Serotonergic functioning in depressed abused children: clinical and familial correlates

Effects of physical activity in child and adolescent depression and anxiety: role of inflammatory cytokines and stress-related peptide hormones

Depression and anxiety are the most common mental illnesses affecting children and adolescents, significantly harming their well-being. Research has shown that regular physical activity can promote cognitive, emotional, fundamental movement skills, and motor coordination, as a preventative measure for depression while reducing the suicide rate. However, little is known about the potential role of physical activity in adolescent depression and anxiety. The studies reviewed in this paper suggest that exercise can be an effective adjunctive treatment to improve depressive and anxiety symptoms in adolescents, although research on its neurobiological effects remains limited.

Childhood attachment and schizophrenia: the "attachment-developmental-cognitive" (ADC) hypothesis

Schizophrenia is a complex psychiatric syndrome whose exact causes remain unclear. However, current scientific consensus has highlighted the importance of neurodevelopmental and neurocognitive processes in the development of schizophrenic symptoms. Research over the past three decades, motivated by the findings of the World Health Organization's large-scale studies, has highlighted the importance of psychosocial adversities - including childhood abuse and neglect - in this disorder. In this paper, I propose a hypothesis based on John Bowlby's framework of attachment theory, which I have termed the attachment-developmental-cognitive (ADC) hypothesis. The ADC hypothesis integrates recent developments related to (1) existing models of schizophrenia, (2) studies examining the effect of attachment on brain biology and cognitive development, and (3) various known facts about the course and outcome of this disorder. In doing so, it explains how disturbed childhood attachment leads to core psychological and neurochemical abnormalities which are implicated in the genesis of schizophrenia and also affect its outcome. The ADC hypothesis compasses and expands on earlier formulations, such as the "social defeat" and "traumagenic" models, and has important implications regarding the prevention and treatment of schizophrenia. Ways of testing and refining this hypothesis are outlined as avenues for future research. Though provisional, the ADC hypothesis is entirely consistent with both biological and psychosocial research into the origins of schizophrenia.

Prolactin and psychopathology in schizophrenia: a literature review and reappraisal

Secretion of the anterior pituitary hormone prolactin can be significantly increased by antipsychotic drugs, leading to a range of adverse effects in patients with schizophrenia. However, there is evidence from a variety of studies that prolactin may also be related to symptom profile and treatment response in these patients, and recent work has identified variations in prolactin secretion even in drug-free patients. In this paper, a selective review of all relevant studies pertaining to prolactin and schizophrenia, including challenge and provocation studies, is presented. The implications of this work are discussed critically. A tentative model, which synthesizes these findings and argues for a significant role for prolactin in the development of schizophrenia, is outlined.

Mood disorders in youth: exercise, light therapy, and pharmacologic complementary and integrative approaches

The therapeutic value of physical exercise, bright light therapy and dawn simulation, and several pharmacologic treatments, including hypericum (St. John's wort), S-adenosylmethionine, and 5-hydroxytryptophan, are reviewed, with a focus on their use for treating major depressive disorder in children and adolescents and also for alleviating depressed mood in the general (nonclinical) population of youth. For each treatment discussed, all published randomized, double-blind, placebo-controlled trials are summarized, along with some additional selected studies. Nutritional psychopharmacology and several other approaches to treating depression will be presented in an upcoming volume in the Child and Adolescent Psychiatric Clinics of North America.

Understanding behavioral effects of early life stress using the reactive scope and allostatic load models

The mechanisms through which early life stress leads to psychopathology are thought to involve allostatic load, the "wear and tear" an organism is subjected to as a consequence of sustained elevated levels of glucocorticoids caused by repeated/prolonged stress activations. The allostatic load model described this phenomenon, but has been criticized as inadequate to explain alterations associated with early adverse experience in some systems, including behavior, which cannot be entirely explained from an energy balance perspective. The reactive scope model has been more recently proposed and focuses less on energy balance and more on dynamic ranges of physiological and behavioral mediators. In this review we examine the mechanisms underlying the behavioral consequences of early life stress in the context of both these models. We focus on adverse experiences that involve mother-infant relationship disruption, and dissect those mechanisms involving maternal care as a regulator of development of neural circuits that control emotional and social behaviors in the offspring. We also discuss the evolutionary purpose of the plasticity in behavioral development, which has a clear adaptive value in a changing environment.

