Current and future strategies for insomnia management

Different forms of insomnia are present as symptoms of many psychiatric and other disorders. The first step for a treatment strategy is therefore a correct diagnosis. As insomnia is more common in patients with psychiatric disorders than in the general population, a careful consideration should be given, depressive and anxiety disorders should especially be carefully investigated. There are reasons to believe that even in so-called insomnia not obviously related to psychiatric disorders, stressful life situations may play a role. Therefore a co-morbidity with emotional disorders which may follow these events is worth considering. Insomnia should always be considered as pan of a sleep-wake schedule disturbance and this has an impact on the importance of the pharmacological properties of the drugs used to treat insomnia. The recent trend for more specific agents both on receptor sub-populations and on relevant sites of the GABA receptor complex will help very much in selecting the most appropriate drug for treating patients.

Stigma and discrimination against people with schizophrenia related to medical services

OBJECTIVE

To investigate whether people with schizophrenia experience discrimination when using health care services.

METHODS

A cross-sectional survey in 27 countries in centres affiliated to the INDIGO Research Network, using face-to-face interviews with 777 participants with schizophrenia (62% male and 38% female). We analysed the data related to health issues, including health care, disrespect of mental health staff, and also personal privacy, safety and security, starting a family, pregnancy and childbirth. Discrimination was measured by the Discrimination and Stigma Scale (DISC), which consists of 36 items comprising three sub-scales: positive experienced discrimination; negative experienced discrimination; and anticipated discrimination.

RESULTS

More than 17% of patients experienced discrimination when treated for physical health care problems. More than 38% of participants felt disrespected by mental health staff, with higher ratings in the post-communist countries.

CONCLUSIONS

Mental health service providers have a key role in decreasing stigma in their provision of health care, and by doing more against stigmatizing and discriminating practices on the therapeutic and organizational level. This will require a change of attitudes and practices among mental and physical health care staff.

Comorbid substance abuse in first-episode schizophrenia: effects on cognition and psychopathology in the EUFEST study

Studies and meta-analyses investigating the influence of substance use disorder (SUD) (substance abuse or dependence) on psychopathology and neurocognitive function in schizophrenia patients have revealed controversial results. Most studies did only have small samples and did not focus exclusively on first-episode schizophrenia patients.

METHOD

In a post-hoc analysis of the European First Episode Schizophrenia Trial (EUFEST) psychopathology and cognitive performances of patients with (FE-SUD, N=119, consisting of N=88 patients with persisting SUD at baseline and N=31 patients with previous SUD) and without SUD (FE-non-SUD, N=204) were compared at baseline and 6 months follow-up. Neurocognitive assessment included the Rey Auditory Verbal Learning Test (RAVLT); Trail Making Tests A and B (TMT), Purdue Pegboard and Digit-Symbol Coding.

RESULTS

In total 31.1% of patients reported SUD, and 22.2% of patients used cannabis. There were no significant differences between patients with and without SUD concerning PANSS scores, extrapyramidal motor symptoms or neurocognitive measures except better performance in psychomotor speed (TMT-A, p=0.033, Cohen's d=0.26) in patients with SUD at 6 months follow-up. Interestingly, SUD patients with ongoing substance use at follow-up showed elevated positive symptoms (PANSS positive score, p=0.008, Cohen's d=0.84) compared to those who abstained. PANSS scores at baseline were increased in patients with an onset of SUD before the age of 16 years. In addition we found a correlation between longer duration of cannabis use and higher cognitive performance as well as reduced symptom improvement and more extrapyramidal motor symptoms in patients with higher frequency of cannabis consumption.

CONCLUSIONS

FE-SUD and FE-non-SUD show similar psychopathology and neuropsychological performances at baseline and during the first 6 months of antipsychotic treatment.

Depressive-type emotional response pattern in impulsive-aggressive patients with borderline personality disorder

INTRODUCTION

Borderline personality disorder (BPD) is typically characterized by severe affective dysregulation leading to impulsive behaviors. Accordingly, preliminary data suggest the hypothesis that BPD patients could have a specific and altered pattern of subjective emotional response to stimuli. The nature of the emotional response in BPD can be compared with other affective disorders and provide further insight on the nosological proximity with other psychiatric disorders.

METHODS

Subjective emotional response was investigated in 19 patients with DSM-IV BPD with no current depressive episode and in 19 healthy control subjects by using the International Affective Picture System (IAPS). The intensity of arousal, valence and dominance was rated in response to 60 images categorized as pleasant, unpleasant and neutral by using a self-assessment instrument. ANOVA of multiple factors was used for between-groups comparisons.

RESULTS

The obtained pattern showed that BPD patients considered the unpleasant and neutral images as less aversive than controls, but the activation that these images induced was higher. Patients showed significantly greater arousal than controls for unpleasant and neutral images (p<0.05) but presented greater valence (more positive emotion) for these images (p<0.05). In addition, BPD patients showed lower dominance (greater insecurity and dyscomfort) for positive images (p<0.05).

CONCLUSIONS

The subjective emotional response pattern of BPD patients suggests a trait of vulnerability to pleasant stimuli and is similar to the pattern found in depressive patients in previous studies. This supports the evidence that BPD could in part be related with the spectrum of the affective temperament and affective disorders.

Orbitofrontal dysfunction related to depressive symptomatology in subjects with borderline personality disorder

OBJECTIVE

In order to explore the relationships of fronto-limbic dysfunction with the clinical features of borderline personality disorder (BPD), the authors investigated brain electrophysiological activity in BPD patients following stimulation with emotionally arousing images.

