Dose-dependent opposite effects of nortriptyline on affective-like behavior in adolescent rats: Comparison with adult rats

Antidepressant drugs elicit different behavioral and neurochemical responses with age. In fact, the use of antidepressants during adolescence is associated with an increased risk of suicidal thinking, being the best pharmacological treatment during this critical period a matter of constant debate in terms of its risk-benefit outcome. In this regard, the present study compared the effects of nortriptyline (3-10 mg/kg, 7 days) on regulating different aspects of affective-like behavior by screening adolescent and adult Sprague-Dawley rats through several consecutive tests (forced-swim, open field, sucrose preference). Brains were later collected to evaluate hippocampal neurogenesis and mBDNF protein content as potential molecular correlates of the observed behavioral responses. The main results in adolescent rats showed that nortriptyline induced dose-dependent opposite effects: while 3 mg/kg decreased immobility and increased mBDNF (indicative of an antidepressant-like response), 10 mg/kg decreased exploratory time in the open field and mBDNF (suggestive of an anxiogenic-like response). These effects were not associated with changes in neurogenesis regulation. In adult rats, nortriptyline failed to modulate affective-like behavior or the neuroplasticity markers evaluated at the doses tested. In conclusion, clear behavioral and neurochemical differences were observed between adolescent and adult rats in response to nortriptyline treatment. Interestingly, while nortriptyline displayed an antidepressant-like potential at the lowest dose examined in adolescence, a higher dose shifted these results towards a negative outcome, thus reinforcing the need to extreme caution when considering this treatment for our younger population.

Assessing alexithymia in forensic settings: Psychometric properties of the 20-item Toronto Alexithymia Scale among incarcerated adult offenders

BACKGROUND

Alexithymia is a trait involving difficulty identifying feelings (DIF), difficulty describing feelings (DDF) and externally orientated thinking (EOT). It is a risk factor for criminal behaviour. It is commonly assessed with the Toronto Alexithymia Scale (TAS-20), but the psychometrics of the TAS-20 have not been tested across the range of offender populations, and it has been suggested it might be unsuitable in incarcerated offenders.

AIM

To establish the psychometrics of the TAS-20 among incarcerated offenders.

METHODS

Factorial validity was examined using confirmatory factor analyses, and the invariance of this factor structure was tested against a published community sample. Reliability coefficients were calculated.

RESULTS

One hundred and forty six incarcerated offenders were recruited. The factor structure of the TAS-20 was invariant across the samples. The intended factor structure composed of DIF, DDF and EOT factors performed well overall (with a reverse-scored method factor added), but six EOT items had low factor loadings. The total scale score and DIF and DDF subscales had acceptable reliability, but EOT did not.

CONCLUSIONS

Our results suggest that the TAS-20 functions similarly in offender and community samples. Its total scale score, and DIF and DDF subscale scores can be used confidently, but the assessment of externally oriented thinking may not be adequate with this scale alone. In sum, the TAS-20 can facilitate robust assessment of alexithymia in closed criminal justice settings as well as in the wider community.

Alexithymia in nonviolent offenders

BACKGROUND

Alexithymia is a trait involving difficulties processing emotions. Existing data suggest it is associated with violent offending. In violent offender programmes, therefore, violent offenders are screened for alexithymia and it is attended to if necessary. No studies have, however, examined alexithymia levels in nonviolent offenders and it is, therefore, unknown whether it is also a criminogenic factor in this population.

AIMS

To investigate alexithymia levels among incarcerated nonviolent offenders and compare them with a community comparison group.

METHOD

The 20-item Toronto Alexithymia Scale was used to compare the alexithymia levels of 67 incarcerated nonviolent offenders with a group of 139 people from the general public living in the community.

RESULTS

Alexithymia levels did not differ between the groups.

CONCLUSION

It appears that alexithymia is not a criminogenic factor for nonviolent offenders and screening of such offenders appears unnecessary.

Neuro-cognitive correlates of alexithymia in patients with circumscribed prefrontal cortex damage

Alexithymia has been extensively reported in studies of psychiatric patients. However, little attention has been paid regarding its occurrence in the context of patients with circumscribed prefrontal cortex lesions. Moreover, the neuro-cognitive impairments that lead to alexithymia remain unclear and limited numbers of studies have addressed these issues. The authors investigated the impact of prefrontal cortex lesions on alexithymia and its neuro-cognitive correlates in a population of 20 patients with focal frontal lesions, 10 patients with parietal lesions and 34 matched control participants. Alexithymia was screened using the Toronto Alexithymia Scale (TAS-20) and executive functions were assessed using a large battery of executive tasks that address inhibition, flexibility and the planning process. Results showed that patients with prefrontal cortex damage showed significantly increased difficulty in facets of identifying feelings (DIF) and externally oriented thinking (EOT) on TAS-20, compared to parietal patients and control participants. Moreover, both correlation and regression analysis revealed that higher alexithymia levels on the three facets of TAS-20 were consistently but differentially associated with impairment in inhibition, flexibility and planning tasks for frontal patients and both control groups. These findings provide clinical evidence of the implication of prefrontal cortex damage and executive control in alexithymia. Our results were also discussed in the light of the cognitive appraisal concept as a mechanism involved in emotion episode processing. This study suggests that increased neuropsychological attention should be directed to the relation between the neuro-cognitive model of executive functions and cognitive appraisal theory in processing emotion.