Neurobiological adaptations to violence across development

Developmental adaptations to violent environments involve a multitude of cascading effects spanning many levels of analysis from genes to behavior. In this review, we (a) examine the potentiating effects of violence on genetic vulnerabilities and the functioning of neurotransmitter systems in producing both internalizing and externalizing psychopathology; (b) describe implications of violence exposure for brain development, particularly within the hippocampus and prefrontal cortex; and (c) consider the effects of violence on developing human stress and startle responses. This review integrates literatures on the developmental effects of violence among rodents, nonhuman primates, and humans. Many neurobiological changes that are adaptive for survival in violent contexts become maladaptive in other environments, conferring life-long risk for psychopathology.

Early life stress, the development of aggression and neuroendocrine and neurobiological correlates: what can we learn from animal models?

Early life stress (child and adolescent abuse, neglect and trauma) induces robust alterations in emotional and social functioning resulting in enhanced risk for the development of psychopathologies such as mood and aggressive disorders. Here, an overview is given on recent findings in primate and rodent models of early life stress, demonstrating that chronic deprivation of early maternal care as well as chronic deprivation of early physical interactions with peers are profound risk factors for the development of inappropriate aggressive behaviors. Alterations in the hypothalamic-pituitary-adrenocortical (HPA), vasopressin and serotonin systems and their relevance for the regulation of aggression are discussed. Data suggest that social deprivation-induced inappropriate forms of aggression are associated with high or low HPA axis (re)activity and a generally lower functioning of the serotonin system in adulthood. Moreover, genetic and epigenetic modifications in HPA and serotonin systems influence the outcome of early life stress and may even moderate adverse effects of early social deprivation on aggression. A more comprehensive study of aggression, neuroendocrine, neurobiological and (epi)genetic correlates of early life stress using animal models is necessary to provide a better understanding of the invasive aggressive deficits observed in humans exposed to child maltreatment.

Towards a scientific taxonomy of depression

Many concepts have been introduced into the classification of depression, including manic-depressive/bipolar disorder depression, etc. Kraepelin's original concept of manic-depressive disorder has evolved into the concept of polarity, and bipolar and unipolar disorders. Psychiatric classification is characterized by an inflation of the diagnostic categories, including subtypes of depression. This rapid multiplier effect is primarily descriptive, and there is a need to rethink, in a pragmatic fashion, the classification system, in order to develop one that is likely to be of utility and which has a scientific basis. Is the time now right to ask whether there are essential conditions relevant to depression? I think that it is, and here I will introduce the notion with two such conditions. The first is early life stress disorder, and the second vascular depression. These conditions have reached a point where the data supports them as distinct entities. In this paper, the rationale for this is discussed.

Stress, genes and the biology of suicidal behavior

Suicidal behavior is partly heritable. Studies seeking the responsible candidate genes have examined genes involved in neurotransmitter systems shown to have altered function in suicide and attempted suicide. These neurotransmitter systems include the serotonergic, noradrenergic, and dopaminergic systems and the hypothalamic-pituitary-adrenal axis. With some exceptions, most notably the serotonin transporter gene promoter polymorphism (HTTLPR), replication of candidate gene association studies findings has been difficult. This article reviews current knowledge of specific gene effects and gene-environment interactions that influence risk for suicidal behavior. Effects of childhood stress on development and how it influences adult responses to current stress are shown to be relevant for mood disorders, aggressive/impulsive traits, and suicidal behavior.

Familial transmission of suicidal behavior

Adoption and twin studies show that familial transmission of suicidal behavior is partly attributable to genetic factors. Transmission of suicidal behavior is mediated by transmission of impulsive aggression or neuroticism and neurocognitive deficits. The most plausible explanations for nongenetic familial transmission are the intergenerational transmission of abuse and adverse familial environments. Bereavement and relationship disruption contribute to suicidal risk via the development of complicated grief, although long-term effects may be mediated by a complex chain of interrelated events. Imitation may contribute to suicidal risk, at least in attempted suicide. However, so-called family environmental factors often are related to risk factors that are heritable. Conversely, genetic factors exert their impact on depression and suicidal behavior via interaction with a stressful environment.

Completed suicide in childhood

Suicide in children and young adolescents up to 14 years of age has increased in many countries, warranting research and clinical awareness. International reported suicide rates per 100,000 in this young population vary between 3.1 and 0 (mean rate worldwide, approximately 0.6/100.000; male-female ratio, 2:1). Suicide occurs only in vulnerable children; this vulnerability begins with parental mood disorder and impulsive aggression, and family history of suicide. Childhood affective and disruptive disorders and abuse are the most often reported psychiatric risk factors. Suicide becomes increasingly common after puberty, most probably because of pubertal onset of depression and substance abuse, which substantially aggravate suicide risk. Biologic findings are scarce; however, serotonergic dysfunction is assumed. The most common precipitants are school and family problems and may include actual/anticipated transitions in these environments. Suicides in children and young adolescents up to 14 years of age often follow a brief period of stress. Cognitive immaturity/misjudgment, age-related impulsivity, and availability of suicide methods play an important role. Psychologic autopsy studies that focus on suicides in this age group are needed.

