Descriptions of Disordered Eating in German Psychiatric Textbooks, 1803-2017

The most common eating disorders (EDs) according to DSM-5 are anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). These disorders have received increasing attention in psychiatry due to rising prevalence and high morbidity and mortality. The diagnostic category "anorexia nervosa," introduced by Ernest-Charles Lasègue and William Gull in 1873, first appears a century later in a German textbook of psychiatry, authored by Gerd Huber in 1974. However, disordered eating behavior has been described and discussed in German psychiatric textbooks throughout the past 200 years. We reviewed content regarding eating disorder diagnoses but also descriptions of disordered eating behavior in general. As material, we carefully selected eighteen German-language textbooks of psychiatry across the period 1803-2017. Previously, in German psychiatry, disordered eating behaviors were seen as symptoms of depressive disorders, bipolar disorder or schizophrenia, or as manifestations of historical diagnoses no longer used by the majority of psychiatrists such as neurasthenia, hypochondria and hysteria. Interestingly, 19th and early 20th century psychiatrists like Kraepelin, Bumke, Hoff, Bleuler, and Jaspers reported symptom clusters such as food refusal and vomiting under these outdated diagnostic categories, whereas nowadays they are listed as core criteria for specific eating disorder subtypes. A wide range of medical conditions such as endocrinopathies, intestinal or brain lesions were also cited as causes of abnormal food intake and body weight. An additional consideration in the delayed adoption of eating disorder diagnoses in German psychiatry is that people with EDs are commonly treated in the specialty discipline of psychosomatic medicine, introduced in Germany after World War II, rather than in psychiatry. Viewed from today's perspective, the classification of disorders associated with disordered eating is continuously evolving. Major depressive disorder, schizophrenia and physical diseases have been enduringly associated with abnormal eating behavior and are listed as important differential diagnoses of EDs in DSM-5. Moreover, there are overlaps regarding the neurobiological basis and psychological and psychopharmacological therapies applied to all of these disorders.

Consumer Reports of "Keto Flu" Associated With the Ketogenic Diet

Background: The ketogenic diet (KD) is a high-fat, low-carbohydrate diet that limits glucose and results in the production of ketones by the liver and their uptake as an alternative energy source by the brain. KD is an evidence-based treatment for intractable epilepsy. KD is also self-administered, with limited evidence of efficacy, for conditions including weight loss, cognitive and memory enhancement, type II diabetes, cancer, neurological and psychiatric disorders. A commonly discussed side effect of KD in media and online forums is “keto flu,” a cluster of transient symptoms generally reported as occurring within the first few weeks of KD. This study aimed to characterize the pattern of symptoms, severity and time course of keto flu as related by users of online forums.

Method: Online forums referring to “keto flu,” “keto-induction,” or “keto-adaptation” in the URL were identified in Google. Passages describing personal experiences of keto flu were categorized manually with reference to pattern of symptoms, severity, time course, and remedies proposed.

Results: The search criteria identified 75 online forums, 43 met inclusion criteria and contained 448 posts from 300 unique users. Seventy-three made more than one post (mean 3.12, range 2–11). Descriptors of personal experience of keto flu, reported by 101 of 300 users, included 256 symptom descriptions involving 54 discrete symptoms. Commonest symptoms were “flu,” headache, fatigue, nausea, dizziness, “brain fog,” gastrointestinal discomfort, decreased energy, feeling faint and heartbeat alterations. Symptom reports peaked in the first and dwindled after 4 weeks. Resolution of keto flu symptoms was reported by eight users between days 3 and 30 (median 4.5, IQR 3–15). Severity of symptoms, reported by 60 users in 40 forums, was categorized as mild (N = 15), moderate (N = 23), or severe (N = 22). Eighteen remedies were proposed by 121 individual users in 225 posts.

Conclusions: Typically, individual posts provided fragmentary descriptions related to the flow of forum conversations. A composite picture emerged across 101 posts describing personally experienced symptoms. User conversations were generally supportive, sharing remedies for keto flu reflecting assumptions of physiological effects of KD.

Risk prediction using natural language processing of electronic mental health records in an inpatient forensic psychiatry setting

OBJECTIVE

Instruments rating risk of harm to self and others are widely used in inpatient forensic psychiatry settings. A potential alternate or supplementary means of risk prediction is from the automated analysis of case notes in Electronic Health Records (EHRs) using Natural Language Processing (NLP). This exploratory study rated presence or absence and frequency of words in a forensic EHR dataset, comparing four reference dictionaries. Seven machine learning algorithms and different time periods of EHR analysis were used to probe which dictionary and which time period were most predictive of risk assessment scores on validated instruments.