Alexithymia and reactive aggression: The role of the amygdala

Past research suggests an association between reactive aggression and alexithymia, but neural mechanisms underlying this association remain unknown. Furthermore, the relationship between proactive aggression and alexithymia remains untested. This study aimed to: (1) test whether alexithymia is more related to reactive than proactive aggression; and (2) determine whether amygdala, insula, and/or anterior cingulate cortical (ACC) volume could be neurobiological mechanisms for this association. One hundred and fifty-six community males completed the Reactive-Proactive Aggression Questionnaire and the Toronto Alexithymia Scale. Amygdala, insula, and ACC volumes were assessed using MRI. Alexithymia was positively associated with reactive but not proactive aggression. Alexithymia was positively and bilaterally associated with amygdala and anterior cingulate volumes. Reactive aggression was positively associated with right amygdala volume. Controlling for right amygdala volume rendered the alexithymia-reactive aggression relationship non-significant. Results suggest that increased right amygdala volume is a common neurobiological denominator for both alexithymia and reactive aggression. Findings suggest that greater right hemisphere activation may reflect a vulnerability to negative affect, which in turn predisposes to experiencing negative emotions leading to increased aggression. Findings are among the first to explicate the nature of the alexithymia-aggression relationship, with potential clinical implications.

Altered Associations between Pain Symptoms and Brain Morphometry in the Pain Matrix of HIV-Seropositive Individuals

Pain remains highly prevalent in HIV-seropositive (HIV+) patients despite their well-suppressed viremia with combined antiretroviral therapy. Investigating brain abnormalities within the pain matrix, and in relation to pain symptoms, in HIV+ participants may provide objective biomarkers and insights regarding their pain symptoms. We used Patient-Reported Outcome Measurement Information System (PROMIS®) pain questionnaire to evaluate pain symptoms (pain intensity, pain interference and pain behavior), and structural MRI to assess brain morphometry using FreeSurfer (cortical area, cortical thickness and subcortical volumes were evaluated in 12 regions within the pain matrix). Compared to seronegative (SN) controls, HIV+ participants had smaller surface areas in prefrontal pars triangularis (right: p = 0.04, left: p = 0.007) and right anterior cingulate cortex (p = 0.03) and smaller subcortical regions (thalamus: p ≤ 0.003 bilaterally; right putamen: p = 0.01), as well as higher pain scores (pain intensity-p = 0.005; pain interference-p = 0.008; pain-behavior-p = 0.04). Furthermore, higher pain scores were associated with larger cortical areas, thinner cortices and larger subcortical volumes in HIV+ participants; but smaller cortical areas, thicker cortices and smaller subcortical volumes in SN controls (interaction-p = 0.009 to p = 0.04). These group differences in the pain-associated brain abnormalities suggest that HIV+ individuals have abnormal pain responses. Since these abnormal pain-associated brain regions belong to the affective component of the pain matrix, affective symptoms may influence pain perception in HIV+ patients and should be treated along with their physical pain symptoms. Lastly, associations of lower pain scores with better physical or mental health scores, regardless of HIV-serostatus (p < 0.001), suggest adequate pain treatment would lead to better quality of life in all participants.

Acquired alexithymia following damage to the anterior insula

Alexithymia is a subclinical condition characterized by impaired awareness of one's emotional states, which has profound effects on mental health and social interaction. Despite the clinical significance of this condition, the neurocognitive impairment(s) that lead to alexithymia remain unclear. Recent theoretical models suggest that impaired anterior insula (AI) functioning might be involved in alexithymia, but conclusive evidence for this hypothesis is lacking. We measured alexithymia levels in a large sample of brain-injured patients (N=129) and non-brain-injured control participants (N=33), to determine whether alexithymia can be acquired after pronounced damage to the AI. Alexithymia levels were first analysed as a function of group, with patients separated into four groups based on AI damage: patients with >15% damage to AI, patients with <15% damage to AI, patients with no damage to AI, and healthy controls. An ANOVA revealed that alexithymia levels varied across groups (p=0.009), with >15% AI damage causing higher alexithymia relative to all other groups (all p<0.01). Next, a multiple linear regression model was fit with the degree of damage to AI, the degree of damage to a related region (the anterior cingulate cortex, ACC), and the degree of damage to the whole brain as predictor variables, and alexithymia as the dependent variable. Critically, increased AI damage predicted increased alexithymia after controlling for the other two regressors (ACC damage; total lesion volume). Collectively, our results suggest that pronounced AI damage causes increased levels of alexithymia, providing critical evidence that this region supports emotional awareness.

Can Emotional and Behavioral Dysregulation in Youth Be Decoded from Functional Neuroimaging?

INTRODUCTION

High comorbidity among pediatric disorders characterized by behavioral and emotional dysregulation poses problems for diagnosis and treatment, and suggests that these disorders may be better conceptualized as dimensions of abnormal behaviors. Furthermore, identifying neuroimaging biomarkers related to dimensional measures of behavior may provide targets to guide individualized treatment. We aimed to use functional neuroimaging and pattern regression techniques to determine whether patterns of brain activity could accurately decode individual-level severity on a dimensional scale measuring behavioural and emotional dysregulation at two different time points.

METHODS

A sample of fifty-seven youth (mean age: 14.5 years; 32 males) was selected from a multi-site study of youth with parent-reported behavioral and emotional dysregulation. Participants performed a block-design reward paradigm during functional Magnetic Resonance Imaging (fMRI). Pattern regression analyses consisted of Relevance Vector Regression (RVR) and two cross-validation strategies implemented in the Pattern Recognition for Neuroimaging toolbox (PRoNTo). Medication was treated as a binary confounding variable. Decoded and actual clinical scores were compared using Pearson's correlation coefficient (r) and mean squared error (MSE) to evaluate the models. Permutation test was applied to estimate significance levels.

RESULTS

Relevance Vector Regression identified patterns of neural activity associated with symptoms of behavioral and emotional dysregulation at the initial study screen and close to the fMRI scanning session. The correlation and the mean squared error between actual and decoded symptoms were significant at the initial study screen and close to the fMRI scanning session. However, after controlling for potential medication effects, results remained significant only for decoding symptoms at the initial study screen. Neural regions with the highest contribution to the pattern regression model included cerebellum, sensory-motor and fronto-limbic areas.

CONCLUSIONS

The combination of pattern regression models and neuroimaging can help to determine the severity of behavioral and emotional dysregulation in youth at different time points.