Biopsychosocial model in Depression revisited

There are two fundamental etiological perspectives about mental disorders; biomedical and psychosocial. The biopsychosocial model has claimed to integrate these two perspectives in a scientific way, signalling their interconnection and interdependence. To that end, it used a systemic conceptual framework, taking advantage of the possibilities which it offers to establish general principles for diverse systems, independently of their physical, biological or sociological nature. In recent years, drawing on the theory of systems, theories have been developing of the dynamic non-linear systems, applicable to networks of a large quantity of densely interconnected elements (also called complex systems), like the mind or the brain. We believe that this revised systemic conceptual framework can bring integrative ideas to apply to Depression, such as the "binding dysfunction" concept we use in this article. According to this, vulnerability or predisposition to Depression would be associated with the imbalance between activating and inhibiting interactions (between some cognitions and emotions at a mental level, and between certain neuronal groups at a cerebral level). Precipitating factors would imply the increase of the activation level over this pattern of cognitions and emotions, or over those neuronal systems. When stress goes beyond the vulnerability threshold an excessive positive feedback between cognitions and emotions would appear (and between groups of neurons) with insufficient inhibitory control to mitigate it, which would imply a mental/cerebral dissociation in dominions of different level of activation. As a consequence, the generation and dissolution of patterns of cerebral and mental activation will no longer have the dynamism and flexibility that permits an optimal interaction with the environment ("binding dysfunction"). Therefore, our hypothesis is that the person with Depression will suffer at a cerebral level a functional dissociation in neural dominions (some rigidly hyperactive and others rigidly hypoactive) in determined locations, which would be a different combination from those found in other mental disorders. At a mental level, this would correlate with a functional dissociation in several cognitive-emotive dominions; some corresponds to over activated patterns of "depressive" cognitions and emotions that for that reason invade the consciousness frequently, intrusively and repetitively; meanwhile there are other alternative hypoactive emotions and cognitions that do not manage to become powerful enough to avoid the consequent distortion in the communication with the environment.

Depressive disorders in childhood and adolescence: an overview: epidemiology, clinical manifestation and risk factors

The diagnostic category of depressive disorder in pediatric age is a relatively new concept that is rooted in empirical studies that date back to only the late 1980s. This article discusses the current consensus nosology and epidemiology of unipolar depressive disorders in young age and the risk factors for depression onset and recurrence. There is also a brief overview of psychosocial and pharmacologic evidence-based therapies and suggested areas for future research. This article also contains a brief description of the items discussed in detail in this issue.

Neurobiology of depression in children and adolescents

This article reviews classical and updated studies of the neurobiology of depressive disorders in children and adolescents. Most studies of childhood and adolescent depression and suicide have followed up the observations and methods used in studies in adults. These studies include neuroendocrine studies, which particularly look at the hypothalamic-pituitary-adrenal axis, the serotonergic system, peripheral blood and cerebrospinal fluid biologic markers, genetics, gene-environment interactions and sleep studies, and neuroimaging and postmortem studies, although in these areas the number of studies is limited.

Longevity following the experience of parental divorce

An archival prospective design was used to study mediating and moderating variables for the association between parental divorce and increased mortality risk, using a sub-group (n = 1183) of individuals from the US Terman Life Cycle Study covering the period 1921-2000. In childhood, both socioeconomic status (SES) and family psychosocial environment were related to parental divorce but did little to explain its effects. The higher mortality risk associated with experiencing parental divorce was ameliorated among individuals (especially men) who achieved a sense of personal satisfaction by mid-life. Behaviorally, smoking was the strongest mediator of the divorce-mortality link. This study extends previous work on the long-term effects of parental divorce and reveals some reasons why the stress of parental divorce in childhood need not necessarily lead to negative later-life outcomes.

The association between childhood and adolescent sexual abuse and proxies for sexual risk behavior: a random sample of the general population of Sweden

OBJECTIVE

Several studies with small and "high risk" samples have demonstrated that a history of childhood or adolescent sexual abuse (CASA) is associated with sexual risk behaviors (SRBs). However, few studies with large random samples from the general population have specifically examined the relationship between CASA and SRBs with a comprehensive set of measures.

DESIGN

The study was a cross-sectional retrospective survey of past and current sexual health and behavior.

