[Pharmacotherapy of attention deficit hyperactivity disorder in adults]

Pharmacotherapy is a central component in the context of an overall therapeutic concept in the treatment of adults with attention deficit hyperactivity disorder (ADHD). In this concept psychosocial interventions with psychoeducation or specific psychotherapy measures also play an important role. In adults three compounds are currently approved for the pharmacological treatment of ADHD in Germany. The long-acting stimulants retarded methylphenidate preparations and lisdexamfetamine can be prescribed. Alternatively, the adrenergic uptake inhibitor atomoxetine can be used. In several meta-analyses good effectiveness and tolerance of these drugs on ADHD psychopathology has been shown. They also improve ADHD-related disorders of emotional regulation capability and disorganization in everyday life. Importantly, an improvement in everyday functionality and quality of life under medication could also be shown in several studies. In this review the evidence for pharmacotherapy of ADHD and its implementation into treatment of adult patients is presented.

Suchtmittelgebrauch bei jungen erwachsenen Straftätern mit und ohne Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS)

Prospective studies of children with ADHD have shown a high level of substance use disorder comorbidity, particularly when associated with social maladaptation and antisocial behavior. Conversely, studies of drug abusing participants and delinquents revealed a high prevalence of ADHD comorbidity. In this study 129 young male prison inmates were systematically examined for ADHD and substance use disorders. 64,3 % showed harmful alcohol consumption. 67,4 % fulfilled DSM-IV criteria for any drug abuse or dependence. 28,8 % of these participants were diagnosed with ADHD, combined type, other 52,1 % showed ADHD residual type. Opioid dependence was more common in delinquents without ADHD. Addicted delinquents with ADHD showed worse social environment and a higher degree of psychopathology, including externalizing and internalizing behavior, compared to addicted delinquents without ADHD. Neuroticism and conscientiousness ratings of the addicted ADHD group, but not of those without ADHD, differed from non-addicted delinquents. The results underline the need of adequate therapeutic programs for addicted young prison inmates considering ADHD comorbidity, which is associated with additional psychopathology and social problems.

Impaired cortical inhibition in adult ADHD patients: a study with transcranial magnetic stimulation

The aim of this study was to analyze motor inhibition and facilitation of adult ADHD patients using double pulse transcranial magnetic stimulation (TMS). Twenty-six right handed adult ADHD patients according to DSM-IV were investigated and compared to 26 age and sex-matched controls. In the left hemisphere, mean motor inhibition was 0.53 +/- 0.33 (mean +/- SD) in ADHD patients and 0.34 +/- 0.16 (mean +/- SD) in controls (p = 0.012). There were no significant differences in motor excitability concerning facilitation or in the right hemisphere. Decreased motor inhibition correlated with a higher symptom score derived from the Wender Reimherr Interview (WRI) (p = 0.28; p = 0.04) and also with self rated hyperactivity/impulsivity symptoms (p = 0.30; p = 0.03). In conclusion, decreased motor inhibition in adult ADHD corroborate similar findings in children with ADHD (Moll et al., 2000) and reflect disturbed impulsivity and hyperactivity on a neurophysiological level.

[Awareness of memory deficits in patients with probable Alzheimer's disease]

Thirty-eight patients with Alzheimer's disease were asked to give a qualitative (estimation of memory changes) and quantitative assessment of their own performance on memory tasks and also of their relatives' performance. Qualitative assessment showed to be independent from measured memory-deficits, while the precision of quantitative prediction of performance deteriorated with increased cognitive impairment. Cognitive impairment of the demented patients did not influence the prediction of the performance of their relatives. Both, qualitative and quantitative assessment of memory performance were influenced by premorbid coping-strategies. Patients, who were attributed to use strategies of cognitive avoidance, more often claimed to have no changes in memory function or over-estimated their memory performance. The results of this investigation reveal that methodological issues influence studies on the association of meta-cognitive abilities with the severity of dementia to a great extent. They also suggest that awareness of deficits should be based on a complex, multi-dimensional concept.