METHODS

Seventeen non-medicated patients with borderline personality disorder were studied with magneto-encephalography. Regional cortical activities were obtained by minimum norm estimate (MNE) of steady-state visual evoked fields (ssVEFs). Linear regression models were conducted to explore clinical correlates of brain activity.

RESULTS

Although no interaction group × picture category × brain region was found, a significant interaction group × brain region appeared for orbito-frontal cortex (OFC). BPD patients showed significantly reduced magnetocortical activity in left OFC across all picture categories (F = 26.4; p<.05; F = 31.4). Left OFC activity was inversely correlated with depression score in the BDI (r: -0.48, p < 0.05), with score in the Cornell Dysthymia rating scale (r: -0.52, p < 0.05) and with the number of criteria met for depressive personality disorder (r: -0.44, p < 0.05). Left orbitofrontal activity was also inversely correlated with the global score in the GAF (r-0.63, p < 0.01). No correlations were found between OFC activity and impulsivity or global severity of BPD symptoms.

CONCLUSIONS

Abnormal functioning at orbitofrontal areas in BPD could be related to the presence of affective symptomatology and is associated with greater functional deterioration of patients.

Diagnostic features of the cycloid psychoses in a first psychotic episode sample

INTRODUCTION

The cycloid psychoses have not been included in the modern classifications-what makes scientific research difficult. The aim of the present study is to investigate the presence and specific characteristics of the cycloid psychoses in a broad sample of first psychotic episodes.

METHODS

Seventy patients diagnosed with one-year first schizophrenia episode, schizophreniform disorder, or schizoaffective disorder were studied (mean age, 27.9 years old; SD±6.34). The detection of the possible cases of cycloid psychosis was done according to the Perris and Brockington operational criteria. Two groups of "cycloid" (n=11) and "non cycloid" (n=59) patients were compared according to demographic and clinical variables, and possible diagnostic variables were evaluated by the ROC curves.

RESULTS

Significant differences were found between cycloid and non cycloid groups for a number of clinical variables: prodromic symptoms (p<0.001), PANSS total score (p=0.003), PANSS-P (p=0.009), PANSS-GP (p=0.001), total score for mania by EVMAC (p=0.001), and CDSS for depression (p=0.004). ROC curves were significant for PANSS-GP (AUC=0.791, p=0.002), EVMAC (AUC=0.938, p=0.001), and CDSS (AUC=0.770, p=0.005). A sensitivity/specificity study demonstrated a negative predictive value for PANSS-GP (93.88%), EVMAC (96.30%), and CDSS (93.88%).

CONCLUSIONS

According to these results, cycloid psychoses might represent differentiated and well-defined clinical entity.

Sustained attention as a potential endophenotype for bipolar disorder

OBJECTIVE

Nowadays, it is accepted that to identify the biological basis of psychiatric illnesses it would be useful to deconstruct them into the most basic manifestations, such as cognitive deficits. The aim of this study was to set attention deficit as a stable vulnerability marker of bipolar disorder.

METHOD

Sustained attention was evaluated by the Continuous Performance Test (DS-CPT) in 143 euthymic bipolar patients and 105 controls. To estimate the influence of clinical profile in attention, patients completed a semi-structured interview.

RESULTS

Bipolar patients showed a deficit in attention during euthymic periods. This disturbance correlated with years of evolution, age of onset and age of first hospitalisation; and was not influenced by other clinical data.

CONCLUSION

Sustained attention may be considered as an endophenotype of the illness.

[Analysis of brain complexity and mental disorders]

The knowledge of the brain processes underlying mental disorders has significantly increased during the last decades, but in spite of this very important research effort a biological marker is not available for such disorders. For example, neurophysiological techniques (EEG and MEG),have been broadly utilized in the investigation of the most important psychiatric syndromes such as schizophrenia, major depression, bipolar disorder or obsessive/compulsive disorder. The outcomes of some of those neurophysiological studies allowed the building of statistical models with very high sensitivity and specificity, although those models did not reach day-to-day clinical practice. A potential explanation for this situation is an inadequate analysis procedure which might be missing some important quantums of information contained in brain signals. In this vein, new methods of non-linear analysis have been proposed for the investigation of neurophysiological data. Particularly, the analysis of brain signals' complexity has been broadly utilized in the investigation of psychiatric disorders. Parameters of EEG-MEG complexity usually estimate the predictability of brain oscillations and/or the number of independent oscillators underlying the observed signals. More importantly, complexity parameters seem to be sensitive to the temporal components of brain activity, and therefore might reflect the dynamical nature of psychiatric disorders. This paper reviews some of the most relevant studies within this field, especially those focusing on the diagnosis, follow-up and prediction of response to treatment.

[Neuropsychological dysfunctions in personality borderline disorder: detection strategies]

INTRODUCTION

Borderline personality disorder (BPD) is characterized by emotional instability and impulsivity. However, there is evidence that neurocognitive alterations have a relevant role in the clinical features of these patients. The present study investigates cognitive function in BPD in order to search for a specific profile of neuropsychological alterations.

METHODS

Based on previous research and cognitive complaints reported by patients, a neuropsychological assessment protocol focused on prefrontal functioning was applied. The applied neuropsychological battery included tests assessing the following cognitive domains: memory (fixation, consolidation and recovery processes) categorical evocation, cognitive flexibility, sustained attention, processing rate, inhibitory control and working memory. The patient sample was recruited from an outpatient BPD unit and was composed by 26 patients (14 women, 12 men) diagnosed of BPD.

RESULTS

In comparison to the normative values, BPD patients have a deficit in the execution of most of the neuropsychological tests. This deficit was especially present in the following: recovery processes of the immediate and differed memory, working memory, sustained attention and processing rate, verbal fluency, impulse control, cognitive flexibility, abstraction and planning.