METHODS

A random sample of 4781 persons from the Swedish Post Address Register was obtained, which included 6,119,000 Swedish citizens in 1996. Of those persons, 2810 participants agreed to participate in the study. Participants were interviewed as well as administered a questionnaire regarding their sexual health and behavior.

RESULTS

Using Mann-Whitney U tests, a history of CASA was found to be associated with younger age at first intercourse; younger age at diagnosis of first sexually transmitted infection (STI); greater frequency of unintended pregnancy; greater likelihood of participation in group sex; higher likelihood of not interrupting sexual intercourse despite the risk of pregnancy or risk of an STI; greater likelihood of exchanging sex for money or other necessities/drugs; more frequent substance use in the last 48 hours; and higher likelihood of adult sexual and physical assault.

CONCLUSIONS

The findings of this study confirm previous research, which has reported an association between CASA and SRBs in smaller and high-risk samples. Clinicians working with adults with a history of CASA should be aware of the relationship between CASA and SRBs and be prepared to address such issues during therapy.

Hostility, depressive symptoms, and smoking in early adolescence

Using logistic and multiple regression, we examined the association between hostility, level of depressive symptoms, and smoking in a sample of 1699 ethnically diverse students in California. Self-reports were collected twice from each student, at the beginning of the 6th and 7th grade years. Among 6th graders who had not smoked, depressive symptoms and hostility were associated with smoking initiation by the 7th grade. Among those students who had already tried smoking, increases in depressive symptoms and hostility were associated with more frequent smoking. The association between hostility and smoking was stronger for students reporting higher levels of depressive symptoms.

Child maltreatment and HPA axis dysregulation: relationship to major depressive disorder and post traumatic stress disorder in females

A history of child maltreatment increases the vulnerability to the development of Major Depressive Disorder (MDD) and/or Posttraumatic Stress Disorder (PTSD), especially in females. Both MDD and PTSD are associated with a dysregulation of the Hypothalamic-Pituitary-Adrenal (HPA) axis. Dysregulation of the HPA axis may be an important etiological link between child maltreatment and subsequent psychiatric disorder, yet little is known about the relationship between exposure and outcome. The aim of this review is to explore the role of HPA axis dysregulation in the link between child maltreatment and MDD/PTSD among women. Studies of females with MDD frequently indicate a hyperactivity of the HPA axis, and contribute to our understanding of the underlying mechanisms involved in mood dysregulation. Evidence for HPA axis dysregulation in PTSD is less convincing and suggests that timing of the stressful experience as well as the type of the trauma may influence the outcome. The strongest evidence to date suggesting that the development of the HPA axis may be affected by early life stressful experiences comes from pre-clinical animal studies. Together these studies add to our understanding of the role of the HPA axis in psychiatric disorders in relation to stress. The literature on HPA axis function in both children and adults following child maltreatment further highlights the potential relevance of early stress to later onset of major psychiatric disorders. Such knowledge may also contribute to the development of early interventions targeted at primary prevention.

Altering the course of neurodevelopment: a framework for understanding the enduring effects of psychotropic drugs

Childhood is a time filled with wondrous changes, as brain plasticity permits experiences to shape the immature brain to meet the demands of the environment. Change occurs at various levels--from neuroanatomy, including within a given region and its connectivity to other regions, to the function of neurotransmitter systems and their reactivity to pharmacological agents in the short- and long-term. The nature and degree to which drug exposure influences the final adult topography is influenced greatly by the maturational phase of these critical factors. Moreover, evidence is slowly emerging that suggests that the long-term effects of drug exposure are delayed and expressed once the vulnerable system reaches maturation (i.e., typically during adulthood). This phenomenon is known as neuronal imprinting and occurs when the effects of drug exposure outlast the drug itself. Thus, understanding the persistent effects critically depends on the window of observation. Embracing this concept should influence how we conduct preclinical assessments of developmental drug exposure, and ultimately how we conduct clinical assessments of drug efficacy, effectiveness, and safety for the treatment of childhood psychiatric disorders. In this article, we present a model to provide a heuristic framework for making predictions about imprinted effects of childhood drug exposure. We then review epidemiological data on attention deficit hyperactivity disorder (ADHD) and childhood depression, prescription practices, and what is known regarding the long-term consequences of drug exposure in these populations. We conclude with a discussion of the current status of preclinical studies on juvenile stimulant exposure.