Dorsal Anterior Cingulate Thickness Is Related to Alexithymia in Childhood Trauma-Related PTSD

Alexithymia, or “no words for feelings”, is highly prevalent in samples with childhood maltreatment and posttraumatic stress disorder (PTSD). The dorsal anterior cingulate cortex (dACC) has been identified as a key region involved in alexithymia, early life trauma, and PTSD. Functional alterations in the dACC also have been associated with alexithymia in PTSD. This study examined whether dACC morphology is a neural correlate of alexithymia in child maltreatment-related PTSD. Sixteen adults with PTSD and a history of childhood sexual abuse, physical abuse, or exposure to domestic violence, and 24 healthy controls (HC) completed the Toronto Alexithymia Scale 20 (TAS–20) and underwent magnetic resonance imaging. Cortical thickness of the dACC was measured using FreeSurfer, and values were correlated with TAS–20 scores, controlling for sex and age, in both groups. Average TAS–20 score was significantly higher in the PTSD than the HC group. TAS–20 scores were significantly positively associated with dACC thickness only in the PTSD group. This association was strongest in the left hemisphere and for TAS–20 subscales that assess difficulty identifying and describing feelings. We found that increasing dACC gray matter thickness is a neural correlate of greater alexithymia in the context of PTSD with childhood maltreatment. While findings are correlational, they motivate further inquiry into the relationships between childhood adversity, emotional awareness and expression, and dACC morphologic development in trauma-related psychopathology.

Significant grey matter changes in a region of the orbitofrontal cortex in healthy participants predicts emotional dysregulation

The traditional concept of 'categorical' psychiatric disorders has been challenged as many of the symptoms display a continuous distribution in the general population. We suggest that this is the case for emotional dysregulation, a key component in several categorical psychiatric disorder constructs. We used voxel-based magnetic resonance imaging morphometry in healthy human subjects (n = 87) to study how self-reported subclinical symptoms associated with emotional dysregulation relate to brain regions assumed to be critical for emotion regulation. To measure a pure emotional dysregulation, we also corrected for subclinical symptoms of non-emotional attentional dysregulation. We show that such subclinical emotional symptoms correlate negatively with the grey matter volume of lateral orbitofrontal cortex bilaterally-a region assumed to be critical for emotion regulation and dysfunctional in psychiatric disorders involving emotional dysregulation. Importantly, this effect is mediated both by a decrease in volume associated with emotional dysregulation and an increase in volume due to non-emotional attentional dysregulation. Exploratory analysis suggests that other regions involved in emotional processing such as insula and ventral striatum also show a similar reduction in grey matter volume mirroring clinical disorders associated with emotional dysregulation. Our findings support the concept of continuous properties in psychiatric symptomatology.

Emotional and behavioral symptoms in neurodegenerative disease: a model for studying the neural bases of psychopathology

Disruptions in emotional, cognitive, and social behavior are common in neurodegenerative disease and in many forms of psychopathology. Because neurodegenerative diseases have patterns of brain atrophy that are much clearer than those of psychiatric disorders, they may provide a window into the neural bases of common emotional and behavioral symptoms. We discuss five common symptoms that occur in both neurodegenerative disease and psychopathology (i.e., anxiety, dysphoric mood, apathy, disinhibition, and euphoric mood) and their associated neural circuitry. We focus on two neurodegenerative diseases (i.e., Alzheimer's disease and frontotemporal dementia) that are common and well characterized in terms of emotion, cognition, and social behavior and in patterns of associated atrophy. Neurodegenerative diseases provide a powerful model system for studying the neural correlates of psychopathological symptoms; this is supported by evidence indicating convergence with psychiatric syndromes (e.g., symptoms of disinhibition associated with dysfunction in orbitofrontal cortex in both frontotemporal dementia and bipolar disorder). We conclude that neurodegenerative diseases can play an important role in future approaches to the assessment, prevention, and treatment of mental illness.

First-episode medication-naive major depressive disorder is associated with altered resting brain function in the affective network

Background

Major depressive disorder (MDD) has been associated with abnormal structure and function of the brain's affective network, including the amygdala and orbitofrontal cortex (OFC). However, it is unclear if alterations of resting-state function in this affective network are present at the initial onset of MDD.

Aims

To examine resting-state function of the brain's affective network in first-episode, medication-naive patients with MDD compared to healthy controls (HCs).

Methods

Resting-state functional magnetic resonance imaging (rs-fMRI) was performed on 32 first-episode, medication-naive young adult patients with MDD and 35 matched HCs. The amplitude of low-frequency fluctuations (ALFF) of the blood oxygen level-dependent (BOLD) signal and amygdala-seeded functional connectivity (FC) were investigated.

Results

Compared to HC, MDD patients showed reduced ALFF in the bilateral OFC and increased ALFF in the bilateral temporal lobe extending to the insular and left fusiform cortices. Enhanced anti-correlation of activity between the left amygdala seed and the left OFC was found in MDD patients but not in HCs.

Conclusions

Reduced ALFF in the OFC suggests hypo-functioning of emotion regulation in the affective network. Enhanced anti-correlation of activity between the amygdala and OFC may reflect dysfunction of the amygdala-OFC network and additionally represent a pathological process of MDD.

Orbitofrontal sulcogyral patterns are related to temperamental risk for psychopathology

There are marked individual differences in the pattern of cortical (sulcogyral) folding in the orbitofrontal cortex (OFC), and there is a growing literature suggesting that these individual differences are associated with risk for psychotic disorders. To date, however, no study has investigated whether OFC folding patterns are associated with broader risk factors relevant to a range of psychopathology. This study helps address this knowledge gap by examining whether OFC sulcogyral folding patterns are associated with putative risk factors, specifically affective temperament and psychiatric symptoms, in a large community sample (N = 152) of adolescents. Results showed that the most common pattern of folding ('Type I', marked by discontinuity of the medial orbital sulcus and continuity of the lateral orbital sulcus) was associated with low levels of Surgency, high levels of Negative Affectivity (in girls) and higher depressive symptoms. This pattern was also associated with reduced thickness of OFC gray matter. Overall, the findings, combined with previous work, suggest some specificity of neurodevelopmental risk for different types of psychopathology. Thus, these results have the potential to inform the early identification of at-risk individuals.