MATERIALS AND METHODS

The EHR dataset comprised de-identified forensic inpatient notes from the Wilfred Lopes Centre in Tasmania. The data comprised unstructured free-text case note entries and serial ratings of three risk assessment scales: Historical Clinical Risk Management-20 (HCR-20), Short-Term Assessment of Risk and Treatability (START) and Dynamic Appraisal of Situational Aggression (DASA). Four NLP dictionary word lists were selected: 6865 mental health symptom words from the Unified Medical Language System (UMLS), 455 DSM-IV diagnoses from UMLS repository, 6790 English positive and negative sentiment words, and 1837 high frequency words from the Corpus of Contemporary American English (COCA). Seven machine learning methods Bagging, J48, Jrip, Logistic Model Trees (LMT), Logistic Regression, Linear Regression and Support Vector Machine (SVM) were used to identify the combination of dictionaries and algorithms that best predicted risk assessment scores.

RESULTS

The most accurate prediction was attained on the DASA dataset using the sentiment dictionary and the LMT and SVM algorithms.

CONCLUSIONS

NLP, used in conjunction with NLP dictionaries and machine learning, predicted risk ratings on the HCR-20, START, and DASA, based on EHR content. Further research is required to ascertain the utility of NLP approaches in predicting endpoints of actual self-harm, harm to others or victimisation.

Consensus Paper: Cerebellum and Emotion

Over the past three decades, insights into the role of the cerebellum in emotional processing have substantially increased. Indeed, methodological refinements in cerebellar lesion studies and major technological advancements in the field of neuroscience are in particular responsible to an exponential growth of knowledge on the topic. It is timely to review the available data and to critically evaluate the current status of the role of the cerebellum in emotion and related domains. The main aim of this article is to present an overview of current facts and ongoing debates relating to clinical, neuroimaging, and neurophysiological findings on the role of the cerebellum in key aspects of emotion. Experts in the field of cerebellar research discuss the range of cerebellar contributions to emotion in nine topics. Topics include the role of the cerebellum in perception and recognition, forwarding and encoding of emotional information, and the experience and regulation of emotional states in relation to motor, cognitive, and social behaviors. In addition, perspectives including cerebellar involvement in emotional learning, pain, emotional aspects of speech, and neuropsychiatric aspects of the cerebellum in mood disorders are briefly discussed. Results of this consensus paper illustrate how theory and empirical research have converged to produce a composite picture of brain topography, physiology, and function that establishes the role of the cerebellum in many aspects of emotional processing.

Online computer-aided vicarious exposure for OCD symptoms: A pilot study

BACKGROUND AND OBJECTIVES

Computer-aided vicarious exposure (CAVE) for obsessive-compulsive disorder (OCD) is an intervention in which participants learn and rehearse exposure with response prevention (ERP) by directing a character around a virtual world. This study aimed to pilot an online CAVE program for OCD in a community sample with high OCD symptomatology.

METHODS

Participants (n = 78) were allocated to an intervention group (three 45-min weekly CAVE sessions) or to a waitlist control group. The treatment group were asked to complete three 45-min sessions over a four week period.

RESULTS

Those who completed at least one CAVE session showed greater improvement on measures of OCD symptomatology at one-month post-treatment (d = 0.49-0.81) compared to waitlist (d = 0.01-0.1). Older age, past treatment and higher symptom severity were associated with non-adherence.

LIMITATIONS

These findings should be considered preliminary due to sample size limitations and an absence of an active control group. However, the findings suggest that further development and evaluation of the program is warranted.

CONCLUSIONS

Preliminary findings suggest that online CAVE programs have potential to bridge treatment gaps among those reluctant to attend treatment or engage with in vivo exposure exercises. These programs may also have potential applications as an adjunct to face-to-face or online cognitive behavioural therapy.

Habituation of self-reported anxiety and cortical hyper-vigilance during image-based exposure to spiders

BACKGROUND AND OBJECTIVES

The aim of the study was to examine habituation of subjective anxiety and electrophysiological correlates of cortical hyper-vigilance during exposure to spider images among high (n = 12) and low (n = 11) spider fear groups.

METHODS

Participants viewed a six-stage hierarchy of spider images. The images used at stage 1 and stage 6 were the same. Subjective anxiety was rated at four intervals during each three-minute exposure stage (0, 60, 120, and 180 s) and event-related potentials (ERPs) were averaged across these epochs (0-60, 60-120, 120-180).

RESULTS

High spider fearfuls demonstrated greater habituation of self-reported anxiety within and between exposure stages compared to low fearfuls. Consistent with attentional hyper-vigilance, the high-fear group also demonstrated greater P1 amplitude in response to spider images. In both groups, habituation of P1 amplitude was found at later relative to earlier stages, but increased at stage six when the stage 1 image was re-presented, despite low subjective anxiety.