Irritability in pediatric mania and other childhood psychopathology

Irritability is an important symptom in childhood psychopathology that has received relatively little research attention. Recent controversy concerning the diagnosis of mania in children has focused attention on how little is known about how to assess irritability in a systematic way, and about its diagnostic associations. For example, subtyping irritability according to course (chronic vs. episodic), precipitants, and family history may facilitate the identification of psychopathology and the study of pathophysiology. While normative and pathologic irritability can be differentiated reliably, the validity of the distinction is unclear. In addition, there is a need for scales designed to measure the severity of irritability in children with mood and anxiety disorders. In order to facilitate research, we propose a definition of irritability from the perspective of affective neuroscience. Because reactive aggression may be a helpful animal model for irritability, we review the neural circuitry mediating this behavior. Behavioral paradigms that evoke frustration, as well as those that assess the ability to inhibit a prepotent motor response, maintain attentional focus, execute response reversal, recognize angry faces, and regulate emotional responses, may be useful in the study of irritability. Examples of such paradigms are described, and the pharmacology of irritability is reviewed briefly.

Early life influences on life-long patterns of behavior and health

The stability of a child's early life has profound effects on physical and mental health, and unstable parent-child relationships, as well as abuse, can lead to behavioral disorders and increased mortality and morbidity from a wide variety of common diseases later in life. One common consequence, namely, depressive illness, is associated with chemical imbalances in the brain and hormonal dysregulation, constituting a form of allostatic load that alters interpretations of stimuli and influences, behavioral, and hormonal responses to potentially stressful situations. The brain not only encodes information and controls the behavioral responses but it is also changed structurally by those experiences. Structural changes in the hippocampus and amygdala, which are important brain structures for cognition and emotion, are representative of what may be occurring throughout the brain as a result of allostatic load resulting from the chronic stress of a disorder such as depression. Such structural changes include dendritic debranching and hypertrophy, cell proliferation, and synaptic remodeling; they are produced by the combined overactivity of stress hormones and endogenous neurotransmitters. These mediators are normally involved in adaptation, but can also promote damage when they are dysregulated and over-active. They are very likely to be strongly biased by early life experiences. The findings from animal models thus provide a basis for understanding potential mechanisms of environmental and developmental determinants of individual differences in human stress reactivity, as well as anxiety, depression, and a host of related systemic disorders. There is an increasing amount of translational research that is beginning to tie the basic research to clinical outcomes of individuals exposed to abusive or inconsistent care-giving in early life. A major goal of studies on this important topic is to define times in development and strategies for intervening to prevent or reverse the effects of adverse early life experiences. Although prevention is clearly the preferable route, some degree of reversal of psychopathology and pathophysiology caused by early life adversity appears to be an achievable goal.

Suicidal ideations and attempts in juvenile delinquents

BACKGROUND

Suicidality among adolescents is a common focus of clinical attention. In spite of links to disruptive behaviors and other types of psychopathology, it is not clear whether other factors commonly associated with suicide, such as personality and parenting, predict suicidality over and above psychopathology. The purpose of the present study was to assess suicidal ideations and attempts and their relationship to psychopathology, violence exposure, personality traits and parental rearing in Russian male juvenile delinquents with conduct disorder (CD).

METHOD

Suicidality and psychopathology were assessed using a semi-structured psychiatric interview in 271 incarcerated male juvenile delinquents diagnosed with CD. Violence exposure, personality characteristics and perceived parental rearing were assessed via self-reports.

RESULTS

Thirty-four percent of those diagnosed with CD (92 subjects) reported a lifetime history of either suicidal thoughts or attempts. Suicidal ideators and attempters did not differ significantly on any variable of interest, but both reported significantly higher rates of psychopathology and violence exposure than the non-suicidal group, as well as higher levels of harm avoidance, lower self-directedness, and higher rates of perceived negative parental rearing. Finally, even when controlling for the relationship with psychopathology, personality and perceived parental rearing factors showed significant associations with suicidality.

CONCLUSIONS

Juvenile delinquents with CD have high rates of suicidal ideations and attempts, related to a wide spectrum of psychopathology and specific personality traits. These findings suggest that a combination of intrinsic and extrinsic factors create vulnerability to stressors, which under the influence of situational factors (e.g., repeated traumatization) may lead to suicidal thoughts and acts. Factors potentially contributing to vulnerability for suicidality should be identified when planning prevention and rehabilitation efforts for troubled youth.