Altered resting state connectivity of the default mode network in alexithymia

Alexithymia is a trait characterized by a diminished capacity to describe and distinguish emotions and to fantasize; it is associated with reduced introspection and problems in emotion processing. The default mode network (DMN) is a network of brain areas that is normally active during rest and involved in emotion processing and self-referential mental activity, including introspection. We hypothesized that connectivity of the DMN might be altered in alexithymia. Twenty alexithymic and 18 non-alexithymic healthy volunteers underwent a resting state fMRI scan. Independent component analysis was used to identify the DMN. Differences in connectivity strength were compared between groups. Within the DMN, alexithymic participants showed lower connectivity within areas of the DMN (medial frontal and temporal areas) as compared to non-alexithymic participants. In contrast, connectivity in the high-alexithymic participants was higher for the sensorimotor cortex, occipital areas and right lateral frontal cortex than in the low-alexithymic participants. These results suggest a diminished connectivity within the DMN of alexithymic participants, in brain areas that may also be involved in emotional awareness and self-referential processing. On the other hand, alexithymia was associated with stronger functional connections of the DMN with brain areas involved in sensory input and control of emotion.

[Depressive frustration at vascular diseases of a brain in patients of elderly and senile age]

According to inspection of 206 patients of 60 years old and elder on the basis of neurologic department of the Geriatric Center of Republican Hospital No 3 high prevalence of depression of small and average degree in the persons of advanced age suffering from cerebrovascular diseases is revealed. To estimate the expressiveness of depression the Hamilton's scale including 17 parameters was used.

Alexithymia in neurodegenerative disease

We investigated alexithymia, a deficit in the ability to identify and describe one's emotions, in a sample that included patients with neurodegenerative disease and healthy controls. In addition, we investigated the relationship that alexithymia has with behavioral disturbance and with regional gray matter volumes. Alexithymia was examined with the Toronto Alexithymia Scale-20, behavioral disturbance was assessed with the Neuropsychiatric Inventory, and regional gray matter volumes were obtained from structural magnetic resonance images. Group analyses revealed higher levels of alexithymia in patients than controls. Alexithymia scores were positively correlated with behavioral disturbance (apathy and informant distress, in particular) and negatively correlated with the gray matter volume of the right pregenual anterior cingulate cortex, a region of the brain that is thought to play an important role in self and emotion processing.

Annual Research Review: Development of the cerebral cortex: implications for neurodevelopmental disorders

The cerebral cortex has a central role in cognitive and emotional processing. As such, understanding the mechanisms that govern its development and function will be central to understanding the bases of severe neuropsychiatric disorders, particularly those that first appear in childhood. In this review, I highlight recent progress in elucidating genetic, molecular and cellular mechanisms that control cortical development. I discuss basic aspects of cortical developmental anatomy, and mechanisms that regulate cortical size and area formation, with an emphasis on the roles of fibroblast growth factor (Fgf) signaling and specific transcription factors. I then examine how specific types of cortical excitatory projection neurons are generated, and how their axons grow along stereotyped pathways to their targets. Next, I address how cortical inhibitory (GABAergic) neurons are generated, and point out the role of these cells in controlling cortical plasticity and critical periods. The paper concludes with an examination of four possible developmental mechanisms that could contribute to some forms of neurodevelopmental disorders, such as autism.

Atrophy of basal ganglia nuclei and negative symptoms in temporal lobe epilepsy

Recent work has identified the presence of negative symptoms in a subset of temporal lobe epilepsy (TLE) patients. The authors hypothesized that negative symptoms in TLE are associated with disruption in the mesolimbic system. Basal ganglia and anterior cingulate region of interest volumes were compared between 22 TLE patients with negative symptoms, 22 TLE patients without negative symptoms, and 22 comparison subjects. The negative symptom group showed significantly reduced volumes in the putamen and globus pallidus. It appears that these structures within the broader mesolimbic system contribute to the phenomenon of negative symptoms in TLE.

Obesity and sleep disturbances: meaningful sub-typing of obesity

Obesity, excessive daytime sleepiness (EDS), and self-reported short sleep duration appear to be on the rise, while there is evidence that obesity and these sleep disorders are strongly connected. In this paper, we review data that challenge the common belief that the sleep apnoea and sleep loss, frequently associated with obesity, are the primary determinants of obesity-related objective daytime sleepiness and subjective fatigue (tiredness without increased sleep propensity). Specifically, obesity is associated with objective and subjective EDS regardless of the presence of sleep apnoea. The association between obesity and EDS was confirmed in recent studies of large random samples of the general population or clinical samples, which showed that the primary determinants of subjective EDS were depression, metabolic disturbances, i.e. obesity/diabetes and insulin resistance, and lack of physical activity, and, secondarily, sleep apnoea or sleep loss. Paradoxically, within the obese, with or without sleep apnoea, those who slept objectively better at night are sleepier (objectively) during the day than those who slept worse. The distinguishing factor between those that slept better vs. those that slept worse appears to be level of emotional stress. Furthermore, many studies reported that obesity is associated with self-reported short sleep duration; however, it appears that short sleep duration is a marker of emotional stress rather than a reflection of true sleep loss. Based on these data, we propose that obesity-related deeper sleep and objective EDS are primarily related to metabolic disturbances, whereas obesity-related poorer sleep and subjective fatigue appear to be the result of psychological distress. Furthermore, based on data from studies in normal controls and patients with sleep disorders, it appears that the interaction of the hypothalamic-pituitary-adrenal (HPA) axis and pro-inflammatory cytokines determines the level of sleep/arousal within the 24-hour cycle, i.e. "eucortisolemia" or "hypocortisolemia" plus hypercytokinemia is associated with high sleep efficiency and objective sleepiness, whereas "hypercortisolemia" plus hypercytokinemia is associated with low sleep efficiency and fatigue. In conclusion, we propose that the above-reviewed data provide the basis for a meaningful phenotypic and pathophysiologic sub-typing of obesity. One subtype is associated with emotional distress, poor sleep, fatigue, HPA axis "hyperactivity," and hypercytokinemia while the other is associated with non-distress, better sleep but more sleepiness, HPA axis "normo or hypoactivity," and hypercytokinemia. This proposed sub-typing may lead to novel, preventive and therapeutic strategies for obesity and its associated sleep disturbances.

