Association between dopamine receptor D3 gene BalI polymorphism and cognitive impulsiveness in alcohol-dependent men

The gene coding for the dopamine receptor D3 (DRD3) is considered as a major candidate gene in various addictive disorders. Association studies in alcohol-dependence for this gene are nevertheless controversial. We made the hypothesis that phenotypical heterogeneity of alcohol-dependence (i.e. the DRD3 gene is a vulnerability gene in a specific subgroup of patients only) could explain these spurious findings, focusing on a core dimension of addictive disorders, namely impulsiveness. In our sample of 108 French alcohol-dependent patients, patients above the median value for cognitive impulsiveness (one of the three dimensions of the Barratt scale) were more frequently heterozygous than both alcohol-dependent patients with lower impulsiveness (OR = 2.51, P = 0.019) and than 71 healthy controls (OR = 2.32, P = 0.025). Age at interview, antisocial personality disorder, other comorbid addictive disorder, age at onset of alcohol-dependence, and lifetime mood disorders did not constitute confusing intermediate factors.

[Prevalence of pathological gambling in the general population around Paris: preliminary study]

INTRODUCTION

Pathological gambling is characterized in the DSM IV-TR as one of the disorders of impulse control. Problem gambling is also part of what is considered as behavioural addictions, the criteria of which have been defined by Goodman, with intrusive thoughts about the game, spending more and more to play, unable to control, reduce or stop gambling despite negative consequences, etc.

AIM OF THE STUDY

There is no epidemiological study in France on the prevalence of pathological gambling. We wanted to study the prevalence of pathological gambling in a sample of 529 persons: 368 gamblers of Pari Mutuel Urbain and La Française des Jeux, and 161 persons in the general population. The study took place between January 2008 and June 2009.

METHODS

As instruments, we used: the South Oaks Gambling Scale (SOGS) for screening of pathological gambling and the BIS-10 for impulsiveness' evaluation, the HAD scale to assess anxiety and depression and the ASRS for the evaluation of attention deficit disorder/hyperactivity disorder (ADHD).

RESULTS

The rate of pathological gambling in the general population is 1.24% (this result is similar to those found in other places, such as in Quebec). In the general population, the rate of play at risk is of 5.59%. Among the population of gamblers, the rate for pathological gambling (JP) amounted to 9.23% and risk gambling to 10.86%. Men are overrepresented in the group of pathological gamblers (88.9%), also with consumption of alcohol and tobacco. Suicide attempts are more important than in the general population, but the difference was statistically significant. Depression and anxiety are particularly high, 40% of gamblers with an anxiety score significantly higher.

DISCUSSION

The results indicate rates close to those of other countries, such as Canada. It would be necessary to establish follow-up studies of populations and patients, as well as specific studies on people who frequent casinos, racetracks and internet gambling. The importance of the phenomenon is obvious, because almost 20% of players have a gambling problem or risk and these people do not consult despite their psychological problems, family, work, debts.

Influence of the serotonin transporter gene polymorphism, cannabis and childhood sexual abuse on phenotype of bipolar disorder: a preliminary study

OBJECTIVE

The gene coding for the 5-HT transporter (5-HTT) is considered as a candidate gene for bipolar disorder, either as a "vulnerability" or as a "modifying the phenotype" gene. Psychotic symptoms occur at least once in one bipolar patient out of two, the relevant risk factors being insufficiently understood. The gene × environment interaction approach offers the opportunity to disentangle the latter, including childhood sexual abuse and cannabis abuse.

METHODS

We investigated the 5-HTTLPR of the 5-HTT gene (G) and the presence of childhood sexual abuse and cannabis comorbidity (E) in 137 bipolar patients with (versus without) lifetime psychotic symptoms.

RESULTS

The short allele and cannabis abuse were significantly more frequent among patients with psychotic symptoms than in those without (p=0.01 and p=0.004, respectively), while childhood sexual abuse was not. Complex interactions were found between presence of the short allele, cannabis abuse or dependence and childhood sexual abuse.

CONCLUSIONS

The short allele of the 5-HTTLPR polymorphism of the 5-HTT gene was a risk factor for psychotic symptoms in bipolar disorder in the present sample, directly but also indirectly, through the presence of cannabis abuse or dependence, as an exacerbating factor heightening psychotic symptoms.

Switching to the bingeing/purging subtype of anorexia nervosa is frequently associated with suicidal attempts

OBJECTIVE

Anorexia nervosa has the highest suicide mortality ratio of psychiatric disorders, suicide being associated with many factors. We assessed the first lifetime occurrence of these factors taking into account their possible overlap.

METHOD

Three hundred and four in- and out-patients with anorexia nervosa (DSM-IV) were systematically recruited in three hospitals of Paris suburbs, between December 1999 and January 2003. Patients were assessed by a face-to-face interview (DIGS). Current eating disorder dimensions were measured, and patients interviewed by a trained clinician to assess minimal BMI and, retrospectively, the age at which anorexia nervosa, major depressive disorder, anxiety disorders and switch to bingeing/purging type occurred for the first time, if applicable.

RESULTS

Major depressive disorder (p<0.001) and subtype switch from the restrictive to the bingeing/purging type (p<0.001) were the two factors significantly more frequently occurring before suicidal attempts, and remained involved when a multivariate analysis is performed, whether syndromic or dimensional measures are being used. Taking into account lifetime occurrence with a survival analysis, the switch to bingeing/purging type of anorexia appears as a major predictive factor, with a large increase of the frequency of suicidal attempts (OR=15) when compared to patients with neither major depressive disorder nor bingeing/purging type.

CONCLUSIONS

Bingeing/purging type of anorexia nervosa is largely associated with suicidal attempts, and may deserve specific attention. If confirmed on a prospectively designed study, these results would argue for early detection and/or more intensive and specific therapeutic intervention on this aspect of bingeing and purging behaviors.

Méta-analyse des gènes candidats dans le trouble déficit attentionnel avec hyperactivité (TDAH)

