Psychological Pain, Depression, and Suicide: Recent Evidences and Future Directions

PURPOSE OF REVIEW

The definition of psychological pain is complex. It is a lasting unpleasant and unsustainable feeling characterized by a perception of inability or deficiency of the self, as well as frustrated psychological needs and social disconnection. The aim of our review was to summarize the most recent and updated findings supporting the role of psychological pain in the pathophysiology of depression and suicidal behavior. We also explored the relationship between psychological and physical pain in depression and suicide.

RECENT FINDINGS

Psychological pain is a prominent dimension of depressive disorder and has been associated with higher risk of suicidal ideation and suicidal behavior. Sensitivity to psychological and physical pain is increased in depression. Conversely, higher tolerance to physical pain is associated with suicidal behavior. A better understanding of the pathophysiology of pain processing in depression and suicide offers new therapeutic options for the treatment of depression through the use of analgesic drugs.

Social rhythm disrupting events increase the risk of recurrence among individuals with bipolar disorder

OBJECTIVES

As outlined in the social zeitgeber hypothesis, social rhythm disrupting (SRD) life events begin a cascade of social and biological rhythm disruption that may lead to the onset of affective episodes in those vulnerable to bipolar disorder. Thus, the study of SRD events is particularly important in individuals with this chronic condition. The purpose of the current study was to evaluate (i) the extent to which SRD life events increased the risk of recurrence of a bipolar mood episode, and (ii) whether the social rhythm disruption associated with the event conferred an increased risk of recurrence, after accounting for the level of threat associated with the life event.

METHODS

We examined the effect of SRD events on recurrence during preventative treatment in a sample of 118 patients with bipolar disorder who achieved remission from an acute episode after receiving psychotherapy and pharmacotherapy. Life events were measured with the Bedford College Life Events and Difficulty Schedule and were rated for degree of SRD and threat.

RESULTS

Time-dependent Cox proportional hazards models showed that having a higher SRD rating was significantly associated with an increased risk of recurrence, even when accounting for the threat effect of a life event and psychosocial treatment (hazard ratio = 1.33, 95% confidence interval: 1.04-1.70, p = 0.023). However, this finding fell below conventional levels of statistical significance when accounting for other covariates.

CONCLUSIONS

Our findings lend partial support to the social zeitgeber hypothesis.

Late-onset recurrent mania as a manifestation of Wallenberg syndrome: a case report and review of the literature

OBJECTIVE

The aim of the present case report was to describe the late onset of recurrent mania in a patient after ischemic injury to the cerebellum and dorsolateral medulla.

METHODS

We studied an 86-year-old male with no prior psychiatric history who developed recurrent episodes of mania following a brain stroke. Additionally, he had neurological symptom constellation typical of Wallenberg syndrome.

RESULTS

Magnetic resonance imaging of the brain revealed infarction in the inferomedial right cerebellar hemisphere and the right dorsolateral medulla in the right posterior inferior cerebellar artery (PICA) distribution. He was successfully managed with a combination of antipsychotic and mood-stabilizer medications.

CONCLUSIONS

Post-stroke mania may be one of the rare manifestations of Wallenberg syndrome. This case adds to the emerging literature on cerebellar involvement in mood regulation and pathology of mania.

Influence of the tyrosine hydroxylase val81met polymorphism and catechol-O-methyltransferase val158met polymorphism on the antidepressant effect of milnacipran

OBJECTIVE

Genetic polymorphisms of the noradrenergic pathway can be factors to predict the effect of antidepressants when their pharmacological mechanisms of action include the noradrenergic system. The purpose of the present study was to determine whether the tyrosine hydroxylase (TH) val81met and catechol-O-methyltransferase (COMT) val158met polymorphisms are associated with the antidepressant effect of milnacipran, a serotonin/noradrenaline reuptake inhibitor.

METHOD

Eighty-one Japanese patients with major depressive disorder were treated with milnacipran for 6 weeks. Severity of depression was assessed with the Montgomery and Asberg Depression Rating Scale (MADRS). Assessments were carried out at baseline and at 1, 2, 4 and 6 weeks of treatment. The method of polymerase chain reaction was used to determine allelic variants.

RESULTS

The met/met genotype of the COMT val158met polymorphism was associated with a significantly faster therapeutic effect of milnacipran in the MADRS score during this study. No influence of the TH val81met polymorphism on the antidepressant effect of milnacipran was detected.

CONCLUSION

These results suggest that the COMT val158met polymorphism in part determines the antidepressant effect of milnacipran.