Cerebellar tumour presenting with pathological laughter and gelastic syncope

There is no report of patients in whom pathological laughter, a rare condition characterized by uncontrollable episodes of laughter usually triggered by unrelated stimuli, was ever closely associated with a loss of consciousness overtly linked with the onset of such uncontrollable laughter, also referred to as a gelastic syncope. A 53-year-old man presented with a 4-month history of syncope following intense and uncoordinated laughter. Physical and neurological examination was normal and the patient had no other typical cerebellar signs. We found a mass in the cerebellar vermis abutting the floor of the fourth ventricle, which upon histological examination after surgery proved to be an ependymoma. We emphasize that pathological laughter and gelastic syncope could represent unique and sole features of a cerebellar disorder.

Diffuse axonal injury in severe traumatic brain injury visualized using high-resolution diffusion tensor imaging

Traumatic brain injury (TBI) is the most common cause of death and disability in young people. The functional outcome in patients with TBI cannot be explained by focal pathology alone, and diffuse axonal injury (DAI) is considered a major contributor to the neurocognitive deficits experienced by this group. The aim of the present study was to investigate whether diffusion tensor imaging (DTI) offers additional information as to the extent of damage not visualized with standard magnetic resonance imaging (MRI) in patients with severe TBI. Nine chronic male TBI patients and 11 matched healthy controls were recruited. Results of the voxel-based analysis of fractional anisotropy (FA) maps and apparent diffusion coefficient (ADC) maps revealed significant differences in anisotropy in major white matter tracts, including the corpus callosum (CC), internal and external capsule, superior and inferior longitudinal fascicles, and the fornix in the TBI group. The FA and ADC measurements offered superior sensitivity compared to conventional MRI diagnosis of DAI. Region-of-interest (ROI) analyses confirmed these results in the investigated regions. The findings of this study support the hypothesis that severe TBI is accompanied by DAI. The DTI changes were more prominent on the right side that contained the focal pathology in most of the patients and accurately reflected differences in both hemispheres. In conclusion, DTI holds great promise as a diagnostic tool to identify and quantify the degree of white matter injury in TBI patients.

Diffusion-tensor MR imaging for evaluation of the efficacy of hyperbaric oxygen therapy in patients with delayed neuropsychiatric syndrome caused by carbon monoxide inhalation

The purpose of this study is to assess the efficacy of hyperbaric oxygen therapy (HBOT) in patients with delayed neuropsychiatric syndrome (DNS) caused by carbon monoxide (CO) inhalation using diffusion tensor magnetic resonance (MR) imaging and neuropsychological test. Conventional and diffusion tensor brain MR imaging exams were performed in six patients with DNS immediately before and 3 months after the HBOT to obtain fractional anisotropy (FA) values. Six age- and sex-matched normal control subjects also received MR exams for comparison. Mini-Mental State Examination (MMSE) was also performed in patients immediately before and 3 months after the HBOT. A significantly higher mean FA value was found in control subjects as compared with the patients both before and 3 months after the HBOT (P < 0.001). The mean FA value 3 months after the HBOT was also significantly higher than that before the HBOT in the patient group (P < 0.001). All of the patients regained full scores in the MMSE 3 months after the HBOT. Diffusion tensor MR imaging can be a quantitative method for the assessment of the white matter change and monitor the treatment response in patients of CO-induced DNS with a good clinical correlation. HBO may be an effective therapy for DNS.

Alexithymia-like disorder in right anterior cingulate infarction

The frontal midline structures have been demonstrated by functional neuroimaging to be involved in the affective control of human behavior. However, due to the rareness of diseases affecting this part of the brain little is known about behavioral abnormalities following damage to these brain areas. We present a patient with a right anterior cingulate infarct who presented with an alexithymia-like disorder. Event-related potentials revealed an abnormality of emotional face perception in the right cerebral hemisphere. We suggest that the anterior cingulate lesion induced a deficit of emotion processing including emotional face perception probably due to an interference in a critical node of a large-scale network subserving affective control of behavior.

Empathy and Judging Other's Pain: An fMRI Study of Alexithymia

Because awareness of emotional states in the self is a prerequisite to recognizing such states in others, alexithymia (ALEX), difficulty in identifying and expressing one's own emotional states, should involve impairment in empathy. Using functional magnetic resonance imaging (fMRI), we compared an ALEX group (n = 16) and a non-alexithymia (non-ALEX) group (n = 14) for their regional hemodynamic responses to the visual perception of pictures depicting human hands and feet in painful situations. Subjective pain ratings of the pictures and empathy-related psychological scores were also compared between the 2 groups. The ALEX group showed less cerebral activation in the left dorsolateral prefrontal cortex (DLPFC), the dorsal pons, the cerebellum, and the left caudal anterior cingulate cortex (ACC) within the pain matrix. The ALEX group showed greater activation in the right insula and inferior frontal gyrus. Furthermore, alexithymic participants scored lower on the pain ratings and on the scores related to mature empathy. In conclusion, the hypofunction in the DLPFC, brain stem, cerebellum, and ACC and the lower pain-rating and empathy-related scores in ALEX are related to cognitive impairments, particularly executive and regulatory aspects, of emotional processing and support the importance of self-awareness in empathy.

