) in EtOH-induced neuroadaptations that result in higher levels of intake, encourage alcohol seeking during abstinence and alter EtOH sensitivity. Furthermore, genetic findings in rodents, non-human primates and humans have provided some evidence of associations of genetic polymorphisms in CRF-related genes with EtOH drinking, although additional data are needed. These results suggest that CRF(1) antagonists have potential as pharmacotherapeutics for alcohol use disorders. However, given the broad and important role of these receptors in adaptation to environmental and other challenges, full antagonist effects may be too profound and consideration should be given to treatments with modulatory effects.
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Affiliation(s)
- T J Phillips
- VA Portland Health Care System, Portland Alcohol Research Center, Methamphetamine Abuse Research Center, Oregon Health & Science University, Portland, OR, USA; Department of Behavioral Neuroscience, Portland Alcohol Research Center, Methamphetamine Abuse Research Center, Oregon Health & Science University, Portland, OR, USA
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Flanagan JC, Baker NL, McRae-Clark AL, Brady KT, Moran-Santa Maria MM. Effects of adverse childhood experiences on the association between intranasal oxytocin and social stress reactivity among individuals with cocaine dependence. Psychiatry Res 2015; 229:94-100. [PMID: 26231584 PMCID: PMC4546857 DOI: 10.1016/j.psychres.2015.07.064] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 07/21/2015] [Accepted: 07/22/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Drug dependence and adverse childhood experiences (ACE) are commonly reflected by dysregulation of the hypothalamic-pituitary-adrenal axis (HPA). Accumulating research indicates that the neuropeptide oxytocin may regulate HPA function, resulting in reductions in neuroendocrine reactivity to social stress among individuals with drug dependence. However, emerging literature suggests that individual differences may differentially impact intranasal oxytocin's effects on human social behaviors. METHODS This study employed a double-blind, placebo-controlled design to examine the extent to which ACE influenced the effects of intranasal oxytocin (40IU) on neuroendocrine reactivity to a laboratory social stress paradigm in a sample of 31 cocaine-dependent individuals. RESULTS ACE scores modified the relationship between intranasal oxytocin and cortisol reactivity. While ACE modified the relationship between intranasal oxytocin and DHEA response in a similar direction to what was seen in cortisol, it did not reach statistical significance. CONCLUSIONS Findings are congruent with the emerging hypothesis that intranasal oxytocin may differentially attenuate social stress reactivity among individuals with specific vulnerabilities. Future research examining the nuances of intranasal oxytocin's therapeutic potential is necessary.
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Affiliation(s)
- Julianne C. Flanagan
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 5 Charleston Center Drive, Suite 151, Charleston, SC, USA, 29401
| | - Nathaniel L. Baker
- Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon Street, Suite 303, Charleston, SC, USA, 29425
| | - Aimee L. McRae-Clark
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 5 Charleston Center Drive, Suite 151, Charleston, SC, USA, 29401
| | - Kathleen T. Brady
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 5 Charleston Center Drive, Suite 151, Charleston, SC, USA, 29401,Ralph H. Johnson Veterans Affairs Medical Center, 109 Bee St., Charleston, SC, USA, 29401
| | - Margaret M. Moran-Santa Maria
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 5 Charleston Center Drive, Suite 151, Charleston, SC, USA, 29401
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Golkar A, Johansson E, Kasahara M, Osika W, Perski A, Savic I. The influence of work-related chronic stress on the regulation of emotion and on functional connectivity in the brain. PLoS One 2014; 9:e104550. [PMID: 25184294 PMCID: PMC4153588 DOI: 10.1371/journal.pone.0104550] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 07/11/2014] [Indexed: 12/29/2022] Open
Abstract
Despite mounting reports about the negative effects of chronic occupational stress on cognitive and emotional functions, the underlying mechanisms are unknown. Recent findings from structural MRI raise the question whether this condition could be associated with a functional uncoupling of the limbic networks and an impaired modulation of emotional stress. To address this, 40 subjects suffering from burnout symptoms attributed to chronic occupational stress and 70 controls were investigated using resting state functional MRI. The participants' ability to up- regulate, down-regulate, and maintain emotion was evaluated by recording their acoustic startle response while viewing neutral and negatively loaded images. Functional connectivity was calculated from amygdala seed regions, using explorative linear correlation analysis. Stressed subjects were less capable of down-regulating negative emotion, but had normal acoustic startle responses when asked to up-regulate or maintain emotion and when no regulation was required. The functional connectivity between the amygdala and the anterior cingulate cortex correlated with the ability to down-regulate negative emotion. This connectivity was significantly weaker in the burnout group, as was the amygdala connectivity with the dorsolateral prefrontal cortex and the motor cortex, whereas connectivity from the amygdala to the cerebellum and the insular cortex were stronger. In subjects suffering from chronic occupational stress, the functional couplings within the emotion- and stress-processing limbic networks seem to be altered, and associated with a reduced ability to down-regulate the response to emotional stress, providing a biological substrate for a further facilitation of the stress condition.
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Affiliation(s)
- Armita Golkar
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Emilia Johansson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Maki Kasahara
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Walter Osika
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Center for Social Sustainability, Department of Neurobiology, Care Sciences and Society, Karolinska institute, Stockholm, Sweden
| | | | - Ivanka Savic
- Department of Women's and children's health, and Neurology Clinic, Karolinska Institute and Hospital, Stockholm, Sweden
- * E-mail:
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