CONCLUSIONS

BPD patients could present a pattern of neurocognitive alterations that suggests a specific impairment of the prefrontal areas and requires a more detailed study. The neuropsychological dysfunctions could partially explain the behavioral alterations in BPD patients.

[Neuropsychological rehabilitation in patients with borderline personality disorder: a case series]

Recent research studies have been confirming the evidence that patients with personality borderline disorder (BPD) suffer significant neuropsychological disorders. Neurocognitive dysfunction of BPD seems to mainly affect the functions characteristic of the prefrontal areas that participate in information processing and management and in the regulation of complex behavioral responses. Neuropsychological disorders not only are seen in the specific tests but are also reflected and could play an important role in the clinical manifestations of borderline disorder, such as emotional dysregulation and impulsive behaviors. Neurocognitive rehabilitation therapy has been used successfully in psychiatric disorders such as schizophrenia, also characterized by the presence of neuropsychological dysfunctions. Thus, it can be expected that rehabilitation of the neurocognitive functions affected in BPD contributes to the patient's functional improvement. The present work describes a series of five patients with BPD who presented important neuropsychological dysfunctions and who were treated successfully with a specific program of neurocognitive rehabilitation. The results observed justify the performance of controlled clinical studies on the efficacy of this technique in the treatment of BPD.

The founding of the first psychiatric hospital in the World in Valencia

Several hospitals, countries and cultures claim the privilege of being the first to have provided care to people suffering mental illnesses. Among them, the <<Hospital de los Inocentes>> (Hospital of the Innocents) founded in Valencia in 1410 stands out due to its originality and there are historic and cultural reasons to recognize its primacy. Furthermore, the organization and functioning of this institution and the model, spread like wildfire through the entire Iberian Peninsula during the 15th Century and shortly after through American Spanish speaking countries. For centuries, these establishments were considered exemplary and were copied in other European Countries. At the beginning of the 19th Century in Spain a forced sale of the Catholic Church properties or their disamortization among other a large number of hospitals establishments took place. This lead to a terrible collapse of health care for the mentally. From then on it took more than one century to recover a decent standard. The vicissitudes of the creation and progress of the hospital of Valencia and others which followed the example that allows to affirm that it was really the first psychiatric hospital in the World are analyzed in this present work.

Generalized anxiety disorder: a 40-year follow-up study

OBJECTIVE

There is insufficient knowledge of the long-term course of generalized anxiety disorder (GAD). We studied the course of this disorder in patients who were followed up for 40 years.

METHOD

Patients admitted with the diagnosis of anxiety states ('anxious thymopathy' ) to the Lopez Ibor Neuropsychiatric Research Institute between 1950 and 1961 were examined between 1984 and 1988 (n = 65). The retrospective diagnosis of GAD was made according to DSM-III-R criteria during 1984-1988 (first examination). A re-examination was performed by the same psychiatrist in the period 1997-2001 (n = 59; second examination).

RESULTS

At first and second examinations 20% and 17% of subjects were diagnosed as GAD. Improvement was observed in 83%. GAD tended to disappear around age 50, but was replaced by somatization disorders. Lack of regular treatment compliance, female sex, and onset of GAD before age 25 were variables associated with a worse outcome. Undifferentiated somatization disorder was the most prevalent clinical status at follow-up.

CONCLUSION

After several decades, participants improve with regard to GAD, although most continue to present somatizations.

[Revision of the primary care version of the ICD-10. Mental disorders]

Although the difficulty of applying psychiatric classifications to primary care has been widely criticized, there have been few investigations up to now to define and systematize the real demands in regards to these nosological systems. Recently, the revised version of the Mental and Behavior Disorders Chapter of the ICD 10 has been published. The new tool is the result of an elaboration process mainly developed by a group of 971 primary care physicians coordinated by 55 psychiatrists. The project was organized into three phases: a) evaluation of the current version and collection of proposals for change; b) definition of objectives for an optimized version; and c) writing a proposal of revised text. The result is a text that is more assimilable to a diagnostic and therapeutic guide than a mere coding system, more adapted to the role that the primary care physician can play in each disorder, more up-dated (especially in the treatment section) and more specific in many aspects.

Paroxysmal MEG activity in obsessive compulsive patients without SSRIs therapy

We describe a fronto-temporal paroxysmal rhythmic activity registered by magnetoencephalography (MEG) in two patients with obsessive compulsive disorder (OCD) without SSRIs treatment. The localization of the activity involves cingulate cortex and frontal areas. We think that these MEG findings are related to the disease itself, rather than representing pharmacological SSRIs effect.

[Effects of venlafaxine extended release formulation on the clinical management of patients]

One of the issues related with antidepressant drug use is to improve patient compliance. Investigations have searched for simplified administration schedules that focus on having a significant impact on the management of depressive patients. This article has reviewed the extended release formulation characteristics and its effect on the drug pharmacokinetics and clinical assessments of depressive patients. The conclusion of this review is that venlafaxine extended release formulation represents an innovation in the treatment of depression. This formulation provides the same total exposure to venlafaxine with a once-daily dose as the immediate release formulation with several doses, slower gastrointestinal release and smaller fluctuations between maximum and minimal plasma concentrations. These differential characteristics result in a potential improved efficacy and a better tolerability profile. The increased compliance observed with venlafaxine extended release formulation could improve the appropriate management of depressive patients.