Abnormal pontine activation in pathological laughing as shown by functional magnetic resonance imaging

To explore the aetiology of pathological laughing, a 65-year-old woman with pathological laughing was examined by 3-T functional magnetic resonance imaging (fMRI) before and after treatment with drugs. Here, we report that the patient consistently showed exaggerated pontine activation during the performance of three tasks before treatment, whereas abnormal pontine activation was no longer found after successful treatment with the selective serotonin reuptake inhibitor, paroxetine. Our findings in this first fMRI study of pathological laughing suggest that serotonergic replacement decreases the aberrant activity in a circuit that involves the pons.

Impaired self-awareness and theory of mind: an fMRI study of mentalizing in alexithymia

Alexithymic individuals have difficulty in recognizing and describing emotions in themselves. We investigated the neuronal basis of mentalizing in alexithymia to determine whether there is a common neuronal substrate associated with knowing the mental states of the self and others. Individuals high in alexithymia (n = 16) and low in alexithymia (n = 14) were selected from a pool of 310 college students using a combination of the Toronto Alexithymia Scale (TAS-20) and the Structured Interview version of the Beth Israel Questionnaire (SIBIQ). We compared the two groups on psychological measures, including ratings of mentalizing and the Interpersonal Reactivity Index (IRI), and regional brain activation using functional magnetic resonance imaging (fMRI) during a mentalizing animation task. The results for both groups showed activation in regions associated with mentalizing: medial prefrontal cortices (MPFC), temporo-parietal junctions (TPJ), and the temporal pole (TP). Alexithymics had lower mentalizing and IRI perspective-taking scores and less activation in the right MPFC. Activity in the MPFC was positively correlated with the mentalizing score and the IRI perspective-taking score. Although there were no group differences in cerebral activity in the TPJ and the TP, the activity in the right TP had a positive correlation with mentalizing and IRI personal distress scores. These results suggest that alexithymic individuals have an impairment in mentalizing associated with an inability to take the perspective of others. Thus, the skills involved in comprehending the self and others are inter-related and play an important role in emotion regulation.

The natural history of temporal variant frontotemporal dementia

BACKGROUND

The temporal variant of frontotemporal dementia (tvFTD) features asymmetric anterior temporal/amygdala degeneration as well as ventromedial frontal, insular, and inferoposterior temporal involvement. Left temporal atrophy has been linked to loss of semantic knowledge, whereas behavioral symptoms dominate the right temporal variant.

OBJECTIVE

To investigate the first symptoms and the timing of subsequent symptoms in patients with left versus right tvFTD.

METHODS

Twenty-six patients with tvFTD were identified. Six had right > left temporal atrophy (right temporal lobe variant [RTLV]) and were matched with six having comparable left > right temporal atrophy (left temporal lobe variant [LTLV]). Clinical records were reviewed to generate individualized symptom chronologies.

RESULTS

In all patients, first symptoms involved semantics (4/6 LTLV, 1/6 RTLV), behavior (4/6 RTLV, 1/6 LTLV), or both (1 LTLV, 1 RTLV). Semantic loss began with anomia, word-finding difficulties, and repetitive speech, whereas the early behavioral syndrome was characterized by emotional distance, irritability, and disruption of physiologic drives (sleep, appetite, libido). After an average of 3 years, patients developed whichever of the two initial syndromes--semantic or behavioral--that they lacked at onset. A third stage, 5 to 7 years from onset, saw the emergence of disinhibition, compulsions, impaired face recognition, altered food preference, and weight gain. Compulsions in LTLV were directed toward visual, nonverbal stimuli, whereas patients with RTLV were drawn to games with words and symbols.

CONCLUSIONS

The temporal variant of frontotemporal dementia follows a characteristic cognitive and behavioral progression that suggests early spread from one anterior temporal lobe to the other. Later symptoms implicate ventromedial frontal, insular, and inferoposterior temporal regions, but their precise anatomic correlates await confirmation.

Reduced activation of posterior cingulate cortex during imagery in subjects with high degrees of alexithymia: a functional magnetic resonance imaging study

BACKGROUND

Although the brain areas involved in imagery have been reported, the neural bases of individual differences in imagery remain to be elucidated. People with high degrees of alexithymia (HDA) are known to have constricted imaginal capacities. The purpose of this study was to investigate neural correlates of imagery disturbance in subjects with HDA.

METHODS

A functional magnetic resonance imaging (fMRI) study was undertaken in 10 subjects with HDA and 10 subjects with low degrees of alexithymia (LDA), who were selected according to their scores on the 20-item Toronto Alexithymia Scale (TAS-20). The two groups' regional cerebral activation was compared during various imagery conditions. In those conditions, the subjects imaged a past happy (PH) event, a past sad (PS) event, a past neutral (PN) event, a future happy (FH) event, a future sad (FS) event, and a future neutral (FN) event. The activation levels during these conditions were compared with those during a rest condition (REST).

RESULTS

The t tests showed that the mean subjective ratings of both the vividness of the imagery and the intensity of emotion during the imagery were higher in the subjects with LDA than in those with HDA for the PS and FS imagery conditions. On the other hand, relative to the LDA group, the HDA group showed significantly less activation in the posterior cingulate cortex (PCC) during the PH and FH imagery conditions compared with REST and during the FH imagery condition compared with the FN imagery condition.

CONCLUSION

The present results suggest an association between an HDA and reduced activation of the PCC during happy imagery. Given the function of this brain region, these results might be related to a dysfunction of episodic memory retrieval during happy imagery in subjects with HDA.