Attention-deficit hyperactivity disorder (ADHD) is a common behavioral disorder observed during childhood, detected in 3% to 5% of school-age children. The disorder is characterised by marked inattention, hyperactivity, and impulsiveness. In most cases, symptoms can be treated by catecholamine-releasing drugs, such as methylphenidate. Children with ADHD are at higher risk for substance abuse and oppositional, conduct and mood disorders. Familial and adoption studies shed light on the genetic vulnerability of ADHD. Twin studies estimated the broad heritability to range between 40% and 90%. The mode of transmission is yet unknown, but is likely polygenic. Molecular genetic studies in ADHD should contribute to a greater understanding of the pathophysiology of the disorder (genetics of the vulnerability), and could help to select a more rational type of treatment (pharmacogenetic). Family-based association studies already performed are reviewed in this manuscript. Association studies, using haplotype relative risk (HRR) or transmission disequilibrium test (TDT) have focused on candidate genes which code for proteins potentially involved in the etiopathogenesis of the disorder. Genes involved in dopamine, serotonin, and noradrenalin systems have thus been assessed for their role in core features of ADHD, such as motor overactivity, inattention, and impulsiveness. According to a meta-analysis, the DAT1 gene, an obvious candidate gene in ADHD vulnerability, does not appear to be involved (OR = 1.13, p = 0.21). On the other hand, DRD4 (OR = 1.26, p = 0.01) and DRD5 (OR = 1.4, p = 0.01) are significantly associated to ADHD according to the present meta-analysis, confirming previous ones. Recent studies showed a trend for an association between one allele of the 5-HTT (considering case-control studies) and DBH (OR = 1.27, p = 0.06) genes and ADHD, but these positive findings have to be replicated. ADHD is a complex disorder with potentially many different risk factors. Genetic and phenotypic heterogeneity could explain why some association studies are positive, whereas others are negative. For instance, different developmental pathways are likely to lead to similar clinical outcomes. More clear-cut phenotypes, such as ADHD with conduct disorder, or ADHD with bipolar disorder, could be more homogenous, the genes involved being therefore more easy to detect. These phenotypes are beginning to be specifically studied in molecular genetics. In addition, the development of pharmacogenetics could help to identify predictors of clinical response for a specific type of treatment, which would be clearly helpful in clinical practice.

Meta-analysis of family-based association studies between the dopamine transporter gene and attention deficit hyperactivity disorder

INTRODUCTION

Molecular genetic research has mainly focused on the D4 dopamine receptor (DRD4) and the dopamine transporter (DAT) genes in attention-deficit hyperactivity disorder (ADHD). A recent meta-analysis showed that the DRD4 gene has a significant role in the vulnerability to ADHD.

OBJECTIVES

With an equal number of positive and negative association studies between the 10-repeat of the DAT gene and ADHD, a meta-analysis is required for this other candidate gene.

METHODS

We re-analysed the 13 published family-based association studies between ADHD and the DAT gene. Following recent recommendations, different biases were specifically assessed, such as the sample-size effect and the time effect.

RESULTS

The meta-analysis showed no significant association between ADHD and the DAT gene (P = 0.21), but an important between-samples heterogeneity (P = 0.0009). Odds ratios above 1 are mostly observed in studies with a small number of informative transmissions, and decrease with larger sample size.

CONCLUSIONS

Contrary to what was found for the DRD4 gene, the 10-repeat allele of the DAT gene has at most a minor role in the genetic susceptibility of ADHD. The different biases detected herein probably explain the initial impression of a significant impact of the DAT gene on hyperactivity.

Family-based association studies between 5-HT5A receptor gene and schizophrenia

BACKGROUND

Pharmacological and neurodevelopmental data support the idea that the gene, which codes for the 5-HT(5A) receptor is an important candidate gene for schizophrenia susceptibility. However, previous genetic studies focusing on this gene yielded conflicting results, potentially because of: (i) stratification biases of case-control association studies, (ii) genetic and phenotypic heterogeneity of schizophrenia, and (iii) variability in the loci analyzed (the 5-HT(5A) gene having many polymorphic sites).

METHODS

A transmission disequilibrium test was used in the present study aimed at investigating two polymorphisms in exon 1 of the 5-HT(5A) gene, the A12T silent substitution and the C43T transversion leading to a 15Pro --> Ser substitution, in 103 patients with DSM-IV diagnosis of schizophrenia, and their 206 parents.

RESULTS

We found an excess of transmission of the 12T allele from the parents to their affected children (P = 0.02), with evidence for linkage disequilibrium between the 12T-43C haplotype and schizophrenia (P = 0.002). Furthermore, patients with the 12T allele had a significantly later age at onset (P = 0.003), and the Q-TDT approach confirmed that this allele was transmitted with an older age at onset (P = 0.01).

CONCLUSIONS

These data provided convergent evidence for a significant role of the 5-HT(5A) gene in schizophrenia and more specifically in patients with later age at onset.

Family-based association study of the serotonin-6 receptor gene (C267T polymorphism) in schizophrenia

The expression of serotonin type 6 receptor (5-HT(6)) in limbic and cortical regions of the brain, and its high affinity for atypical antipsychotics suggest that its encoding gene may play a role in the pathogenesis of schizophrenia. We firstly performed a meta-analysis of the C267T polymorphism of the 5-HT(6) gene in schizophrenia, based on four different case/control studies, and showed that the allelic distribution is not significantly different between patients and controls, even when taking into account the role of between samples heterogeneity. We then recruited 103 trios (patients with Diagnostic and Statistical Manual Mental Disorders, 4th ed. (DSM-IV) diagnosis of schizophrenia and their parents), and investigated the C267T polymorphism of the 5-HT(6) receptor gene with regard to family-based association study approach (haplotype relative risk (HRR) and transmission disequilibrium test (TDT)). We found no excess of transmission of one allele from the parents to their affected children, using the HRR (P = 0.60), as well as no evidence for linkage between C267T polymorphism and schizophrenia, using the TDT (P = 0.71). Furthermore, the 267T allele frequency was comparable in the different subgroups defined on age at onset, family history of schizophrenia, treatment response, and subtypes of patients based on positive versus negative predominant symptoms. These data do not support the idea that the 5-HT(6) receptor gene plays a major role in the etiopathogenesis of schizophrenia.

Rheumatoid arthritis and schizophrenia: a negative association at a dimensional level

There is wide evidence for a decreased risk of rheumatoid arthritis in patients with schizophrenia. Nevertheless, very few studies have looked at the risk of schizophrenia in a group of patients with rheumatoid arthritis. We prospectively investigated, with the SCL-90R, 220 consecutive outpatients with rheumatoid arthritis and 196 consecutive outpatients with various medical conditions, half of them suffering from psoriatic arthritis (a medical condition close to rheumatoid arthritis). The SCL-90R appears to be a valuable tool to distinguish patients with schizophrenia from the outpatients of our sample, the former having more "paranoid ideation" (p = 0.004) and more "psychoticism" (p < 0.001) than the latter. The "paranoid ideation" dimension was significantly lower (25% decrease) in the sample of patients with rheumatoid arthritis compared to the combined control group (p = 0.005), ratings under the median value being more frequent in the former group (p = 0.025). Confounding factors might not explain this difference according to the regression logistic analysis performed. As patients with rheumatoid arthritis have a lower score of paranoid ideation than controls in our sample, even after controlling for age, gender and severity of the disease, these data represent further evidence for a decreased risk of schizophrenia in individuals with rheumatoid arthritis.

Impulsiveness as the intermediate link between the dopamine receptor D2 gene and alcohol dependence

OBJECTIVES

Reinforcement and reward processes have been proposed as being an intermediate link between the risk for alcohol dependence and the gene coding for the dopamine receptor D2 (DRD2). This hypothesis remains open to speculation, and personality traits such as impulsiveness, a core dimension in addictive disorders, should also be taken into account. For instance, recent evidence in rats showed that DRD2 antagonists might increase impulsivity in decreasing the value of delayed rewards.