Early experience and depressive disorders: human and non-human primate studies

This paper reviews evidence from both human and non-human primate studies concerning the role of early adverse experiences in the onset and course of adult depressive disorders. Despite accumulating evidence that stressful life events can play a major role in precipitating the onset of depressive episodes in humans, the mechanisms by which early experiences mediate and moderate the risk for later affective illnesses are not fully understood. Experimental paradigms in primates have documented the important role of undeveloped (social deprivation) or disrupted attachment systems (social separation). Effects of early social deprivation can be seen in many domains. Behavioral effects include repetitive idiosyncratic behaviors, increased self-directed behaviors, inappropriate expression of aggressive behaviors, non-modulated patterns of consumption, and inappropriate sexual and maternal behaviors. Cognitively, such animals require longer habituation time for any task and demonstrate increased perseverance on tasks following non-reward. Physiological effects include an altered hypothalamic-pituitary-adrenal response to stress, changes in diurnal temperature regulation, and alterations in immune function. Neurochemical effects include abnormalities in noradrenergic, serotonergic, and dopaminergic systems. Even neuroanatomical changes following early social deprivation have been reported. Studies with primates have also confirmed that early maternal and peer separations are major behavioral and neurobiological events with both short- and long-term consequences that parallel human depression. Future utilization of experimental paradigms in non-human primates may assist in better understanding the role of early experiences in predisposing to the development of affective illnesses in humans. This review concludes by presenting a model for understanding a developmentally based vulnerability to adult depressions.

Peripartum cortisol levels and mother-infant interactions in Japanese macaques

As evidence accumulates regarding the influence of hormones and stress-related conditions on maternal behavior, it becomes critical to better understand the relationship between physiological stress and the ability to cope with infants. Eight Japanese macaque females were observed 3 hr per week during the first 12 weeks after parturition; fecal samples were collected twice a week from each mother, starting 4 weeks before parturition and ending 4 weeks after parturition. Time spent in contact, maternal responsiveness, latency of response, and maternal rejection were measured and correlated with peripartum excreted cortisol and estradiol metabolite levels. Two indices of peripartum hormonal status were also tested against behavior: the postpartum stress index, and the postpartum cortisol/prepartum estradiol ratio (F/E). Postpartum cortisol levels showed a positive correlation with maternal rejection. The cortisol/estradiol ratio was positively correlated with rejection and latency of response, and negatively correlated with maternal responsiveness. Prepartum cortisol levels and the postpartum stress index did not correlate with any aspect of maternal behavior. Our findings suggest that hypothalamic-pituitary-adrenal (HPA) axis activity per se is not enough to predict the quality of interaction between mother and infant. Only when cortisol is high relative to estradiol could it be symptomatic of a possible negative feedback response involving stress, adrenal activity, and the ability of mothers to cope with the additional problems imposed by newborns.

Hyperresponsiveness of hypothalamic-pituitary-adrenal axis to combined dexamethasone/corticotropin-releasing hormone challenge in female borderline personality disorder subjects with a history of sustained childhood abuse

BACKGROUND

High coincidence of childhood abuse, major depressive disorder (MDD), and posttraumatic stress disorder (PTSD) has been reported in patients with borderline personality disorder (BPD). Animals exposed to early trauma show increased stress-induced hypothalamic-pituitary-adrenal (HPA) axis activity due to an enhanced corticotropin-releasing hormone (CRH) drive and glucocorticoid feedback resistance. In humans, PTSD and MDD are associated with decreased and increased resistance to glucocorticoid feedback, respectively, which might reflect persistent changes in neuroendocrine sequelae following childhood abuse.

METHODS

We investigated the relationship between childhood abuse and HPA axis function using a combined dexamethasone/CRH (DEX/CRH) test in 39 BPD patients with (n = 24) and without (n = 15) sustained childhood abuse and comorbid PTSD (n = 12) or MDD (n = 11) and 11 healthy control subjects.

RESULTS

Chronically abused BPD patients had a significantly enhanced corticotropin (ACTH) and cortisol response to the DEX/CRH challenge compared with nonabused subjects. Comorbid PTSD significantly attenuated the ACTH response.

CONCLUSIONS

Hyperresponsiveness of the HPA axis in chronically abused BPD subjects might be due to the enhanced central drive to pituitary ACTH release. Sustained childhood abuse rather than BPD, MDD, or PTSD pathology accounts for this effect. Possibly due to an enhanced efficacy of HPA suppression by dexamethasone, PTSD attenuates the ACTH response to DEX/CRH.

Self-rated childhood emotional neglect and CSF monoamine indices in abstinent cocaine-abusing adults: possible implications for suicidal behavior

Non-human primate studies suggest that early environmental influences may have an enduring effect on central serotonin function. Therefore, it was decided to examine in humans whether childhood trauma might be related to cerebrospinal fluid (CSF) concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) as an adult. A total of 29 withdrawn cocaine-dependent patients completed the Childhood Trauma Questionnaire. They also had a lumbar puncture for determination of CSF concentrations of 5-HIAA. CSF concentrations of the dopamine metabolite homovanillic acid (HVA) were also determined. Childhood emotional neglect scores showed significant negative correlations with CSF levels of 5-HIAA and HVA, and patients with emotional neglect scores above the median had significantly lower CSF 5-HIAA and HVA levels than patients with emotional neglect scores at or below the median. These findings suggest the possibility that childhood trauma may have an effect on central monoamine function as an adult.