Emotional withdrawal, CT abnormalities and drug response in late life depression

In this study, the authors investigated if CNS degenerative abnormalities could correlate with depressive symptoms in elderly patients, if the presence of mild/moderate cognitive impairment could be related to the response to treatment and the role of peculiar clinical features in influencing the response to treatment. Fifty-three patients (60-75 years) diagnosed as affected by late onset (after 60 years) Major Depressive Episodes according to DSM-IV criteria were studied. Brain vascular and degenerative markers were assessed by computed tomography (CT) through measurements of a lateralized version of the bifrontal index and a rating scale addressing subcortical disease. The presence of mild/moderate cognitive impairment [(24-28 total score at the Mini-Mental State Examination (MMSE)], and of specific symptoms were assessed at baseline and evaluated with respect to the antidepressant response. Patients with CT abnormalities showed higher baseline scores on Hamilton Rating Scale for Depression (HAM-D) items "late insomnia" (t=-2.674, P=.002), "somatic symptoms" (t=-3.355 P=.002), and Brief Psychiatric Rating Scale (BPRS) item "emotional withdrawal" (t=-3.355, P=.002). No significant correlation was found between the vascular index and baseline clinical symptoms, while the HAM-D "depressed mood" item was negatively correlated to the right frontal index (R=-0.692, P=.006). Patients with CT abnormalities showed a lower reduction of HAM-D total scores than patients with normal CT (time effect: F=29.277, P<.0001; group effect: F=5.154, P<.03), while a significant reduction of symptoms in time (time effect: F=33.33, P<.0001) but no differences between groups were found on Hamilton Rating Scale for Anxiety (HAM-A). Both patients with and without mild cognitive impairment improved on the HAM-D (time effect: F=19.668, P<.0001), BPRS (time effect: F=18.345, P<.0001), and HAM-A (time effect: F=17.959, P<.0001) total scores. Patients with emotional withdrawal showed lower improvement on BPRS total scores (time effect: F=26.946, P<.0001; group effect: F=5.121, P<.03). The results from this study showed that patients with baseline emotional withdrawal and CT abnormalities have poorer outcome. Further investigations on larger samples are needed to confirm these findings.

Alexithymia correlates with the size of the right anterior cingulate

OBJECTIVE

The authors investigated a possible relationship between interindividual variability in anterior cingulate gyrus (ACG) morphology and alexithymia.

MATERIALS AND METHODS

Magnetic resonance images were obtained in 100 healthy university graduates (51 female, 49 male; mean age 25.6 y). Surface area measurements of the ACG were performed on reformatted sagittal views in both hemispheres. The Toronto Alexithymia Scale (TAS-20) and the Temperament and Character Inventory (TCI) were administered.

RESULTS

Right ACG surface area significantly correlated with TAS-20 total score in men (r = 0.37; p = 0.009) and in women (r = 0.30; p = 0.034). After controlling for three TCI subscales (harm avoidance, self-directedness, and self-transcendency), the correlation between TAS-20 total and right ACG became nonsignificant in women, but was only slightly reduced (r = 0.32; p = 0.032) in men. A linear regression model with right ACG as a dependent variable revealed brain volume, TCI-harm avoidance and TAS 20 total score as significant predictors in the total sample (explained proportion of total variation (EPTV) 37%). In men, beside brain volume, only TAS-20 total score showed a highly significant contribution (EPTV 41%), whereas in women only TCI-harm avoidance was a significant predictor (EPTV 36%).

CONCLUSIONS

The authors' findings indicate that there is a significant positive relation between the size of the right ACG and alexithymia as measured with the TAS in healthy subjects. This applies especially for men whereas in women ACG size is more associated with the subscale harm avoidance of the TCI. Our findings also suggest a partial lateralization of human emotion processing, especially negative emotion.

Apathy in Alzheimer's disease

Apathy, or loss of motivation, is arguably the most common change in behavior in Alzheimer's disease (AD) but is underrecognized. Apathy represents a form of executive cognitive dysfunction. Patients with apathy suffer from decreased daily function and specific cognitive deficits and rely on families to provide more care, which results in increased stress for families. Apathy is one of the primary syndromes associated with frontal and subcortical pathology, and apathy in AD appears to have multiple neuroanatomical correlates that implicate components of frontal subcortical networks. Despite the profound effects of this common syndrome, only a few instruments have been designed to specifically assess apathy, and these instruments have not been directly compared. Assessment of apathy in AD requires clinicians to distinguish loss of motivation from loss of ability due to cognitive decline. Although apathy may be misdiagnosed as depression because of an overlap in symptoms, current research has shown apathy to be a discrete syndrome. Distinguishing apathy from depression has important treatment implications, because these disorders respond to different interventions. Further research is required to clarify the specific neuroanatomical and neuropsychological correlates of apathy and to determine how correct diagnosis and treatment of apathy may improve patient functioning and ease caregiver burden.

The pathomorphology of schizophrenia and mood disorders: similarities and differences

In this article, post-mortem neurohistological and structural imaging studies of schizophrenia and mood disorders are briefly reviewed. In contrast to the large number of post-mortem studies on schizophrenia published during the last 20 years, very few histological studies of affective disorders are available. After commenting on CT and MRI studies, as well as on neuropathological findings on whole-brain size, cortex, frontal and temporal lobes, limbic system, basal ganglia, thalamus, brain stem, and cortical asymmetry, it is concluded that despite a broad overlap in structural findings in the so-called endogenous psychoses, heteromodal association cortex, limbic system, and structural asymmetry are more affected in schizophrenia, while subtle structural abnormalities in the basal ganglia, especially in the nucleus accumbens and in hypothalamic areas, might play a crucial role in mood disorders.

Structural and functional brain changes in bipolar disorder: a selective review

The purpose of this paper is to provide a concise, selective review of the major issues and findings germane to structural and functional neuroimaging studies of bipolar affective disorder (BPD). In attempting to identify the brain changes associated with BPD, investigators have used neuroimaging techniques to focus on several interrelated questions. These are: What are the changes and where do they occur? Do their nature and location suggest a particular etiopathologic basis or have notable clinical correlates? With regard to specificity, are the changes unique to BPD, or do they overlap with those reported in other neuropsychiatric illnesses, especially schizophrenia? Do they occur in brain systems that normally play a role in modulating mood? Finally, how do the brain changes integrate with neurocognitive, neurogenetic, and neuropathologic data in the same patients? To date, these questions have been addressed only preliminarily. We outline some of the strategies used to pursue answers to these questions and review conclusions to date.