METHODS

Considering the pro-impulsiveness role of ethanol observed in clinical practice and epidemiological studies, we analysed the Barratt impulsiveness scores in a sample of 92 alcohol-dependent French patients (57 men and 35 women), according to the TaqI A polymorphism of the DRD2 gene.

RESULTS

A2/A2 and A1/A2 genotypes were significantly associated with a higher global impulsiveness than A1/A1 genotype (P=0.02 and P=0.03, respectively).

CONCLUSIONS

We propose that reward-related impulsiveness may constitute a risk factor for alcohol dependence, and that this core temperament could be partly mediated by the DRD2 gene.

5-HT(2A) gene promoter polymorphism as a modifying rather than a vulnerability factor in anorexia nervosa

The A allele of the 5-HT(2A) gene (-1438A/G polymorphism) has been associated with anorexia nervosa in four studies, but not in three others. One possibility to explain such a discrepancy is that the A allele acts as a modifying rather than a vulnerability allele. To test this hypothesis, we increased our initial sample of 102 trios left open bracket Mol. Psychiatry 7 (2002) 90 right open bracket with 43 new patients with anorexia nervosa and 98 healthy controls. In addition to confirming the absence of association on the global sample of 145 patients, we found that patients with the A allele had a significantly later age at onset of the disease (P = 0.032). Furthermore, the A allele was also transmitted with an older age at onset (P = 0.023) using a quantitative-trait TDT approach. The A allele may thus act as a modifying factor (delaying onset), potentially explaining variations of allele frequency across samples, in which differences in average age at onset are not only possible, but also expected. Taking into account vulnerability genes, but also genes modifying the expression of the disorder, will help to disentangle the complexity of the etiological factors involved in anorexia nervosa.

The 5-HT(2A) -1438G/A polymorphism in anorexia nervosa: a combined analysis of 316 trios from six European centres

Several case-control association studies have raised the possibility that the A allele of a -1438 G/A polymorphism in the type 2A serotonin receptor (HTR2A) gene may be a risk factor for anorexia nervosa. However the absence of linkage and the existence of negative association studies raise the possibility of false positive findings, resulting from population stratification or lack of statistical power. To address this controversy we recruited a sample of 316 patients with anorexia nervosa from six European centres, and utilised a family-based transmission disequilibrium (TDT) approach to analyse the HTR2A-1438 G/A polymorphism. Age at onset and minimal BMI were also taken into consideration in order to detect clinical heterogeneity or a quantitative trait effect. The TDT approach showed that the A allele was transmitted 133 times and not transmitted 148 times (McNemar chi(2) = 0.29, df = 1, P = 0.59). Also, the haplotype-based haplotype relative risk method showed no evidence for association of the A allele, in samples from each centre (chi(2) < 2.15, df = 1, P > 0.14) and in the total sample (chi(2) = 0.55, df = 1; P = 0.46). Furthermore, we found no evidence for heterogeneity of the A allele frequency between samples (chi(2) = 2.54, df = 4, P = 0.64), either according to minimal-BMI (F1/242 = 2.14, P = 0.45) or age at onset (F1/224 = 2.39; P = 0.12). QTL-TDT analyses also showed no direct role of the A allele on these traits. We thus found no evidence for a significant role of the 5-HT(2A) gene in anorexia nervosa. Previous results may have been exposed to stratification bias (which we controlled by the TDT method) and/or the risk of type 1 error (from which we were less exposed because of the sample size).

Comparison of alcohol-dependent patients with and without physiological dependence

Sociodemographic and clinical characteristics of alcohol-dependent patients with or without physiological dependence (e.g. tolerance to alcohol or withdrawal) were compared. 186 consecutive alcohol-dependent patients hospitalized for alcohol detoxification were assessed. Diagnosis of alcohol dependence, tolerance and withdrawal was determined according to DSM-IV criteria. Assessment also included modalities of alcohol consumption and the Michigan Alcohol Screening Test (MAST). All patients presented alcohol dependence, 124 presented tolerance, 116 alcohol withdrawal and 146 (78.5%) tolerance and/or withdrawal. Patients with physiological dependence were older (51.4 vs. 46.9 years), drank more alcohol each day (20.3 vs. 11.3 drinks/day) and began alcohol consumption more often in the morning (67 vs. 37.5%). MAST scores were significantly higher in patients with physiological dependence (28.8 vs. 24.5), as was the mean corpuscular volume of erythrocytes (108 vs. 83 fl). No difference was found in terms of age, marital status, rate of unemployment, level of education and psychiatric comorbidity between the patients with and without physiological dependence.

The genetics of addiction: alcohol-dependence and D3 dopamine receptor gene

Alcohol-dependence is a complex phenotype, with behavioral, psychological, pharmacological, medical and social dimensions. Aggregation studies, adoption and twin researches have demonstrated that the vulnerability to alcohol-dependence is at least in part linked to genetic factors, the genetic vulnerability to alcoholism being mainly not substance-specific. There are numerous candidate genes, but the D3 dopamine receptor is specifically located in the limbic area, and in particular in the nucleus accumbens, which are involved in reward and reinforcement behavior. Furthermore, a previous collaborative study showed that homozygosity for the Ball DRD3 locus was more frequently observed in opiate dependent patients with high sensation seeking scores. In this study, we analyzed the distribution of Ball DRD3 polymorphism in a new sample of 131 French male alcoholic-patients (DSM III-R criteria) and 68 healthy controls matched for sex and origins. Although we replicated the higher sensation seeking score in alcohol-dependent patients with comorbid dependence, we found no significant difference in the DRD3 gene polymorphism between controls and alcoholic patients, regardless of sensation seeking score, addictive or psychiatric comorbidity, alcoholism typology, and clinical specificities of alcoholism. There is good evidence that gene coding for the dopamine receptor D3 does not play a major role in the genetic vulnerability to alcoholism.

Clinical characteristics of familial versus sporadic alcoholism in a sample of male and female patients

Presence of a family history of alcoholism may predict clinical characteristics in affected subjects, such as an earlier age at onset. More frequent and severe social maladjustment and somatic complications are also regularly cited for familial alcoholism, although subject to many other confusing factors. We analysed the clinical specificities of 79 alcohol-dependent inpatients according to the absence versus presence of family history of alcoholism. Patients were evaluated for lifetime psychiatric morbidity with the Diagnostic Interview for Genetic Studies (DIGS), for somatic complications with a systematic screening list, and first-degree relatives (N = 428) were assessed with the Family Inventory Schedule and Criteria (FISC). Age at onset and social complications were predicting familial versus sporadic alcoholism, even when considering censored data and/or interaction between variables. But differences became non-significant when excluding patients with antisocial personality. If age at onset effectively appears to be the most informative characteristic for predicting familial versus sporadic alcoholism, it seems that it may be necessary in future studies to systematically take into account antisocial personality diagnosis, because of a probable contamination.