Individual differences in extraversion and dopamine genetics predict neural reward responses

Psychologists have linked the personality trait extraversion both to differences in reward sensitivity and to dopamine functioning, but little is known about how these differences are reflected in the functioning of the brain's dopaminergic neural reward system. Here, we show that individual differences in extraversion and the presence of the A1 allele on the dopamine D2 receptor gene predict activation magnitudes in the brain's reward system during a gambling task. In two functional MRI experiments, participants probabilistically received rewards either immediately following a behavioral response (Study 1) or after a 7.5 s anticipation period (Study 2). Although group activation maps revealed anticipation- and reward-related activations in the reward system, individual differences in extraversion and the presence of the D2 Taq1A allele predicted a significant amount of inter-subject variability in the magnitudes of reward-related, but not anticipation-related, activations. These results demonstrate a link between stable differences in personality, genetics, and brain functioning.

A three-factor model of the MADRS in major depressive disorder

Major Depressive Disorder (MDD) may be composed of some symptom clusters with distinct neurochemical disturbances, suggesting the importance of the factor analysis of depressive symptoms; however, the results of previous studies using the Montgomery-Asberg Depression Rating Scale (MADRS) have been inconsistent. In the present study, factor analysis of the MADRS was performed in 132 Japanese patients (range 23-74 years, mean 47.6 years) with MDD without any psychiatric comorbidity. The principal component analysis with Varimax rotation identified three factors, accounting for 61% of the total variance: The first factor, labeled dysphoria, included pessimistic thoughts, suicidal thoughts, and reported sadness; the second factor, labeled retardation, included lassitude, inability to feel, apparent sadness, and concentration difficulties; and the third factor, labeled vegetative symptoms, included reduced sleep, reduced appetite, and inner tension. The score of the vegetative factor showed a significant positive correlation with age and was significantly higher in females than in males. This study suggests that the symptoms of MDD, as assessed by the MADRS, cluster into three factors (dysphoria, retardation, and vegetative symptoms).

Symptom Clusters

The purpose of this article is to analyze the concept of symptom clusters and to discuss its application to cancer nursing to promote communication and enhance scientific knowledge. Rodgers' evolutionary method of concept analysis served as the framework for reviewing literature from psychology/psychiatry, general medicine, and nursing. Attributes of symptom clusters were relationships of symptoms and relationships of clusters, concurrence, underlying dimensions, stability, and common etiology. The major antecedent was the presence of 2 or more symptoms. Consequences were poorer physical health status, interference with activities of daily living, emotional distress, and increased financial burden. A symptom cluster is defined as consisting of 2 or more symptoms that are related to each other and that occur together. Symptom clusters are composed of stable groups of symptoms, are relatively independent of other clusters, and may reveal specific underlying dimensions of symptoms. Relationships among symptoms within a cluster should be stronger than relationships among symptoms across different clusters. Symptoms in a cluster may or may not share the same etiology. Symptom should be broadened to include both subjective (self-reported) symptoms and objective (observed) signs. Implications for researchers include the need to use a clear definition, determine the optimal methods of identifying etiology and nature of symptom clusters in various populations, assess the clinical utility of symptom clusters, and test interventions. Implications for practitioners include the need to comprehensively assess symptoms over the entire cancer trajectory, select interventions that target single and multiple symptoms, and evaluate outcomes that include quality of life and economic variables.

A three-factor analytic model of the MADRS in geriatric depression

OBJECTIVE

Major depression is a heterogeneous disorder, perhaps comprising several clinical subtypes or subgroups of symptoms. This study examined whether items on the Montgomery-Asberg Depression Rating Scale (MADRS) form distinct symptom subgroups among geriatric depressive patients that might form the basis of new outcome measures for tracking treatment effects.

METHOD

The study examined a sample of 225 adults age 59 and older diagnosed with major depression. Factor analysis with oblique rotation was used to analyze baseline MADRS item scores.

RESULTS

Three distinct interpretable factors were obtained; all ten items loaded <0.60 on a domain. The first factor, dysphoric apathy/retardation, comprised five items: apparent sadness, reported sadness, lassitude, reduced concentration, and inability to feel. Psychic anxiety, the second factor, included three items: inner tension, pessimistic thoughts, and suicidal thoughts. The third factor, vegetative symptoms, resulted from items involving sleep and appetite.

CONCLUSIONS

The study produced three interpretable MADRS factors reflecting geriatric depression dimensions that may be useable to monitor focused treatment outcomes.

Functional anatomical abnormalities in limbic and prefrontal cortical structures in major depression

Neuroimaging studies of major depression have identified neurophysiological abnormalities in multiple areas of the prefrontal cortex (PFC), the amygdala, and related parts of the striatum and thalamus. Some of these abnormalities are mood state-dependent, and appear in regions where cerebral blood flow (CBF) increases during other normal and pathological emotional states. These neurophysiological differences between depressives and non-depressed controls may thus locate areas where physiological activity changes to mediate or respond to the emotional, behavioral and cognitive manifestations of major depressive episodes (MDE). Other abnormalities persist following symptom remission, and are found in orbital and medial PFC areas where post mortem studies demonstrate reductions in cortex volume and/or histopathological changes in primary mood disorders. These orbital and medial PFC areas have been shown by other types of evidence to modulate emotional behavior and stress responses, suggesting that dysfunction involving these regions may be involved in the pathogenesis of depressive symptoms. Finally, physiological activity is decreased during MDE in dorsal PFC areas implicated in language, selective attention, visuospatial or mnemonic processing, but these abnormalities reverse with symptom remission. These areas of 'deactivation' during the depressed state may reflect neurophysiological interactions between cognitive and emotional processing, and may relate to the subtle cognitive impairments associated with MDE.