The role of childhood trauma in the neurobiology of mood and anxiety disorders: preclinical and clinical studies

Epidemiologic studies indicate that children exposed to early adverse experiences are at increased risk for the development of depression, anxiety disorders, or both. Persistent sensitization of central nervous system (CNS) circuits as a consequence of early life stress, which are integrally involved in the regulation of stress and emotion, may represent the underlying biological substrate of an increased vulnerability to subsequent stress as well as to the development of depression and anxiety. A number of preclinical studies suggest that early life stress induces long-lived hyper(re)activity of corticotropin-releasing factor (CRF) systems as well as alterations in other neurotransmitter systems, resulting in increased stress responsiveness. Many of the findings from these preclinical studies are comparable to findings in adult patients with mood and anxiety disorders. Emerging evidence from clinical studies suggests that exposure to early life stress is associated with neurobiological changes in children and adults, which may underlie the increased risk of psychopathology. Current research is focused on strategies to prevent or reverse the detrimental effects of early life stress on the CNS. The identification of the neurobiological substrates of early adverse experience is of paramount importance for the development of novel treatments for children, adolescents, and adults.

Are child-, adolescent-, and adult-onset depression one and the same disorder?

This paper reviews prior research studies examining neurobiological correlates and treatment response of depression in children, adolescents, and adults. Although there are some similarities in research findings observed across the life cycle, both children and adolescents have been found to differ from depressed adults on measures of basal cortisol secretion, corticotropin stimulation post-corticotropin releasing hormone (CRH) infusion, response to several serotonergic probes, immunity indices, and efficacy of tricyclic medications. These differences are proposed to be due to 1) developmental factors, 2) stage of illness factors (e.g., number of episodes, total duration of illness), or 3) heterogeneity in clinical outcome (e.g., recurrent unipolar course vs. new-onset bipolar disorder). Relevant clinical and preclinical studies that provide support for these alternate explanations of the discrepant findings are reviewed, and directions for future research are discussed. To determine whether child-, adolescent-, and adult-onset depression represent the same condition, it is recommended that researchers 1) use the same neuroimaging paradigms in child, adolescent, and adult depressed cohorts; 2) carefully characterize subjects' stage of illness; and 3) conduct longitudinal clinical and repeat neurobiological assessments of patients of different ages at various stages of illness. In addition, careful attention to familial subtypes (e.g., depressive spectrum disorders vs. familial pure depressive disorders) and environmental factors (e.g., trauma history) are suggested for future investigations.

Serotonin dysregulation in adolescents with major depression: hormone response to meta-chlorophenylpiperazine (mCPP) infusion

This study examined central serotonin disturbance, as reflected by neuroendocrine hormones, among adolescents with major depression. Prolactin, cortisol, and growth hormone were measured following the infusion of a serotonin agonist, meta-chlorophenylpiperazine (mCPP). Twelve (M=6, F=6) medication-free adolescents with major depression (MDD) were compared with 12 (M=6, F=6) matched normal control subjects, ranging in age from 13 to 17 years. Baseline evaluations and a battery of laboratory tests were completed. mCPP, 0.1 mg/kg i. v., was administered in a placebo-controlled design. Analyses of the neuroendocrine hormones revealed that the depressed group had a higher baseline prolactin level and an augmented prolactin response to mCPP challenge than did the control group. The depressed group experienced a sharper baseline-cortisol decline between 08.00 and 11.00 h, and compared to control subjects they displayed an augmented response to the challenge. The depressed group reported more side effects than the control group during saline infusion, but not during mCPP infusion. Findings suggest that depressed adolescents have an elevated baseline prolactin level, and also experience enhanced prolactin and cortisol responses to the serotonergic challenge. These preliminary findings will be confirmed during our ongoing study.

Aggressive behavior in clinically depressed adolescents

OBJECTIVE

To investigate the prevalence and characteristics of aggressive behavior in adolescent inpatients and outpatients with major depressive disorder (MDD). Differences between males and females in prevalence and type of aggression, and level of parent-child agreement in report of aggression, were analyzed.