Association and excess of transmission of a DRD2 haplotype in a sample of French schizophrenic patients

The gene which codes for dopamine receptor D2 (DRD2) is considered as one of the most relevant candidate genes in schizophrenia. Previous genetic studies focusing on this gene gave conflicting results, potentially because of the differences in methodology (linkage versus association studies), and the different loci analyzed (the DRD2 gene having many polymorphisms). We used a progressive strategy with three different approaches (case/control, haplotype relative risk and transmission disequilibrium test) and investigated two genetic polymorphisms (TaqI B1/B2 and TaqI A1/A2, spanning the coding region of the DRD2 gene) in 50 patients with DSM-IV diagnoses of schizophrenia, in their 100 parents and in 50 healthy, matched controls. Firstly, we found a significant excess of the two alleles (B2 and A2) in the schizophrenic group compared to unaffected controls. Secondly, we found an excess of transmission from the parents to their affected children, using the haplotype relative risk design applied to the B2A2 haplotype. Finally, the transmission disequilibrium test showed evidence for linkage between B2A2 haplotype and schizophrenia. The significant excess of the B2A2 haplotype in schizophrenic patients is specifically observed in a subsample of patients with a disease onset occurring after 20 years of age. As the haplotype contains nearly the entire DRD2 gene, we found convergent evidence in our sample for a significant role of the DRD2 gene in the risk for schizophrenia. This haplotype may be more specifically involved in the disorder's onset at a later age in some patients, or, alternatively, may be implicated as a modifying factor acting on age of onset.

[Precocious and polymorphic factitious disorder]

OBJECTIVE

Pathomimia is a mental disease more frequently diagnosed in women, characterised by a wide range of somatic or psychiatric symptoms, and a chronic course with severe complications.

CASE REPORT

A 22-year-old woman was suffering from severe factitious disorders with thermopathomimia, dermopathomimia, self-injuries with induced abscess, Lasthenie de Ferjol syndrome, and psychiatric factitious disorder. A very precocious age at onset and a previous history of 37 surgical operations were found.

DISCUSSION

This case history is particularly relevant in showing the clinical multiplicity of factitious disorders.

Serotonin transporter gene polymorphisms, alcoholism, and suicidal behavior

BACKGROUND

Dysfunction of serotoninergic transmission could predispose to excessive alcohol consumption and dependence. The functional polymorphism of the serotonin transporter gene (5-HTTLPR) has been associated with different disorders, including alcoholism. Considering the likelihood of heterogeneity in the "alcohol dependence" phenotype, 5-HTTLPR may be more specifically implicated in subsamples of patients or in related traits of alcoholism, such as impulsivity.

METHODS

We analyzed the role of this functional polymorphism in the risk for suicide attempt in a population of male alcohol-dependent subjects. One hundred ten male alcohol-dependent patients (DSM-III-R criteria), French for at least two generations, were personally interviewed with the Diagnostic Interview for Genetic Studies and compared with 61 unaffected blood donors.

RESULTS

The "short" (S) allele of the 5-HTTLPR appeared to be unrelated to alcohol dependence and comorbid depression in our sample, but was found associated with an increased risk for suicide attempts. This association was predominantly observed in severe and repetitive suicide attempts, with a significant dose effect of the S allele (0, 1, or 2) on the number and the severity of suicide attempts.

CONCLUSIONS

Mood disorders and alcohol dependence may interact with a genetic (relative) deficiency in serotonin reuptake, thereby increasing the risk for aggressive/impulsive behaviors such as suicide attempts.

Alcohol dependence among patients admitted to psychiatric emergency services

We assessed the prevalence of alcohol dependence among patients examined in the psychiatric emergency service of a general hospital. We compared socio-demographic data and psychiatric status of patients with and without alcohol dependence. One-hundred and four consecutive patients received by the psychiatric emergency service of Bichat-Claude Bernard Hospital (Paris, France) were assessed. Diagnosis of alcohol dependence, acute alcohol intoxication, and antisocial personality was determined according to DSM-IV criteria. Other psychiatric disorders were identified using a structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Prevalency rate of alcohol dependence was 37.5% among patients examined by the psychiatric emergency service. Alcohol-dependent patients were more often men than women and more often unemployed than non-alcohol-dependent psychiatric emergencies. They presented more dysthymia, acute alcohol intoxication, and antisocial personality than non-alcoholic patients followed by the psychiatric emergency service. Attempted suicide was as frequent in alcohol-dependent patients (23%) as in other patients (29%). Alcohol-dependent patients consumed alcohol more often when alone, and their alcohol consumption began more frequently in the morning. Patients seen in a psychiatric emergency service must be identified as a population at risk for alcohol dependence (37.5%). Alcohol-dependent patients are more often men and have a higher rate of unemployment. They present significantly more often dysthymia and acute alcohol intoxication associated to alcohol dependence.

Relationships between antisocial personality and alcoholism: genetic hypotheses

Genetic factors explain a non-negligible part of the vulnerability to alcohol dependence, the genetic influence in males being estimated at around 60%. The search for gene(s) potentially implicated in alcoholism is counteracted by the clinical heterogeneity of alcoholism, but also by heterogeneity of the etiologic factors involved. It is thus necessary to redefine more specific phenotypes with more simple determinism, and to focus on more specific subsets of candidate genes. In this view, the existence of co-occurrence (presence at the same time, whatever the cause) between antisocial personality and alcoholism is frequently reported. Three hypotheses have been previously proposed to explain this co-occurrence. Firstly, it could be a pure artefact or contamination, due to common items in diagnostic manuals widely used, such as the DSM or ICD. Secondly, antisocial personality and alcoholism could share common etiologic factor(s), and determine a 'real' co-morbidity. Finally, common genetic factors between these two disorders may exist, with the observation of a co-transmission of both disorders more often than expected by chance alone, meaning the existence of co-aggregation. Each of these three hypotheses will be reviewed and discussed.

Reappraisal of the association between the DRD2 gene, alcoholism and addiction

We analysed the impact of the TaqI A1 allele of the D2 dopamine receptor gene on the risk for alcoholism, trying to depict three explanations frequently proposed to explain discrepancies in association and linkage studies: that the A1 allele may act as a marker rather than as a vulnerability factor, that stratification biases and unevaluated controls may explain positive results, and that the A1 allele is modifying the phenotype rather than increasing the risk for alcoholism. We thus tested another (dinucleotide STRP) marker within the DRD2 gene, selected a new homogenous sample of 113 alcoholic patients and 49 unaffected controls strictly matched for ethnic origins, and systematically assessed both samples with a semi-structured interview to detect (in both samples) alcohol dependence, but also such related traits as specificities of complications. The frequency of the A1 allele was not significantly different between alcoholics and controls but when comparing different subgroups of alcoholics, the A1 allele was significantly more frequent in alcoholic patients with somatic complications (OR = 3.00, CI[1.37-6.62]), social and professional complications (OR = 2. 72, CI[1.25-5.90]), or with co-morbid dependence (OR = 2.88, 95% IC [1.16-7.15]). The association for co-morbid dependence and somatic complications was also positive when taking into consideration both STRP and TaqIA polymorphisms. The A1 allele does not increase the risk for alcoholism per se in our sample, but may be involved in a related trait which is partially dependent on the diagnosis of alcoholism, through a disequilibrium with another close mutation.