Instrumente zur Diagnostik der Aufmerksamkeitsdefizit-/Hyperaktivit�tsst�rung (ADHS) im Erwachsenenalter

We report on the development of a German self-rating behaviour questionnaire (ADHD-SR) and diagnostic checklist (ADHD-DC) for the diagnosis of attention-deficit/hyperactivity disorder in adults according to DSM IV and ICD 10 research criteria. When comparing self-rating with expert rating, we found good concordance measured by intraclass coefficients on the level of single symptoms and syndrome scores. High retest reliability of the ADHD-SR demonstrated the ability to assess time-stable behaviour traits. Evaluation of the psychometric properties revealed good internal consistency and adequate convergent and divergent validity measured by the "big five" derived from the NEO-FFI and the constructs impulsivity, venturesomeness, and empathy of Eysenck's impulsiveness questionnaire. We detected a remarkable correlation with the Wender Utah Rating Scale, which targets the detection of childhood ADHD symptoms. Diagnostic sensitivity for different cutoff points was calculated by ROC analysis at 65--88%. Specificity was 67% to 92%.

[Reliability and validity of the Wender-Utah-Rating-Scale short form. Retrospective assessment of symptoms for attention deficit/hyperactivity disorder]

The diagnosis of adult attention deficit/hyperactivity disorder (ADHD) requires the retrospective assessment of ADHD symptoms in childhood. The Wender Utah Rating Scale (WURS) is helpful in detecting ADHD-associated symptomatology in childhood. A German short version (WURS-k) of this instrument has been made available recently. In the present study, we investigated the validity of the WURS-k. In a population of 63 adult ADHD patients (according to ICD-10 and DSM-IV criteria) and 1,303 male controls, ROC analysis indicated a sensitivity of 85% and specificity of 76% at a cutoff of 30 points. In ADHD patients, seven individual factors explained 70.3% of the variance. The highest diagnostic precision was demonstrated using the WURS-k total score. The seven extracted factors of the WURS-k did not differ in diagnostic value. Significant correlations were found between impulsivity according to Eysenck's Impulsivity Questionnaire (EIQ) and excitability, aggression, emotional lability, and satisfaction on the Freiburg Personality Inventory (FPI-R) in ADHD patients. Concerning a 30-50% persistence of ADHD symptomatology in adults, these correlations underline the diagnostic validity of the WURS-k. The scale manifested excellent internal consistency (alpha=0.91) and a split-half correlation of r(12)=0.85.

Dopamine D3 receptor gene polymorphism and violent behavior: relation to impulsiveness and ADHD-related psychopathology

Several lines of evidence indicate that dopaminergic neurotransmission is involved in the regulation of impulsive aggression and violence and that genetically determined variability in dopaminergic gene expression modifies complex traits including that of impulsivity and aggression. In this study we report an association of the dopamine D3 receptor (DRD3) polymorphism with impulsiveness according to Eysenck's EIQ and scores on the German short version of the Wender Utah Rating Scale (WURS-k), which we used for the assessment of a history of ADHD-related symptoms. This association was detected in a group of violent offenders, but not in non-violent individuals. Highest scores of EIQ impulsiveness and of the WURS-k were found in heterozygous violent individuals, while homozygotes showed significant lower rating scores, suggesting an heterosis effect. The results of our study suggest that variations of the DRD3 gene are likely involved in the regulation of impulsivity and some psychopathological aspects of ADHD related to violent behavior.

[Overview of standardised diagnostic instruments of dementia]

The symptoms of dementia refer to a decline in intellectual abilities and to an impairment of general and instrumental activities of daily living (ADL). Beside cognitive decline and loss of ADL's the diagnosis of dementia requires the documentation of changes in social adaptation, psychopathology and behaviour. There are a large number of scales used in the assessment of the various manifestations of the disease. Some scales focus on a particular aspect of the symptomatology, others prefer a comprehensive approach in the detection of dementia symptoms. We present a list of assessment procedures and scales which seem appropriate to detect different aspects of dementia and which are widely accepted in the scientific community. We describe these scales in detail including their methodology and source of informations, psychometric properties regarding validity and reliability as well as time taken to complete the scales. Our synopsis may serve as an orientation mark in the selection of adequate instruments for the assessment of different symptom domains during the process of diagnosis, the observation of the course of dementia and the efficacy of treatment interventions.