Pathological laughter: common vs. unusual aetiology and presentation

Pathological laughter and crying is a well known clinical phenomenon which in most cases appears in association with diverse neurological and psychiatric symptoms and signs. It is not a disturbance of affectivity but rather of the motor concomitant of affective expression. Its main clinical characteristics are: absence of voluntary control and absence of the corresponding change in mood. It is not accompanied by the emotional lability of the organic brain syndromes, it does not present the inappropriate jocularity of the patients with frontal lobe disturbance, it is not due to the intoxicating effect of alcohol or addictive drugs and there are no typical symptoms of manic syndromes (such as grandiose self-esteem, flight of ideas, hyperactivity, etc.). In this paper three cases of pathological laughter are presented, two of these associated with organic brain conditions. The discussion will deal in particular with aetiological considerations and psychopathology of the third case which was unusual because it was a monosymptomatic condition and seemed to be the expression of a posttraumatic stress disorder.

Neuropsychological aspects of multiple sclerosis

Since S. Rao's ["Neuropsychology of Multiple Sclerosis: A Critical Review," A Journal of Clinical and Experimental Neuropsychology, Vol. 85, pp. 503-542] (1986) seminal review, considerable research has been undertaken on the neuropsychological consequences of multiple sclerosis. This review incorporates the research literature of the last decade in presenting an overview of the current state of our knowledge concerning the etiology, course, symptoms, assessment, consequences, and treatment of multiple sclerosis (MS). The concept of subcortical dementia is revisited in light of the most recent literature documenting the neuropsychological deficits in patients with MS. The view that cognitively heterogeneous patient groups may disguise more specific patterns of focal neuropsychological impairment is considered. A critical review of the recent literature is also presented, detailing the degree to which recent research has addressed the areas of research need identified by Rao in 1986. Given recent advances in our knowledge, the need for more attention to be directed toward the evaluation of rehabilitation and psychological intervention is highlighted.

Bihippocampal damage with emotional dysfunction: impaired auditory recognition of fear

A right-handed man developed a sudden transient, amnestic syndrome associated with bilateral hemorrhage of the hippocampi, probably due to Urbach-Wiethe disease. In the 3rd month, despite significant hippocampal structural damage on imaging, only a milder degree of retrograde and anterograde amnesia persisted on detailed neuropsychological examination. On systematic testing of recognition of facial and vocal expression of emotion, we found an impairment of the vocal perception of fear, but not that of other emotions, such as joy, sadness and anger. Such selective impairment of fear perception was not present in the recognition of facial expression of emotion. Thus emotional perception varies according to the different aspects of emotions and the different modality of presentation (faces versus voices). This is consistent with the idea that there may be multiple emotion systems. The study of emotional perception in this unique case of bilateral involvement of hippocampus suggests that this structure may play a critical role in the recognition of fear in vocal expression, possibly dissociated from that of other emotions and from that of fear in facial expression. In regard of recent data suggesting that the amygdala is playing a role in the recognition of fear in the auditory as well as in the visual modality this could suggest that the hippocampus may be part of the auditory pathway of fear recognition.

The symptomatology of depression in the elderly

Older people may have a different pattern of depressive symptoms to that found earlier in life, in particular having more somatic symptoms and less overt low mood symptoms. Few attempts have been made to relate such differences to more general aspects of cognitive or emotional processing, such as the presence of dysfunctional attitudes or of alexithymia. Symptom differences within depression in old age have also received relatively little study, as has the ability of individual symptoms to distinguish between depressed and non-depressed elderly populations. These issues have been examined in two studies. In the first, a random sample of 700 subjects aged 65 years and over were identified through door-knocking in randomized enumeration districts in Islington, a socially deprived region of inner city London, and evaluated using a shortened version of the Comprehensive Assessment and Referral Evaluation (Short-CARE), which incorporates a depression subscale (DPDS). All 18 DPDS items distinguished significantly between depressed and non-depressed subjects (P < 0.0001). Depressed men were significantly more pessimistic than depressed women (63 versus 40%; P < 0.05); non-significant trends suggested that depressed women are more worried (39 versus 22%) and more restless (50 versus 31%), and depressed men more likely to be 'not very happy' or 'not happy at all' (53 versus 36%). There were no significant differences between older (age > 74 years) and younger subjects. Several other Short-CARE items, predominantly addressing subjective memory and disability, also distinguished significantly between the depressed and non-depressed groups. Logistic regression analysis identified eight items of the DPDS contributing significantly to the predictive ability of the total scale. In the second study, the Toronto Alexithymia Scale (TAS) and the Dysfunctional Attitudes Scale (DAS; 3) were administered to primary-care attenders aged > 64 years, and those with significant depressive symptoms were matched by age and sex to a depression-free control group. Depressed subjects had higher scores on both the TAS (Mann-Whitney U-test z = -4.71, P < 0.0001) and on the DAS (z = -2.49, P < 0.02).

A case of atypical psychosis associated with alexithymia and a left fronto-temporal lesion: possible correlations

The case history is presented of a man with an atypical psychosis and classical clinical features of alexithymia. On his last admission, the patient presented with starvation and hypernatremic coma. A CT scan, which was done because of the coma, revealed a large left fronto-temporal arachnoid cyst. The significance of this finding is reviewed in the light of previously suggested organic bases for alexithymia and related syndromes. Although the symptom of alexithymia is present, the patient's other symptoms do not fit readily into existing diagnostic categories and the resulting diagnostic dilemma is discussed.

Klüver-Bucy syndrome and amyotrophic lateral sclerosis: a case report with biochemistry, morphometrics, and Golgi study

We studied a patient with amyotrophic lateral sclerosis and the Klüver-Bucy syndrome. At autopsy there was extensive degeneration of the limbic system with the brunt of the changes in the medial temporal lobe, especially the entorhinal cortex and subiculum. Degenerative changes were also seen in the substantia nigra and lower motor neurons. Morphometric and biochemical studies implied a disease process that affected small, possibly somatostatinergic, cortical neurons. These latter findings and the lobar distribution of cortical atrophy were consistent with Pick's disease, but Pick bodies and ballooned neurons were not present.