Epidemiology of behavioral dependence: literature review and results of original studies

The extension of the definition of dependence leads to the consideration of some impulsive disorders as a form of dependence disorder. This pathological condition is characterized by the repetitive occurrence of impulsive and uncontrolled behaviors. Other clinical characteristics are failure to resist an impulse, drive or temptation to perform some act harmful to oneself and/or others, an increasing sense of tension or excitement before acting out, and a sense of pleasure, gratification or release at the time of the behavior or shortly thereafter. Behavioral dependences most often described are pathological gambling, kleptomania, trichotillomania and compulsive buying. Studies using a specific assessment scale, the South Oaks Gambling Screen, distinguished problem gambling from pathological gambling. Social gamblers spend 5% of their money and pathological gamblers 14 to 45%. Prevalence of 'problem gambling' is 4% and pathological gambling 2%. Several studies have suggested that the incidence of pathological gambling is eight to ten times greater in alcohol-dependent patients than in the general population. No systematic study has assessed the prevalence of kleptomania. Data come from case reports. Among subjects arrested after a theft, prevalence of kleptomania varied between 0 and 24%. Trichotillomania prevalence rate is 0.6% among students. Studies using less restrictive diagnostic criteria found a prevalence rate of 3.4% in women and 1.5% in men. The disorder is often unrecognized; 40% of the cases are not diagnosed and 58% of the patients have never been treated. Prevalence studies of compulsive buying found a rate between 1 and 6% in the general population. Compulsive buying is significantly more frequent among women (90% of the cases). Study of family history of compulsive buyers showed a high frequency of alcohol-dependence disorder (20%) and depression (18%). In all cases of behavioral dependence disorders, a high level of impulsivity and sensation-seeking could determine an increased risk.

The DRD2 gene and the risk for alcohol dependence in bipolar patients

The high co-morbidity between bipolar disorder and alcohol dependence may have different explanations, one of them being the existence of common genetic factors for the two disorders. Several candidate genes may be involved but the genes acting in the dopaminergic pathway may be more specifically involved. We have thus tested the role of the gene encoding the D2 dopamine receptor (TaqI A1 allele) in the potentially shared vulnerability to alcohol dependence and bipolar disorder. One hundred and twenty-two French (for at least two generations) patients were recruited on the basis of hospital or outpatient files and were interviewed with the DIGS. The A1 allele frequencies were compared between four groups, namely, with bipolar patients and co-morbid alcohol dependence (N = 21), with bipolar patients without alcohol morbidity (N = 31), with alcohol dependence without mood disorder (N = 35) and unaffected controls (N = 35). The Hardy Weinberg equilibrium for the DRD2 Taq1 A1 genotypes was respected for the sample as a whole, and for each subsample. We observed that 42.9% of control subjects have at least one A1 allele, a frequency which is not significantly different from the one observed in the affected sample as a whole (39.1%), neither from patients with alcohol dependence (37.1%), patients with bipolar disorder (48.4%) nor patients with alcohol dependence and bipolar disorder (28.6%). The regression analysis based on the three variables (bipolar disorder, alcohol dependence and interaction between these two disorders) does not explain the presence of the A1 allele of the DRD2 gene. We thus found no evidence for a significant role of the A1 allele of the D2 dopamine receptor gene in the specific association between bipolar disorder and alcohol dependence in our sample.

[Behçet's disease and factitious manic-depressive psychosis: a case of Münchausen syndrome]

BACKGROUND

Munchausen syndrome is frequently observed in men unlike other factitious conditions. The patient presents a characteristic triad: apparently acute but factitious disorders, migration from hospital to hospital resulting in unnecessary explorations and treatments, and fabulated medical history.

CASE REPORT

A 57-year-old man was hospitalized in the psychiatric unit for alleged insomnia, psychomotor excitation and multiple hallucinatory phenomena. The factitious nature of the patientís condition was rapidly suspected in light of the large number of previous unconfirmed medical conditions and a rather unbelievable history.

DISCUSSION

Unlike the classical description of Munchausen's syndrome, this patient had no history of surgery. This unusual aspect should not exclude the clinical diagnosis as for some patients, the invasive nature of certain explorations may be a valid substitute for surgery.

Genetic factors in anorexia nervosa

Anorexia nervosa is a severe and complex disorder with incompletely known vulnerability factors. It is generally recognized that anorexia nervosa is a familial disorder, but the majority of twin studies have shown that the concordance rate for monozygotic twins is higher (on average 44%) than for dizygotic twins (on average 12.5%). This difference in concordance rates shows that genetic factors, more than common familial environment, may explain why the 'anorexia nervosa' phenotype runs in families. In order to estimate the heritability in the broad sense of anorexia nervosa according to published familial and twin studies, we first assessed the intrapair correlation between monozygotic and dizygotic twins, and secondly calculated the deviation threshold of relatives of affected probands from the relative mean. In this review, we obtained an estimation of the heritability at 0.72 according to all published controlled familial studies (six references quoted in MEDLINE(R)), and 0.71 for all published twin studies (59 references quoted in MEDLINE(R)). This estimation is close to the ones previously proposed, between 0. 5 and 0.8. Familial and twin studies may also help to define the boundaries of the phenotype, shedding light on the complex relationship between anorexia nervosa on the one hand, and bulimia nervosa, mood disorders, and alcoholism on the other. Demonstrating the importance of genetic factors in anorexia nervosa, and more specifically for anorexia of the restrictive type, requires not only prospective and adoption studies (which are still lacking), but also genetic polymorphisms analyses, which began very recently.

Study of impulse-control disorders among alcohol-dependent patients

BACKGROUND

Impulse-control disorders (ICDs) include intermittent explosive disorder, kleptomania, trichotillomania, pyromania, and pathological gambling. Several studies have suggested that the incidence of pathological gambling is substantially higher in alcoholics than in the general population. The rate of co-occurrence of other ICDs and alcohol dependence has never been systematically investigated. In our study, we assessed the frequency of all ICDs in a population of alcohol-dependent patients. We also examined the possibility that the presence of an ICD can correspond to earlier onset and more severe forms of alcoholism, which have a greater association with antisocial personality.

METHOD

All patients hospitalized at our psychiatric unit for detoxification between January and August 1997 met DSM-IV criteria for alcohol dependence and were included in this study. Diagnosis of alcohol dependence was confirmed with the Mini-International Neuropsychiatric Interview. ICDs were investigated using the Minnesota Impulsive Disorders Interview. All patients completed the Michigan Alcoholism Screening Test.