Attitudes about schizophrenia from the pilot site of the WPA worldwide campaign against the stigma of schizophrenia

BACKGROUND

A series of surveys were conducted to assess the attitudes of the public, and other groups, toward those with schizophrenia. The aim of these surveys was to aid in the planning and evaluation of the WPA anti-stigma initiative in Alberta, Canada.

METHOD

A questionnaire was devised and administered via telephone to over 1,200 individuals in three Alberta cities, and in paper and pencil format to 40 members of the Schizophrenia Society of Alberta and 67 medical students.

RESULTS

In contrast to some earlier findings, "loss of mind" was rated to be more disabling than any other handicapping condition. In general, respondents showed a relatively sophisticated understanding of schizophrenia and a higher level of acceptance than might have been predicted. Nonetheless, this acceptance was not as high for situations where closer personal contact was likely, and fears of dangerousness continue to be associated with schizophrenia. The majority of respondents, however, felt that treatment aided those with schizophrenia, expressed support for progressive programmes for the mentally ill, and stated that they would be willing to pay higher taxes so that programming could be improved.

CONCLUSIONS

The results do not support the utility of a broad approach for an anti-stigma campaign, but rather suggest a more specific focus, such as perceived dangerousness.

Eating behavior in morbidly obese patients undergoing gastric surgery: differences between obese people with and without psychiatric disorders

BACKGROUND

This study analyzes eating behavior in a group of morbidly obese patients who have undergone gastric reduction surgery for weight loss, and evaluates whether the existence of psychiatric comorbidity marks significant differences in their eating behavior.

METHODS

The study group was composed of 100 morbidly obese patients (85 females, 15 males) who had received surgical treatment for weight reduction (vertical banded gastroplasty). 40 of these patients (40%) met ICD-10 criteria for the diagnosis of psychiatric disorders and were included in the "Psychiatric Obese group" (PO). The other 60 patients (60%) did not show ICD-10 diagnostic criteria and were included in the "Non-Psychiatric Obese group" (NO). Each patients completed the Binge Eating Scale (BES), the Three Factor Eating Questionnaire, the Bulimia Investigatory Test-Edinburgh (BITE), and the Eating Disorder Inventory (EDI).

RESULTS

Significant differences were found between the two groups (PO and NO) in the Binge Eating Scale (p < 0.001), Three Factor Eating Questionnaire subscale Disinhibition (p < 0.001), BITE (p < 0.001), Eating Disorder Inventory subscale Perfectionism (p < 0.002), and Global EDI (p < 0.001). Logistic regression analysis showed correlation between PO group and Global EDI (Odds Ratio OR = 1.43) and BITE (OR = 1.16). No significant gender differences were found for eating behavior, clinical diagnosis, age, percentage of weight loss, time after operation, and BMI before surgery.

CONCLUSION

Surgically treated morbidly obese patients with a psychiatric disorder (PO) have a more destructured eating pattern (with a predominance of binge eating and disinhibition) than NO.

[Clinical features and weight loss in patients with morbid obesity after bariatric surgery]

OBJECTIVE

To analyze the psychological status of morbidly obese patients suffering changes after surgical procedure for weight reduction.

METHODS

We analyze the weight loss in 100 morbidly obese patients (85 female, 15 male) after bariatric surgery (vertical banded gastroplasty). We correlated the percentage of weight loss with the age of these patients, initial weight (body mass index at surgery), quality of life, eating behaviour, psychopathology, personality, and marital status.

RESULTS

We have found relation between initial weight and weight loss (heavier patients lose more weight). The percentage of weight loss is associated with the Eating Behaviour (Body Dissatisfaction, Disinhibition), the Quality of Life (Positive Affect), the Psychopathology (Hostility), the Personality Traits (Narcissist), and the Marital Status (Idealistic Distortion).

CONCLUSIONS

The weight loss in morbidly obese patients after surgery is major in the more obese one. The satisfactory weight loss after surgery improve the eating behaviour, quality of life, psychological and marital status.

Biological correlations of suicide and aggressivity in major depressions (with melancholia): 5-hydroxyindoleacetic acid and cortisol in cerebral spinal fluid, dexamethasone suppression test and therapeutic response to 5-hydroxytryptophan

5-Hydroxyindoleacetic acid (5-HIAA) and cortisol in cerebrospinal fluid (CSF), response of the dexamethasone suppression test (DST) and the clinical response to treatment with 5-hydroxytryptophan (5-HTp) plus carbidopa were studied in a group of 21 depressed inpatients (major depression with melancholia) in order to correlate biological findings with psychopathologicalones. A positive correlation was found between strong suicidal thoughts, suicidal attempts and self-aggressivity and low concentration of 5-HIAA in CSF and a less significant but still positive correlation with abnormal DST response and with clinical response to the treatment.

The meaning of stress, anxiety and collective panic in clinical settings

The physician is often confronted with questions about the meaning of symptoms or diseases. One of the tasks of those practicing psychosomatic medicine is to delve into the answers to these questions. Anxiety is a common phenomenon in everyday practice, and it is evoked in the most different situations. The relationships of this kind of anxiety (i.e. when having to consider painful or life-threatening diseases or medical or surgical procedures) to both neurotic anxiety and normal anxiety (i.e. the one expressed in poetry or artistic creativity or present in the biographies of outstanding men and women who by no means could be considered as psychiatric cases) leads to define anxiety as the psychological equivalent of stress. Anxiety is the unspecific response to a threat induced by too sudden or too extreme variations in the environment (life changes, stressful situations, life events). Such mechanisms, so important for survival, can become self-destructive, paving the way for the appearance of diseases represented by unsuccessful coping mechanisms. The analogy with the diseases of the general adaptation syndrome of Selye (i.e. autoimmune diseases) and with reactions in collective panics in disasters becomes evident under this perspective. The physician has to face anxiety with the same attitude that he faces pain, that is to say, going beyond a consideration of its 'normality' (it is quite normal to feel chest pain in acute heart infarct), keeping in mind its role in survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Regional cerebral blood flow in obsessive-compulsive patients with and without a chronic tic disorder. A SPECT study