[Presentation and stability of cognitive and noncognitive symptom patterns in patients with Alzheimer's disease. Disease course over a two-year period under constant treatment conditions with rivastigmine]

The course of behavioural and psychotic features of patients with Alzheimer's disease treated with an inhibitor of the acetylcholinesterase (rivastigmine), and their association to cognitive impairment is presented in the study. Standardized examination of global functional deterioration (GDS), cognitive impairment (MMSE) and behavioural or psychotic symptoms (Behave-AD) were performed over two years. We could analyse the complete data from 44 of initially 91 patients with mild to moderate Alzheimer's disease. The cognitive component (measured by MMSE, ADAS-cog) and the functional assessment (GDS) showed a continuous decline after a one year period of stabilization, in contrast with behavioural and psychotic symptoms, especially delusions, which still improved after treatment of two years. While cognitive items in correlation with functional aspects formed a homogeneous factor over the two-year period, psychotic features displayed more variability over time evaluated by factor analysis. Nevertheless mood and anxiety disorder in combination with aggressive behaviour as well as hallucinations formed an independent factor in the course of Alzheimer's disease. In addition to other studies of the course of Alzheimer's disease we could demonstrate that distinct behavioural and psychotic symptoms may also present as independent factors in Alzheimer patients under constant treatment conditions with an inhibitor of the acetylcholinesterase (rivastigmine).

[Wender Utah rating scale. The short-version for the assessment of the attention-deficit hyperactivity disorder in adults]

This work presents a statistical analysis of the German version of the Wender Utah rating scale (WURS) for the retrospective diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults. Data were obtained from 703 subjects. Item selection according to item-total correlation scores, frequency, and plausibility led to a short version of the scale that includes 21 items with item-total correlations from 0.19 to 0.61. Retest reliability of the WURS-k was r=0.9.

[Symptoms from the spectrum of Attention-Deficit/Hyperactivity Disorder (ADHD) in sexual delinquents]

The implications of ADHD for sexual delinquent behavior were investigated in a sample of 127 male sexual delinquents for whom social, forensic and psychiatric data were collected. For the retrospective evaluation of ADHD-symptoms, we used the Wender Utah Rating Scale (WURS, 61-item version). We also used the Eysenck Impulsiveness Questionnaire for the assessment of impulsivity. The prevalence of ADHD within the group of sexual delinquents was 27.6 % with a persistence rate of 14.2 % at a cut-off point of 90 in the WURS. The prevalence of ADHD within the control group was 7.8 % with a persistence rate of 3.0 %. The prevalence within the group of sexual delinquents dropped to 15.7 % for childhood ADHD-symptoms and 11.0 % for partial ADHD persistence in adulthood using a cut-off score of 100. In the control group the rates were 4.8 % and 2.4 % respectively. Based on ICD-10 criteria, 35.4 % of the sexual delinquents had no psychiatric disorder. We found personality disorders of the antisocial type (22.1 % of the sample) and paraphilias in 25.2 %. Approximately, half of the delinquents with paraphilia met the criteria of pedophilia. We also found schizophrenia, organic psychiatric disorders and mental retardations in less than 5 %. The criminal careers of the sexual delinquent group with a history of childhood ADHD symptoms started 10 years earlier. We also found a significant correlation between previous convictions and the retrospective diagnosis of ADHD symptoms. This was more prominent when a previous sexual offence could be found in their criminal record. These results illustrate the hypothesis, that in addition to paraphilias the presence of ADHD-symptoms might be an important vulnerability factor for sexual delinquency, esp. when there is a persistence into adulthood. This demonstrates the need for an early therapeutical intervention, since 44.1 % of the sample had previously undergone psychiatric treatment.

Effects of two-year treatment with the cholinesterase inhibitor rivastigmine on behavioural symptoms in Alzheimer's disease

Alzheimer's disease (AD) is accompanied by prominent behavioural disturbances. They cause significant distress for both caregivers and patients and can play a major role in the decision to institutionalise AD patients. Recent evidence suggests that cholinergic deficiencies not only contribute to the memory and cognitive abnormalities of AD but are also responsible for some behavioural abnormalities seen over the course of the disease. In this study we assessed the ability of rivastigmine, a pseudo-irreversible cholinesterase inhibitor, to improve behavioural and psychopathologic symptoms in AD. The analysis included 34 patients present in the Germanarm of the international study B303 who received and completed long-term treatment with rivastigmine in the open-label study B305. Assessments of behaviour and psychopathological symptoms were performed using the behavioural component of the Clinicians Interview Based Impression of Change Plus (CIBIC-Plus). Results show that long-term treatment with rivastigmine can slow the progression of behavioural and psychopathological symptoms of AD. Behavioural symptoms showing stabilisation included aggressiveness, activity disturbances, hallucinations and paranoid features. Results also suggest that patients treated earlier with rivastigmine may attain a greater benefit compared with patients whose treatment is delayed 6 months. Further studies examining the effects of rivastigmine on behavioural disturbances in AD are therefore warranted.