RESULTS

Among the 79 patients included in the study, 30 (38.0%) met criteria for an ICD. Included in the study were 19 cases of intermittent explosive disorder, 7 cases of pathological gambling, 3 cases of kleptomania, and 1 case of trichotillomania. Patients with co-occurring ICDs were significantly younger than patients without an ICD (mean age = 40.7 vs. 44.5 years; p = .03). Patients with co-occurring pathological gambling were significantly younger at the onset of alcohol dependence than patients without ICDs (mean age = 19.5 vs. 25.9 years; p = .0008). Pathological gamblers had significantly longer duration of alcohol dependence compared with patients without ICDs (26.0 vs. 17.9 years; p = .02). Patients with co-occurring intermittent explosive disorder had the shortest duration of alcohol dependence of all patients (9.9 years). Prevalence of antisocial personality disorder was no different in patients with or without co-occurring ICDs.

CONCLUSION

Thirty-eight percent of the alcohol-dependent patients studied presented with an ICD. Patients with ICDs were younger than those without an ICD. The presence of an ICD was not associated with a specific form of alcohol dependence or with antisocial personality. Co-occurrence of pathological gambling, however, was associated with lower age at onset of alcohol dependence, a higher number of detoxifications, and a longer duration of alcohol dependence than was absence of an ICD.

Comparison of buying behavior in depressed patients presenting with or without compulsive buying

Compulsive buying is defined as repetitive impulsive and excessive buying leading to personal and familial distress. This study compares the buying behavior of depressed patients presenting with or without compulsive buying. The weight of promotional factors such as sales and advertising campaigns was systematically assessed. The impulsive nature of compulsive buying and the choice of items purchased were also investigated. For this purpose, we studied buying behavior among 52 inpatients diagnosed for major depressive episode with DSM-IV criteria. None of the patients presented mania or hypomania, obsessive-compulsive disorder, or alcohol or drug abuse or dependence disorder. We assessed the prevalence of compulsive buying and compared the "buying style" among patients with (CB+) and without (CB-) compulsive buying. The diagnosis of depression was assessed with the Mini International Neuropsychiatric Interview (MINI). The diagnosis of compulsive buying was made using standardized criteria and a specific rating scale. All patients answered a specific questionnaire assessing the phenomenology of the buying behavior. Twenty-one of 52 depressives presented with compulsive buying. The CB+ group was not more sensitive to promotional factors. They did not seek sales or use loans significantly more than others. Upon entering a shop, the CB+ subjects did not change their choice more often than others. CB+ subjects were significantly more often alone while shopping (85% of cases v61% of CB- group, p = .05). Most purchases from the CB+ group were self-gifts or gifts to others (50.4% v 23.5%, p = .003); 14.4% of purchases in the CB+ group (v 2.2% in CB- group, P = .045) were made because the patients believed their social status requires acquisition. Items to be bought were more often considered by CB+ subjects as occasions not to be missed (31.4% v15.1%, P = .03). Purchases were significantly (57% v 16%) less often used than expected by the CB+ group (P = .002). Most purchases, in addition, represented gifts for oneself or others and were used significantly less often than expected.

Impulse-control disorders in alcoholics are related to sensation seeking and not to impulsivity

Impulse-control disorders (ICD) include intermittent explosive disorder, kleptomania, trichotillomania, pyromania and pathological gambling. Several studies have suggested that the incidence of pathological gambling and impulsive violent behavior is substantially higher in alcohol-dependent patients than in the general population. The association between ICD and alcoholism, as well as personality characteristics such as sensation seeking and impulsivity, has never been systematically studied. The present study compared the levels of impulsivity and sensation seeking in age- and sex-matched groups of alcohol-dependent patients with concomitant ICD (ICD+, n = 30), alcohol-dependent patients without ICD (ICD-; n = 30) and control subjects (n = 30). All the alcohol-dependent patients (ICD+ and ICD-) were hospitalized for alcohol detoxification. Diagnoses of ICD were based on DSM-IV criteria and the Minnesota Impulsive Disorders Interview. All patients completed the Zuckerman Sensation-Seeking Scale (SSS) and the Barratt Impulsiveness Rating Scale (BIS). Mean scores on the SSS general factor, the SSS disinhibition subscale, and the SSS experience-seeking scale were significantly higher in ICD+ patients than in either ICD- patients or control subjects. By contrast, total scores and subscale scores on the BIS showed no significant differences among the three groups. Thus, it appears that measures of sensation seeking, rather than impulsivity, are relevant in distinguishing between alcohol-dependent patients with and without concomitant impulse control disorders.

Benzodiazepine treatment for alcohol-dependent patients

Benzodiazepines (BZDs) are the preferred pharmacological agents for treatment of acute alcohol withdrawal. Treatment with BZDs can be administered on an out-patient basis for subjects experiencing mild to moderate withdrawal and on an in-patient basis for the most severe forms of withdrawal. The efficacy of BZDs for long-term treatment of alcoholism has been more controversial. Controlled studies indicate that BZD treatment does not improve abstinence rate. Most reviews of drug treatment of alcoholism conclude that routine use of BZDs is not indicated on a long-term basis. However, the clinical reality is that many alcoholics are treated by BZDs during detoxification and then continue to receive them for the treatment of anxiety disorders or insomnia, often secondary to alcohol dependence. After a review of the biological properties of BZDs related to their therapeutic issues, this review discusses the major indications for BZD treatment of alcoholism. BZDs are first prescribed to prevent and treat symptoms of alcohol withdrawal. Indication of BZD administration during alcohol withdrawal and criteria of choice of an agent according to its half-life or its route of administration are discussed. The different protocols of BZD treatment during withdrawal are considered (e.g. loading techniques, symptom-triggered therapy). The use of BZDs in the treatment of anxiety associated with alcohol dependence is examined. Among unwanted effects, risk of abuse, memory impairment, confusion, and delirium are described. Finally, practical guidelines for the use of BZDs in the treatment of alcoholism are proposed.

Genetics and anorexia nervosa: a review of candidate genes

Anorexia nervosa is a severe disorder which seems likely to have a multifactorial aetiology. However, several studies have stressed that genetic factors play a significant role. Epidemiological studies have shown that the lifetime risk for first-degree relatives of a patient with an eating disorder is 6% compared to 1% among relatives of controls, and a twin study performed on 34 pairs of twins has shown a higher concordance rate in monozygotic twins (55%) compared to dizygotic twins (7%). The vulnerability component of anorexia nervosa that can be attributed to genetic influences has been estimated from twin studies to be around 70%. Despite this, few genetic studies have been performed testing the role of candidate genes which code for proteins potentially implicated in the aetiopathogenesis of the disorder. In this review, genes encoding components of the dopamine, serotonin, opiate, and noradrenaline systems are assessed for their role in anorexia nervosa. Attention is paid to psychological dimensions, clinical symptoms, co-morbidity frequency, pharmacological data, and biological measures that characterize anorexia nervosa.