The main goal of the present study was to explore whether regional cerebral blood flow (rCBF) differs between obsessive-compulsive disorder (OCD) patients without chronic motor tic disorder and those OCD patients with a comorbid chronic tic disorder. Twenty-seven patients suffering from OCD (DSM-IV criteria), including 7 OCD patients who met DSM-IV criteria for simple chronic motor dic disorder, and 16 healthy volunteers were examined at rest using a high resolution SPECT. Seven regions of interest (ROIs) were manually traced and quantified as a percentage of the mean cerebellar uptake. Severity of obsessive-compulsive symptoms (OCS), anxiety and depressive symptoms and presence of motor tics were assessed with the Y-BOCS, HRS-A, HRS-D, MADRS, and Yale Global Tics Severity Scale, respectively. We found a significant relative decrease in rCBF in OCD patients without motor tics compared to healthy volunteers in the right orbitofrontal cortex (OCD without tics = 0.87; healthy volunteers = 0.94; p = 0.02). No significant differences in rCBF were seen when OCD patients with and without chronic tics were directly compared. A lower severity of OCS in OCD patients with chronic tics was found. These results are consistent with previous functional neuroimaging studies at rest that have widely involved the orbitofrontal cortex in the pathophysiology of the OCD. However, our results do not support the idea that OCD patients with chronic tics may constitute a biological subgroup within the OCD.

Subtype criteria for bulimia nervosa: short- versus long-term compensatory behaviors

Weight control methods used by a group of bulimic patients were studied, analyzing the relationship among compensatory strategies and other clinical variables. Sixty-nine female consecutive patients who sought help for DSM-IV bulimia nervosa were recruited for the study. The prevalence and frequency of use of binge eating and six compensatory methods (vomiting, laxatives, diuretics, diet pills, fasting, and compulsive exercise) were assessed in each patient. Factor analysis was used to group the variables, and a cluster analysis was performed on a second step. The clinical variables were finally analyzed in each of the groups isolated through cluster analysis. According to the results of the factor analysis, the compensatory strategies were identified as short-term compensatory methods (vomiting), long-term methods (diet pills, diuretics, and laxatives), and nonpurging methods (dieting and exercise). Three groups of patients were isolated through cluster analysis: short-term purgers (vomiting), long-term purgers (laxatives + diet pills + diuretics), and a mixed group (vomiting + laxatives). Long-term purgers were older and heavier, had a greater prevalence of past overweight, and used more compensatory methods. These results confirm the necessity to continue investigating alternative ways of classifying bulimia nervosa patients based on compensatory behaviors, considering the existence of clinical dimensions rather than rigid clinical subtypes.

Callosal atrophy and associated electromyographic responses in Alzheimer's disease and aging

Alzheimer's disease is a degenerative disorder characterised by cerebral atrophy with cortical and subcortical changes. Our objective is to investigate the patterns of atrophic changes in the corpus callosum in patients with Alzheimer's disease and healthy elderly subjects and to clarify the relations of callosal impairment and the presence of associated electromyographic responses. We compare cross-sectional area of the corpus callosum by age, group and associated electromyographic responses, using quantitative magnetic resonance imaging from 47 subjects (twenty four healthy subjects and twenty three Alzheimer's disease patients). The control population was selected by criteria of optimal health; medical, neurological or psychiatric illnesses were excluded. We find that the first anterior and medial-anterior corpus callosum areas show an atrophy in Alzheimer group patients. These sectors show a clear relationship with the presence of associated movements.

Deficit in sensory motor processing in depression and Alzheimer's disease: a study with EMG and event related potentials

Event related potentials have been examined in depression and Alzheimer disease like clinical utility. To evaluate the influence of visual and auditory stimuli on the P300 latency we studied 12 patients with major depression, 12 patients with Alzheimer disease and 12 normal subjects. The experimental tasks applied was, first a series of 300 auditory stimuli, 255 (85%), with tones of 1,000 Hz, and considered as the frequent stimulus, whereas 45 (15%) were tones of 2,000 Hz and referred as the rare stimulus. A second series of 300 visual stimuli, 255 (85%) that were black circles on a white background, and considered the frequent stimulus (9 cm diameter, 200 ms duration), whereas 45 (15%) were black squares on a white background and referred as the rare stimulus (9 cm diameter, 200 ms duration) in the centre of a computer screen. The results show an increase of P300 latency in depressive and Alzheimer patients during auditory and visual tasks. Differences were found in reaction time to visual or auditory stimuli in Alzheimer disease. These results are consistent with an impairment in brain function in depressive patients that is associated with cortical hypoactivity and deficits in perceptive, auditory or visual, functions, whereas deterioration in Alzheimer's disease is sensorymotor, according to the slowness latency in the reaction time.