The clinical epidemiology of pure and mixed manic episodes

INTRODUCTION

Few large clinical epidemiological studies have been undertaken comparing subjects meeting criteria for mixed and pure states of bipolar disorder. In part, the difficulty comparing these states emanates from confusion in their diagnostic separation. In the current report, we use a definition derived from receiver operating characteristic (ROC) curve analysis as an alternative to the DSM-IIIR/IV definition, and we compare the two subtypes of manic episodes.

METHODS

Three hundred and sixty-six patients meeting DSM-IIIR criteria for bipolar disorder, manic or mixed, were categorized using newly described criteria for mixed states. The two subtypes were compared on demographic variables and clinical history variables, using multiple analysis of variance with post hoc univariate F tests. The same analyses were conducted using the DSM-IIIR-defined subtypes.

RESULTS

Using the ROC criteria, 79 subjects (21.6%) were characterized as mixed, in contrast to 51 subjects (13.9%) using DSM-IIIR criteria for bipolar disorder, mixed. The ROC-defined mixed manic group comprised more Caucasians and more females. Age of first psychiatric hospitalization was earlier and duration of illness longer in the mixed group. First episodes were unlikely to be categorized as mixed (< 5%). When the DSM-IIIR definition was employed, differences were not demonstrated.

CONCLUSIONS

An earlier age of first psychiatric hospitalization and increased duration of illness, as well as a lower frequency of mixed subtype of manic episode during first hospitalization, are compatible with the view that mixed manic episodes occur more frequently later in the course of bipolar disorder. Moreover, differences in race, sex, and clinical histories of subjects in mixed episodes tend to support the separation of mixed mania as a diagnostic subtype of bipolar disorder.

Prefrontal cortical-amygdalar metabolism in major depression

Functional neuroimaging studies of the anatomical correlates of familial major depressive disorder (MDD) and bipolar disorder (BD) have identified abnormalities of resting blood flow (BF) and glucose metabolism in depression in the amygdala and the orbital and medial prefrontal cortical (PFC) areas that are extensively connected with the amygdala. The amygdala metabolism in MDD and BD is positively correlated with both depression severity and "stressed" plasma cortisol concentrations measured during scanning. During antidepressant drug treatment, the mean amygdala metabolism decreases in treatment responders, and the persistence of elevated amygdala metabolism during remission is associated with a high risk for the development of depressive relapse. The orbital C metabolism is also abnormally elevated during depression, but is negatively correlated with both depression severity and amygdala metabolism, suggesting that this structure may be activated as a compensatory mechanism to modulate amygdala activity or amygdala-driven emotional responses. The posterior orbital C and anterior cingulate C ventral to the genu of the corpus callosum (subgenual PFC) have more recently been shown in morphometric MRI and/or post mortem histopathological studies to have reduced grey matter volume and reduced glial cell numbers (with no equivalent loss of neurons) in familial MDD and BD. These data suggest a neural model in which dysfunction of limbic PFC structures impairs the modulation of the amygdala, leading to abnormal processing of emotional stimuli. Antidepressant drugs may compensate for this dysfunction by inhibiting pathological limbic activity.

The emerging role of valproate in bipolar disorder and other psychiatric disorders

Although valproate, a simple branched-chain fatty acid, is generally considered to be an antiepileptic agent, a large literature dating back to 1966 describes its use in primary psychiatric disorders. The significant role that gamma-aminobutyric acid plays in mood provided the rationale to examine valproate in this regard. Numerous uncontrolled as well as placebo- and lithium-controlled studies verified the drug's efficacy in the short-term management of bipolar and schizoaffective disorders. The response appears to be independent of response to traditional therapies such as lithium, neuroleptics, and carbamazepine, and may be maintained for extended periods of time. Valproate should be considered not only in patients with mood disorders who are intolerant of or nonresponsive to traditional therapies, but also in those with rapid cycling, electroencephalographic abnormalities, head trauma antedating the onset of psychiatric illness, or any other factor suggesting an organic component. Preliminary uncontrolled studies suggest that the drug may also eventually play a role in the management of panic disorder and behavioral dyscontrol (agitation, aggression, temper outbursts). Its adverse event profile is well known from years of experience in the management of epilepsy and does not appear to be altered in the presence of psychiatric disorders. Similarly, the drug-drug interaction potential of valproate is reasonably well known, although further research into interactions with psychotropic agents is warranted.