METHOD

Participants were 74 adolescents with MDD, aged 13 to 17 years. The Structured Clinical Interview for DSM-IV Axis I Disorders was used to identify MDD. Adolescents' aggressive behavior was assessed using an adapted version of the Brown-Goodwin Assessment for Lifetime History of Aggression; the Measure of Aggression, Violence, and Rage in Children; and the Buss-Durkee Hostility Inventory-Adapted Version.

RESULTS

Results indicate high levels of aggressive behavior in adolescents with MDD. Amount and type of aggression did not differ by gender. Results indicate poor correspondence between parent and adolescent reports of aggression, which was most marked for females.

CONCLUSIONS

Aggressive behaviors are highly prevalent in depressed youths, with similar types and levels evident in males and females. Parents tend to under-report and may not be cognizant of aggressive behavior that occurs outside the home, particularly for females.

Serotonergic blunting to meta-chlorophenylpiperazine (m-CPP) highly correlates with sustained childhood abuse in impulsive and autoaggressive female borderline patients

BACKGROUND

Disturbances of affect, impulse regulation, and autoaggressive behavior, which are all said to be related to an altered function of the central serotonergic (5-HT) system, are prominent features of borderline personality disorder (BPD). A high coincidence of childhood physical and sexual abuse is reported in these patients. Animal studies indicate that early, sustained stress correlates with a dysfunctional central 5-HT system. Therefore, we hypothesize that sustained traumatic stress in childhood affects the responsivity of the postsynaptic serotonergic system of traumatized BPD patients.

METHODS

Following Axis I, Axis II, and trauma assessment, a neuroendocrine challenge test was performed with the postsynaptic serotonergic agonist meta-chlorophenylpiperazine (m-CPP) in 12 impulsive and autoaggressive female patients with BPD and 9 matched healthy volunteers.

RESULTS

The cortisol and prolactin responses to the m-CPP challenge in BPD patients were significantly lower compared to those in controls. Within the group of patients with BPD, the net prolactin response showed a high inverse correlation with the frequency of the physical (r = -.77) and sexual abuse (r = -.60).

CONCLUSIONS

Our data suggest that severe and sustained traumatic stress in childhood affects the 5-HT system and especially 5-HT(1A) receptors. This finding confirms the data from animal research. The blunted prolactin response to m-CPP appears to be the result of severe traumatization and independent of the BPD diagnosis.

Protective and damaging effects of mediators of stress. Elaborating and testing the concepts of allostasis and allostatic load

Stress is a condition of human existence and a factor in the expression of disease. A broader view of stress is that it is not just the dramatic stressful events that exact their toll but rather the many events of daily life that elevate activities of physiological systems to cause some measure of wear and tear. We call this wear and tear "allostatic load," and it reflects not only the impact of life experiences but also of genetic load; individual habits reflecting items such as diet, exercise, and substance abuse; and developmental experiences that set life-long patterns of behavior and physiological reactivity (see McEwen). Hormones associated with stress and allostatic load protect the body in the short run and promote adaptation, but in the long run allostatic load causes changes in the body that lead to disease. This will be illustrated for the immune system and brain. Among the most potent of stressors are those arising from competitive interactions between animals of the same species, leading to the formation of dominance hierarchies. Psychosocial stress of this type not only impairs cognitive function of lower ranking animals, but it can also promote disease (e.g. atherosclerosis) among those vying for the dominant position. Social ordering in human society is also associated with gradients of disease, with an increasing frequency of mortality and morbidity as one descends the scale of socioeconomic status that reflects both income and education. Although the causes of these gradients of health are very complex, they are likely to reflect, with increasing frequency at the lower end of the scale, the cumulative burden of coping with limited resources and negative life events and the allostatic load that this burden places on the physiological systems involved in coping and adaptation.

Suicide in adolescents with disruptive disorders

OBJECTIVE

To determine the psychiatric risk factors for suicide in adolescents with disruptive disorders.

METHOD

Fifty-nine adolescent suicide completers and 18 community controls, both having a probable or definite current DSM-III diagnosis of disruptive disorders, were compared.

RESULTS

Adolescents with disruptive disorders who committed suicide had higher rates of current substance abuse, past suicide attempt, family history of substance abuse, and family history of mood disorder than disruptive community controls.

CONCLUSIONS

Disruptive adolescents appear to be at risk for completed suicide when comorbid substance abuse and past history of suicide attempt are present. The risk increases if the adolescents have a past history of physical abuse and if they have parents with substance abuse and mood disorders. Clinicians should be aware of these risk factors and implement active interventions to prevent suicide. Treatment should focus on treating not only the adolescents, but also their family members. The findings of this study also highlight the need for future research in the prevention of suicide in adolescents with disruptive disorders and comorbid substance abuse.