Evolution of the management of depression in Spain from the psychiatrist's perspective. A comparative analysis: 1997 vs 1982

The main problem of depression is not only the high prevalence of the disorder but also its serious consequences on the patient's quality of life and the associated social costs in terms of health care resource utilization and productivity losses. In recent years, there has been a considerable improvement in the knowledge of depression from the pathogenic, clinical and therapeutic perspectives. The present study analyzes whether such advances are reflected in a positive evolution of the treatment of depression in Spain. To this effect we have contrasted the results of two socio-sanitary studies published in this country: the White Book editions of 1982 and 1997 (WB82 and WB97, respectively). From the methodological perspective, the physician selection criteria employed were very uniform (structured questionnaires delivered to 128 (WB82) and 300 (WB97) randomly selected psychiatrists). The origin of patients consulting for specialized care has varied over this 15-year period. In effect, WB82 patients were essentially referred by friends (87.5%) and from the primary care setting (44.5%), whereas in the WB97 study referral from primary care predominated (50.1%), followed by the patient's personal decision (24.8%). In turn, 40.7% and 51.7% of the psychiatrists in WB97 respectively considered the diagnostic and therapeutic means available in primary care to be insufficient. The priorities for improving patient quality of life, as reflected by both editions of the study, were the training of primary care physicians and the adequate provision of means in the mental health care centers. On the other hand, fewer problems for establishing a correct diagnosis were referred in the 1997 edition of the study (28.7%) than in 1982 (48.4%). In this sense, the main problem reported in WB82 was the lack of specialized training, whereas the masking of depression by some other disease process or symptoms was the main problem in WB97 (67.6% vs 21.1% according to WB82). The main symptoms upon which the diagnosis of depression are based do not seem to have evolved much in the past 15 years. The most frequently cited manifestations were a worsening of mood, loss of interest and leisure capacity, sleep alterations and diminished vitality. A comparative analysis of the therapeutic resources used was not possible, for prior to 1982 the only drugs available to physicians were the classical tricyclic agents and some MAO inhibitors; the selective serotonin reuptake inhibitors (SSRIs) - possibly the greatest advance in the treatment of depression in these 15 years - had not yet been introduced. Nevertheless, it should be pointed out that 98% of the psychiatrists consulted in WB97 considered pharmacologic treatment to be the most widely adopted form of management once depression has been diagnosed.

[Applications of the magnetoencephalography in the study of schizophrenia]

In this paper we present a revision about magnetoencephalography (MEG) and schizophrenia. We focus on Auditive Magnetic Fields, principally in M100 and in his hemispheric asymmetries. Finally, it was discussed the advantages of the MEG in comparison with other techniques with low temporal (RMf, PET) or spatial (EEG) resolution.

Inhibitory deficits in probable Alzheimer's disease. A study of movement related potentials and EMG response

We have recently reported contralateral associated EMG responses to voluntary hand movement in Alzheimer's disease. Several aspects of this process were not fully explained in our last paper. In the present one we present data on the register of movement-related potentials (Negative Shift, NS) and Lateralized Readiness Potential (LRP), which have shown a very fine capacity to reveal processes that occur in the motor cortex while movement execution is being prepared. The associated EMG responses (so called by us) have almost all the characteristics of the partial errors revealed by cognitive psychology. First, it is a covert response, so it can only be detected by EMG recording; second, the appearance of this partial error changes the reaction time in the same way as described by Coles: mainly, by increasing reaction time as compared with clear responses. Nevertheless, contrary to partial errors, the associated EMG response does not constantly appear before the correct response. Associated EMG responses always appear after correct responses, with a constant delay of 54 +/- 28 ms. Our results show also an incorrect response preparation related to associated EMG response. We interpreted this specific feature in relation to inhibitory deficits in motor cortex and associated callosal pathways that avoid a correct response performance in Alzheimer patients.

[Psychometric validation of the telephone memory test]

INTRODUCTION

Several pathologies (i.e. Alzheimer's disease) that courses with memory alterations, appears in a context of impaired cognitive status and mobility. In recent years, several investigations were carried out in order to design short batteries that detect those subjects under risk of dementia. Some of this batteries were also design to be administrated over the telephone, trying to overcome the accessibility limitations of this patients.

METHODOLOGY

In this paper we present a battery (called Autotest de Memoria) essentially composed by episodic and semantic memory tests, administered both over the telephone and face to face. This battery was employed in the cognitive assessment of healthy controls and subjects diagnosed as probable Alzheimer's disease patients.

RESULTS

Results show the capability of this battery in order to discriminate patients and healthy controls, a great sensibility and specificity, and a nearly absolute parallelism of telephone and face to face administrations.

CONCLUSION

These data led us to claim the usefulness and practicality of our so called <<Autotest de Memoria>>.

[A study of personality in eating disorders]

Some evidence suggests that temperament and personality traits could influence the development and severity of eating disorders. This study was designed to study these aspects.

METHODS

72 patients with DSM-IV eating disorders including 25 anorexia nervosa restricting type, 17 with anorexia nervosa binge eating-purging type and 30 with bulimia nervosa were studied and compared with thirty healthy controls. Personality disorders and temperament were studied with the Eysenck's EPQ, Cloninger's TCI and SCID-II. Impulsive and clinical features were studied with specific rating scales.

RESULTS

61.8% of patients had at least one personality disorder. Avoidant personality disorder was the most commonly diagnosed in anorexia restricting type (25%). Borderline personality disorder was the most frequent in bulimia nervosa and in the binge eating-purging type of anorexia nervosa. Dimensionally, the group of eating disorders presented high scores in neuroticism and low scores in self-directedness. Higher harm avoidance was found in bulimic patients and higher persistence was associated with anorectic patients. Bulimic patients were significantly more impulsive than anorectic and controls.

CONCLUSIONS

Temperament and personality traits differ in anorectic and bulimic patients. Bulimic symptoms are linked to impulsive temperament traits and to impulsive personality features. Anorectic symptoms are linked to persistent temperament traits and anxious personality features.