[Prospective evaluation of antidepressant discontinuation]

The authors prospectively assessed symptoms induced by the interruption of antidepressants in 16 patients (11 women and 5 men), aged from 33 to 85 years (mean = 52.4 +/- 16.4), treated with antidepressants since at least two weeks. All patients were free of alcohol abuse or dependence disorder and of other dependence to psychoactive substances. None of them presented medical illness. Diagnosis were made by separate evaluations by two authors and confirmed with a semistructered assessment instrument: the Schedule for Affective Disorders and Schizophrenia (Lifetime Version). All patients were submitted to a brutal discontinuation of their antidepressant agent. Patients were assessed twice, before the interruption of the antidepressant, and 72 hours later. Effects of antidepressant interruption were assessed by several means. Modification of anxiety and depression were evaluated using the Montgomery Asberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Scale. Symptoms of withdrawal were assessed with Cassano and al.'s scale SESSH including an evaluation of anxiety, agitation, irritability, anergy, difficulty on concentrating, depersonalization, sleep and appetite disorders, muscle pains, nausea, tremor, sweating, altered taste, hyperosmia, paresthesias, photophobia, motor incoordination, dizziness, hyperacousia pain, delirium. Fourteen of the 16 patients (87.5%) presented modifications of their somatic or psychic state 3 days after the interruption of the antidepressant treatment. Most frequent symptoms were: increase in anxiety (31%), increase in irritability (25%), sleep disorders (19%), decrease of anergia and fatigue (19%). Mean scores of anxiety and depression were not significantly modified by the withdrawal. Following TCAs interruption (7 patients) most frequent symptoms were sleep disorders; increase in anxiety, nausea. Among patients withdrawn from SSRIs (6 patients), most frequent symptoms were increase in anxiety, increase in irritability, headache. Patients also presented a decrease of nausea, and of anorexia.

Lack of association between anorexia nervosa and D3 dopamine receptor gene

BACKGROUND

Evidence from family and twin studies suggests a genetic contribution to the etiology of anorexia nervosa. Different genes could contribute to the vulnerability to anorexia nervosa, but dopamine could be more specifically implicated in anorexia nervosa because of pharmacologic, endocrine, and neurobiological specificities. The dopamine receptor D3 (DRD3) may be of additional interest, since it is specifically located in the limbic area, an area implicated in reward and reinforcement behavior.

METHODS

We performed an association study between 39 patients with severe (requiring hospitalization and with young age at onset) anorexia nervosa (DSM-III-R), and 42 controls, with the Bal I polymorphism in exon I of the DRD3 gene.

RESULTS

There was no significant difference between patients with anorexia nervosa and controls in allele frequencies or genotype count. The association was still negative between subgroups separated according to family history of anorexia nervosa or comorbid mood disorders.

CONCLUSIONS

Despite the fact that the number of patients tested is small, there is good evidence that the Bal I DRD3 polymorphism does not play a major role in the genetic component of anorexia nervosa. It would be useful to test polymorphisms of the other genes coding for dopamine receptors.

[Chronic hallucinatory psychosis and late onset schizophrenia: the same entity?]

The distinction between schizophrenia and chronic delusion syndromes (such as paraphrenia, late-paraphrenia and "Psychose Hallucinatoire Chronique") is currently used in France, although there is no international criteria (ICD 10 or DSM IV) for chronic delusion syndromes. It is thus worth analysing the literature in order to compare the differences between late-onset schizophrenia and "Psychose Hallucinatoire Chronique", and the similarities between young-onset schizophrenia and chronic delusion syndromes. Clinical investigations clearly differentiate "Psychose Hallucinatoire Chronique" and late-onset-schizophrenia from young-onset schizophrenia because they have more delusion and hallucinatory symptoms, less negative symptoms, better evolution, and better sensitivity to antipsychotic drugs. Epidemiological data show that "Psychose Hallucinatoire Chronique" and late-onset schizophrenia have both a different sex-ratio (around 7 women for 1 man) than young-onset schizophrenia (nearly 1 woman for 1 man), and that in "Psychose Hallucinatoire Chronique" and in late-onset schizophrenia, social withdrawal is frequently observed before onset of the disorder. Lastly, putative risk factors may be shared by "Psychose Hallucinatoire Chronique" and late-onset schizophrenia, and may isolate them from young-onset schizophrenia, for example regarding the oestradiol hypothesis (oestradiol enhance dopamine efficacy and delay the onset of delusion disorders), the impact of sensory handicaps (which may be clinically and experimentally associated with hallucinations), or the role of genetic and familial factors (with a familial concentration intermediate between the familial concentration of schizophrenia of schizophrenic proband, and the familial concentration of schizophrenia of control probands). In accordance with this review of the literature, the authors conclude that the absence of specific criteria for late-onset schizophrenia and/or "Psychose Hallucinatoire Chronique" In international diagnostic manual risk to counter the facility to detect specific risk factors involved in the pathogenesis of schizophrenia.

Study of compulsive buying in depressed patients

BACKGROUND

Compulsive buying is defined by the presence of repetitive impulsive and excessive buying leading to personal and familial distress. Patients with this disorder also suffer from mood disorder in 50% to 100% of the cases studied, and antidepressants help to decrease the frequency and the severity of uncontrolled buying. To define the correlation between compulsive buying and depression, we assessed this behavior among 119 inpatients answering to DSM-III-R criteria for major depressive episode. Additionally, we evaluated for comorbidity in the patients suffering from compulsive buying and in those free from this disorder. Impulsivity and sensation seeking were also compared in the two groups.

METHOD

Diagnosis of compulsive buying was made using standardized criteria and a specific rating scale. Diagnosis of depression and assessment of comorbidity were investigated using the Mini International Neuropsychiatric Interview and a modified version of the Minnesota Impulsive Disorders Interview. All patients answered the Zuckerman Sensation-Seeking Scale and the Barrat Impulsivity Rating Scale.

RESULTS

The prevalence of the disorder was 31.9%; 38 of the 119 depressed patients were diagnosed as compulsive buyers. Patients from the compulsive buying group were younger in age, more often women than men, and more frequently unmarried. They presented more often than others with recurrent depression (relative risk = 1.4), disorders associated with deficits in impulse control such as kleptomania (relative risk = 8.5) or bulimia (relative risk = 2.8), benzodiazepine abuse or dependence disorder (relative risk = 4.7), and two or more dependence disorders (relative risk = 1.99). Subscores for experience seeking using the Zuckerman Sensation-Seeking Scale were significantly higher (p = .04) and scores of impulsivity were much higher (p < .0001) than corresponding scores in the group without compulsive buying behavior.

CONCLUSION

Compulsive buying is frequent among depressed patients. In most cases, the behavior is associated with other impulse control disorders or dependence disorders and a high level of impulsivity.

Antidepressant discontinuation: a review of the literature

Sudden or tapered withdrawal from treatment with antidepressants, including monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), and serotonin selective reuptake inhibitors (SSRIs), can produce phenomena consisting of somatic and psychological symptoms. The literature about these discontinuation phenomena consists mainly of case reports and a limited number of controlled prospective studies. The symptoms are generally mild and transient for the TCAs and the SSRIs but may be serious for the MAOIs. They are much more common with a shorter acting SSRI, such as paroxetine, than with the longer acting agent fluoxetine. Because the symptoms of antidepressant discontinuation include changes in mood, affect, appetite, and sleep, they are sometimes mistaken for signs of a relapse into depression. Thus, it is important to directly question patients about new symptoms that occur during antidepressant discontinuation to optimally manage treatment discontinuation.