Potential genetic markers of sporadic Alzheimer's dementia

Polymorphisms within the genes encoding apolipoprotein E (ApoE), apolipoprotein CI (ApoCI), alpha1-antichymotrypsin (ACT), the low-density lipoprotein (LDL) receptor and lipoprotein lipase were investigated in patients suffering from Alzheimer's dementia and non-demented psychiatric patients as control subjects. The ApoE allele 4, well known as a risk factor in Alzheimer's disease, and the ApoCI allele A2, which is closely linked to the ApoE allele 4, were found elevated in the index group. Concerning the polymorphism within exon 8 of the LDL receptor (alanin/threonin), there was also a predominance of the allele carrying threonin in the index group, which barely missed significance. Distribution of the polymorphisms of ACT and lipoprotein lipase were similar in both groups investigated. We conclude that, apart from the ApoE allele 4, other genetically regulated factors like ApoCI and the LDL receptor modulate the individual risk for Alzheimer's disease.

Cerebellar vermis area in schizophrenic patients - a post-mortem study

Neuroimaging studies of cerebellar atrophy in schizophrenia have yielded contradictory results. In computer-tomography (CT) studies, cerebellar atrophy was found in up to 40% of schizophrenic patients. However, several recent magnetic resonance imaging (MRI) studies could not replicate these early findings; in addition, contradictory observations of enlargement of vermal structures were reported. In contrast to the number of CT and MRI studies, there are only a few neuropathological reports on this subject. In a post-mortem study we analyzed the midsagittal vermal area of formaldehyde-fixed cerebella of 12 deceased schizophrenic patients and 12 age- and gender-matched control subjects by using morphometrical methods. Statistical analysis using ANOVA revealed no significant group effects, but there were interactions with gender and cerebellar brain weight. In view of the present results, the common concept of cerebellar atrophy in schizophrenic patients appears premature. Gender effects and secondary processes (e.g., relevant alcohol or drug abuse) cannot be excluded as possible factors causing decrease of vermal areas in schizophrenic patients.

[Significance of personality markers in Alzheimer dementia]

Personality traits are of raising importance in the investigation of the causes of Alzheimer's disease. The examination of possible correlations between personality traits and the presence of dementia is complicated by some methodical problems concerning the objective, reliable, and valid assessment especially of premorbid personality style of demented persons. There is some evidence that a higher level of education can not be considered as protective factors but seems to delay the progression and modify the clinical manifestation of the disease. How other premorbid personality traits influence the course of the disease is still unresolved. A trend towards an uniform personality alteration in the course of the disease seems to exist. Especially when selecting non-pharmacological therapeutical or training strategies or even in the interaction with the patients, it seems to be important to take personality change into consideration.

Polymorphisms of the human apolipoprotein E promoter and bleomycin hydrolase gene: risk factors for Alzheimer's dementia?

In addition to the apolipoprotein E (ApoE) tri-allele polymorphism, genetic variants of the apolipoprotein E promoter (-491A/T) and the bleomycin hydrolase (BH-PEN) gene have also been proposed as genetic risk factors for Alzheimer's dementia (AD). Since reports about the relevance of these polymorphisms for the pathogenesis of AD have been contradictory, we performed an association study with some modifications. First, the control group in this study was made up of non-demented psychiatric inpatients, rather than healthy subjects. This procedure allows the specificity of the relationship between a given genotype and AD (as opposed to other psychiatric disorders) to be determined. Second, as an alternative to preexisting relatively time consuming techniques, BH-PEN polymorphism was determined using a simplified method based on PCR genotyping. We found a significant linkage disequilibrium between the -491A/T and ApoE polymorphisms. However, no direct association was observed between the -491A/T or BH-PEN polymorphism and AD.