[Origin, cognitive meaning and clinical applications in psychiatry of the P300 component]

The P300 component studies, have been generated discussion about his source, cognitive meaning and clinical applications. Since the first point of view, different structures have been proposed as a probable source of P3a or P3b in oddball and memory task and in scalp and in a intracraneal recordings. There are many papers that lucubrate about cognitive meaning of P300 and the applications of this component in the diagnostic process of psychiatric pathology. We make critic analysis and different points of view about this component.

Tianeptine therapy for depression in the elderly

1. Depression is frequent in the elderly but difficult both to diagnose and treat due to a number of distinctive features. 2. Tianeptine is a novel antidepressant with a reverse mode of action to that of the selective serotonin reuptake inhibitors yet with proven efficacy and safety. 3. 63 elderly patients (mean age:68.8 years; range:65-80 years) with depressive symptoms (major depression:55.6%; dysthymia:44.4%) were included in a 3-month open multicenter study with tianeptine (25 mg daily). 4. 43 patients (68.2%) completed the study. There were no drop-outs due to side-effects. Total Montgomery and Asberg Depression Rating Scale scores were significantly decreased (p < 0.01) on day 14, with a response rate of 76.7%. 5. Improvements were also observed in anxiety and cognitive performance. Side-effects were seen in only 11.7% of patients, with no changes in laboratory or ancillary safety parameters. Tianeptine is thus effective and well tolerated in this category of patient.

[Landau-Kleffner syndrome (acquired aphasia with epilepsy). Etiopathology and response to treatment with anticonvulsants]

The Landau-Kleffner syndrome consists in the association of an aphasia acquired during childhood or adolescence after a period of normal development, accompanied by epileptic fits and, sometimes, psychological disturbances. The appearance of the symptoms may not be simultaneous. The nature of this syndrome has been widely discussed and even the possibility of being a non-unitary syndrome has been considered. It may be possibly due to diverse etiologies, genetic or acquired (infectious). The relation between the aphasic, the psychologic and the convulsive symptoms has also raised controversies. A case of a female is described in which the psychological symptomatology was so severe, she had to be admitted in a psychiatric unit. The symptoms consisted in agitation during the night and severe persistent insomnia so as difficulties for relationship during day. No abnormalities were detected in a TAC nor in a RM but electroencephalographic and neuropsychological abnormalities were detected. The epileptic fits disappeared with a carbamacepine treatment but the rest of symptoms remained even more accentuated. After her admission, a treatment with valproate achieved to control her fits and the aphasic symptoms and neuropsychological deficits were compensated in the course of several months. After a year of treatment the patient's life was normalized, she resumed her studies, the EEG abnormalities disappeared so as the psychological disturbances and the behavior problems with the exception of phobic symptoms, similar to the ones of other family members. The patient has a history of epilepsy on its mother's side. The evolution and treatment response suggests that at least in some cases of the Landau-Kleffner syndrome, the etiology of the aphasia and other neuropsychological deficits and of the behavior disorders are related with some subclinical epileptic discharges and with a "functional inhibition" of some areas of the nervous system.

Social phobia: a debilitating disease that needs treatment

Social phobia is a recognized clinical condition and is at least as well defined as other psychiatric disorders in which no brain damage has been identified. There are both qualitative and quantitative differences between pathological and normal anxiety. The separation of social phobia from normal shyness is clear from the distress suffered, the impact on daily activities, the duration of the condition and the qualitative difference of the anxiety experienced in social phobia.

[Serotonergic function in endogeneity of depression]

OBJECTIVE

This study employed an alternative method for assessing serotonergic function in depression. The neuroendocrine responses to acute intravenous administration of the serotonin (5-HT) reuptake inhibitor clomipramine were assessed in patients with Major Depression with Melancholia (DMM) and matched subjects with Major Depression (DM) (without Melancholia) and Dysthimic disorder (TD).

METHOD

10 patients who met DSM III-R criteria of DMM, 10 patients with DM and 10 with DD matched for age and sex received 12.5 mg of intravenously administered clomipramine. Prl, Cortisol and GH were measured during the next 135 minutes. We divided the samples using the Newcastle Scale.

RESULTS

The DMM patients had significant blunting prolactin responses to clomipramine compared with the other patients. Most of the major depression patients without melancholia were neurotic depressions according to the Newcastle Scale. There was a negative correlation between endogeneity and prolactin response.

CONCLUSIONS

These data support the hypothesis that DMM patients have abnormal neuroendocrine responses to the intravenous administration of the 5-HT reuptake inhibitor clomipramine, and that there is an association between endogeneity and prolactin response.

Psychiatric Care under the Present Economic Era. An International Perspective

There are extrinsic as well as intrinsic limits to the resources available for health care. Therefore, economic factors have become an essential part of medical activity, leading to a disruption of the traditional doctor-patient relationships. A new economic approach of health care (ie, through managed care) and ethical attitude (to overcome the limits of managed care) are essential, especially in psychiatric practice.

The World Health Organization Short Disability Assessment Schedule (WHO DAS-S): a tool for the assessment of difficulties in selected areas of functioning of patients with mental disorders

The World Health Organization Short Disability Assessment Schedule (WHO DAS-S) is an instrument for clinicians' assessment and rating of difficulties in maintaining personal care, in performing occupational tasks and in functioning in relation to the family and the broader social context due to mental disorders. The WHO DAS-S was developed and underwent preliminarily testing in the context of two international field trials of the multiaxial presentation of ICD-10 for use in adult psychiatry. The instrument was found to be useful, user-friendly and reasonably reliable for use by clinicians belonging to different schools of psychiatry and psychiatric traditions. Further work on the WHO DAS-S should include development of national adaptations of the instrument, studies of concurrent validity of the instrument and modification of the instrument to accommodate changes in the next edition of the International Classification of Impairments, Disabilities and Handicaps (ICIDH).