Phenomenology and psychopathology of uncontrolled buying

OBJECTIVE

Uncontrolled buying, defined by the presence of repetitive impulsive and excessive buying that leads to personal and familial distress, is a psychiatric disorder that has only recently been recognized. This review focuses on the prevalence, clinical features, and etiology of this disorder.

METHOD

All published articles on the topic were collected and reviewed. The literature concerning the typology of normal consumerism was also reviewed.

RESULTS

The prevalence of the disorder in the general population is reported to be 1.1%. The main clinical features of uncontrolled buying are impulsivity and repetition of buying, the invasive need to buy, unsuccessful attempts to control spending, and the existence of tangible negative consequences of buying (marked distress, interference with social or occupational functioning, or financial problems). Uncontrolled buying may be related to obsessive-compulsive disorder, depression, addiction, or impulsivity.

CONCLUSIONS

In most cases, uncontrolled buying can be understood as "compensatory buying" that temporarily alleviates depressive symptoms and can thus be associated with the results of antidepressant treatment in cases in which uncontrolled buying is symptomatically associated with depression.

[Alcoholism: value of a search for familial antecedents]

Alcoholism is a complex disorder, with clinical and etiological heterogeneity. The clinical symptoms used for the diagnostic of alcoholism are based on worldwild standard criteria, such as DSM (American Psychiatric Association) or ICD (World Health Organisation). Good agreement between clinicians for the diagnostic of alcoholism can be obtained with these classifications. The diagnostic of alcoholism with such international criteria is mainly based on the cognitive and behavior consequences of alcohol consumption. In order to cope with the heterogeneity of alcoholism, one should analyse the different aspects of alcoholism pathogenesis. One important aspect is its high frequency within some families, as many studies show a direct correlation between the risk for alcoholism and familial frequency of alcoholism. More recent studies tried to detect which clinical aspects of alcoholism are more frequently observed in alcoholic patients with a positive familial history. Those studies also analysed the impact of a familial history of co-morbid psychiatric disorders on the general risk for alcoholism and the specific risk for alcoholism and co-morbid psychiatric disorders. Most clinicians interested in alcoholism look for familial history of alcoholism or psychiatric disorders, but this information is frequently incomplete and partially used. The research on familial history of alcoholism is nevertheless facilitated, and more valid, with the recent clinical tools such as standard clinical questionnaires. The detection of a familial history can be in many aspects useful for establishing clinical subtypes, predicting specific (psychiatric, social or medical) complications, or helping to find the most relevant treatment modality.

[Alternating addictions: apropos of 3 cases]

The concept of addiction is now of interest in psychiatry, but is a great subject of controversies. It is now recognized that as different disorders as alcoholism, drug addiction, bulimia, kleptomania, trichotillomania, pathological gambling are to be considered as addictive states. Other pathological behaviours could be included in the addictive spectrum (i.e. suicidal behaviours, compulsive spending). The comorbidity rates of these disorder are elevated in these populations. For example, high comorbidity rates are found between kleptomania and bulimia or drug addiction and pathological gambling. Polyaddictive states are well established. For some subjects, more than one addiction is present in life-time, but not occurring in the same period. We present three patients in whom different addictive states occurred alternately. All the patients had a history of compulsive spending and kleptomania, two of them had a history of bulimia and sexual compulsion. Some clinical characteristics were common: recurrent mood disorder, depression preceeding the addictive state, no psychoactive substance disorder. In all patients, severity of depressive state decreased when addiction appeared. Depressive symptoms varied inversely to addiction severity. The hypothesis about psychopathological links between kleptomania and bulimia on one hand and mood disorders on the other hand has been known for a long time. Kleptomania as other impulsive disorders is, for some authors, understood in the meaning of a "spectrum affective disorder". For these three patients, an antidepressant effect of the behavioural addictions is suggested. In fact, the addictions appeared alternately. The possibility of common psychopathological and/or biological mechanisms for behavioural addiction is supported by these clinical observations, that could contribute to the addiction concept validity.

Lack of association between alcohol-dependence and D3 dopamine receptor gene in three independent samples

Numerous studies on the involvement of dopamine receptors in the genetics of alcoholism focused on associations between a polymorphism of the D2 dopamine receptor (DRD2) gene and alcohol dependence. However, the results of these studies are conflicting. Another receptor, the D3 dopamine receptor (DRD3), may be of additional interest since it is specifically located in the limbic area, and in particular in the nucleus accumbens which plays a significant role in the reward process of addiction behavior. We thus tested the association in three independent samples of alcoholic patients, with different origins and various inclusion criteria. No difference in the DRD3 gene polymorphism emerged between controls and alcoholic patients, regardless of their origin, inclusion criteria, or presence or absence of the DRD2 TaqI A1-allele. Despite the fact that more information could have been considered and that association studies provide limited information, there is good evidence that this DRD3 polymorphism does not play a major role in the genetic component of alcoholism.

[The serotonin syndrome: review of the literature and description of an original study]

In animals the occurrence of a behavioural syndrome consisting of hyperactivity, stereotyped movements and increase of temperature has been induced by MAOIs, 5-HT precursors (L-tryptophan) and 5-HT reuptake inhibitors. Most of these manifestations were specifically blocked by a pretreatment with an inhibitor of serotonin synthesis. In humans, the association of myoclonus, diarrhea, confusion, hypomania, agitation, hyperreflexia, shivering, incoordination, fever and diaphoresis, when patients are treated with serotoninergic agents, could constitute a "serotonin syndrome". Such cases of serotonin syndrome were reported after treatments with L-tryptophan, MAOIs, serotonin reuptake inhibitors and tricyclics alone or in association. The authors prospectively evaluated all the "serotonin-related" symptoms in 38 depressed inpatients fulfilling DSM III-R criteria of major depression. 16 (42%) out of 38 patients presented at least one symptom of serotonin syndrome. In 14 cases tremor and myoclonus occurred simultaneously and 10 patients presented at the same time tremor, myoclonus, diaphoresis and shivering. Except for two patients, symptoms were transient, lasted less than one week and disappeared with the pursuit of the treatment. Most often, serotonin syndrome thus corresponds to a reaction induced by a combination of serotoninergic agents at high dosages. In very rare cases, a toxic and potentially fatal interaction can occur between MAOIs, tricyclics and selective serotonin reuptake inhibitors at therapeutic dosages. Serotonin syndrome also provides an heuristic model of the putative mode of action of antidepressants. Serotonin-related symptoms are the physical and objective expression of the antidepressant-induced increase in serotonin. The specificity of serotonin-related syndrome also needs to be discussed since most of the symptoms, such as tremor and diaphoresis, are not in all cases related to an increase in serotonin.