Contextual aspects of mental disorders: a proposal for axis III of the ICD-10 multiaxial system

After several years of development and testing, the World Health Organization (WHO) has recently completed work on the multiaxial presentation of ICD-10 for use in adult psychiatry. Axis III of the ICD-10 multiaxial system is intended for clinicians' reporting of contextual factors which may influence the diagnosis, treatment or prognosis of mental disorders that are recorded on Axis I. It was tested in two WHO-co-ordinated international field trials and found to be user-friendly, reasonably reliable and useful in routine clinical work, in the training of mental health professionals and in research on mental disorders.

Double-blind comparison of fluoxetine versus clomipramine in the treatment of obsessive compulsive disorder

There is evidence of the clinical efficacy and safety of clomipramine and the newer selective serotonin reuptake inhibitors (SSRIs) for the treatment of obsessive-compulsive disorder (OCD). In the present study, we have compared the efficacy and safety of 40 mg/day of fluoxetine and 150 mg/day of clomipramine in patients with OCD, diagnosed according to DSM-IIIR. A total of 55 patients entered this 8-week, double-blind controlled study. Efficacy for both drugs was comparable. The primary efficacy criterion, the Y-BOCS Total score, did not show any significant differences between treatment arms. Response rate was higher with clomipramine, using a 25% decrease in Y-BOCS Total score as response threshold, but there were no significant differences between treatment arms using a 35% threshold. Overall safety and tolerability were good for both drugs, being slightly better for fluoxetine.

Dysthymia in DSM-IV and ICD-10: nosology and diagnosis

Since the DSM-III, the category of dysthymia includes patients that were previously considered as neurotic, reactive, characterological, temperamental, minor or atypical depressives as opposed to a category of endogenous, autonomous, morbid, major or typical depressives. Despite certain confusion, the need for a nosological category is very important for patients suffering from years of depressive mood, with a significant impact on their life-styles and adaptation, as they can benefit enormously from modern antidepressant treatments. DSM-IV and ICD-10 describe dysthymia in a very similar way although there are significant differences. The differences are the consequence of the lack of sufficient scientific data in some points and the need to take a decision, but also to indicate areas for future research. Other differences are the consequence of major discrepancies in basic perspectives of the classifications (ie, the importance given to disablement for the diagnosis). The similarities between both classifications allow the use of either of them for most purposes. Research on the different classifications should help in better defining the concept of dysthymia and mood disorders in general (ie, the cut-off points between them) and of psychiatric nosology.

Low platelet monoamine oxidase activity in pathological gambling

Decreased platelet monoamine oxidase (MAO) activity has been reported in association with sensation-seeking personality type and in some mental disorders associated with a lack of impulse control. Pathological gambling itself has been related with both sensation-seeking and reduced impulse control. Platelet MAO activity was investigated in 15 DSM-III-R pathological gamblers from our outpatient clinic. Gamblers had a significantly lower platelet MAO activity than a group of 25 healthy controls. The range of MAO levels in gamblers was also significantly shorter than in controls. In controls, platelet MAO levels showed the previously described negative correlations with sensation-seeking scores but not in gamblers. The findings are consistent with previous studies showing an association of low platelet MAO activity with impulse control disorders and raise some interesting therapeutic alternatives for pathological gambling.

[Spanish adaptation of the Alzheimer's disease assessment scale (ADAS)]

The Alzheimer's Disease Assessment Scale, was designed specifically to evaluate the severity of cognitive and noncognitive behavioral dysfunctions characteristic of persons with Alzheimer's disease. Twenty-one items with significant intraclass correlation coefficients for interrater reliability (0.975 for cognitive subscale, 0.933 for noncognitive subscale and 0.973 for total score), significant Spearman correlation coefficients for test-reliability (0.901 for cognitive subscale 0.574 for noncognitive subscale and 0.824 for total score) and significant correlation coefficients for concurrent validity (0.872 for subscale cognitive, 0,584 for noncognitive subscale), constitute the scale.

Serotonin and psychiatric disorders

One of the ongoing problems in biological psychiatry lies in relating clinical laboratory findings to specific symptoms or behaviour patterns. In recent years it has become clear that serotonin (5-HT) is involved in a wide range of psychiatric disorders and in quite specific behaviour patterns, mainly characterized by a poor control of impulses. Psychopharmacotherapy with substances able to enhance the metabolism of serotonin (mainly antidepressants) is able to clinically improve what appear to be very dissimilar conditions. Moreover, antidepressants with serotonergic activity are the only class of drugs able to relieve the symptoms of obsessive compulsive disorder (OCD), which are characterized by a high control of impulses or, more precisely, by a dysfunctional, non-adaptive control of impulses. Recent neurochemical data suggest that a hypersensitivity to 5-HT exists in this condition. Therefore, the hypothesis that serotonin is important for efficient control of impulses is a key to the interpretation of many laboratory findings and to the penetration of the complex field of biological substrates of psychopathology.

[Treatment with naltrexone in opiate dependents: 2 years' follow-up]

Outcome of a maintenance treatment with naltrexone (350 mg/week) are examined in a sample of 365 patients with opiate dependence disorder. Treatment was followed in an outpatient facility, in a setting similar to patient's own environment. The average attendance rate was of 198 days. Six months after the onset of the treatment, 52% of the patients still remained drug-free. Results of treatment was correlated with family support, HIV, work adjustment, use of other drugs and partner using drugs.