LIMITATIONS

While the passive viewing paradigm mirrored image-based exposure, it was not possible to determine whether participants engaged in avoidance strategies. In addition, further research is needed to assess the relevance of habituation and reinstatement of P1 amplitude to therapeutic outcome.

CONCLUSIONS

Habituation of subjective anxiety during image-based exposure is not necessarily accompanied by a reduction in measures of cortical hyper-vigilance. The reinstatement of the P1 response may indicate either re-activation of previous associations, less avoidance, or a more generalised dishabituation mechanism.

Inflammation and Immune Regulation as Potential Drug Targets in Antidepressant Treatment

Growing evidence supports a mutual relationship between inflammation and major depression. A variety of mechanisms are outlined, indicating how inflammation may be involved in the pathogenesis, course and treatment of major depression. In particular, this review addresses 1) inflammatory cytokines as markers of depression and potential predictors of treatment response, 2) findings that cytokines interact with antidepressants and non-pharmacological antidepressive therapies, such as electroconvulsive therapy, deep brain stimulation and physical activity, 3) the influence of cytokines on the cytochrome (CYP) p450-system and drug efflux transporters, and 4) how cascades of inflammation might serve as antidepressant drug targets. A number of clinical trials have focused on agents with immunmodulatory properties in the treatment of depression, of which this review covers nonsteroidal anti-inflammatory drugs (NSAIDs), cytokine inhibitors, ketamine, polyunsaturated fatty acids, statins and curcumin. A perspective is also provided on possible future immune targets for antidepressant therapy, such as toll-like receptor-inhibitors, glycogen synthase kinase-3 inhibitors, oleanolic acid analogs and minocycline. Concluding from the available data, markers of inflammation may become relevant factors for more personalised planning and prediction of response of antidepressant treatment strategies. Agents with anti-inflammatory properties have the potential to serve as clinically relevant antidepressants. Further studies are required to better define and identify subgroups of patients responsive to inflammatory agents as well as to define optimal time points for treatment onset and duration.

The Current Status of the Ketogenic Diet in Psychiatry

BACKGROUND

The ketogenic diet (KD) has been used in treatment-resistant epilepsy since the 1920s. It has been researched in a variety of neurological conditions in both animal models and human trials. The aim of this review is to clarify the potential role of KD in psychiatry.

METHODS

Narrative review of electronic databases PubMED, PsychINFO, and Scopus.

RESULTS

The search yielded 15 studies that related the use of KD in mental disorders including anxiety, depression, bipolar disorder, schizophrenia, autism spectrum disorder (ASD), and attention deficit hyperactivity disorder (ADHD). These studies comprised nine animal models, four case studies, and two open-label studies in humans. In anxiety, exogenous ketone supplementation reduced anxiety-related behaviors in a rat model. In depression, KD significantly reduced depression-like behaviors in rat and mice models in two controlled studies. In bipolar disorder, one case study reported a reduction in symptomatology, while a second case study reported no improvement. In schizophrenia, an open-label study in female patients (n = 10) reported reduced symptoms after 2 weeks of KD, a single case study reported no improvement. In a brief report, 3 weeks of KD in a mouse model normalized pathological behaviors. In ASD, an open-label study in children (n = 30) reported no significant improvement; one case study reported a pronounced and sustained response to KD. In ASD, in four controlled animal studies, KD significantly reduced ASD-related behaviors in mice and rats. In ADHD, in one controlled trial of KD in dogs with comorbid epilepsy, both conditions significantly improved.

CONCLUSION

Despite its long history in neurology, the role of KD in mental disorders is unclear. Half of the published studies are based on animal models of mental disorders with limited generalizability to the analog conditions in humans. The review lists some major limitations including the lack of measuring ketone levels in four studies and the issue of compliance to the rigid diet in humans. Currently, there is insufficient evidence for the use of KD in mental disorders, and it is not a recommended treatment option. Future research should include long-term, prospective, randomized, placebo-controlled crossover dietary trials to examine the effect of KD in various mental disorders.

Systematic Review of Cognitive Function in Euthymic Bipolar Disorder and Pre-Surgical Temporal Lobe Epilepsy

BACKGROUND

Bipolar disorder (BD) and temporal lobe epilepsy (TLE) overlap in domains including epidemiology, treatment response, shared neurotransmitter involvement and temporal lobe pathology. Comparison of cognitive function in both disorders may indicate temporal lobe mediated processes relevant to BD. This systematic review examines neuropsychological test profiles in euthymic bipolar disorder type I (BD-I) and pre-surgical TLE and compares experimental designs used.

METHODS

A search of PubMed, PsychINFO, and Scopus using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Inclusion criteria were comparison group or pre- to post-surgical patients; reported neuropsychological tests; participants aged 18-60 years. Fifty six studies met criteria: 27 BD-I; 29 TLE.

RESULTS

Deficits in BD-I compared to healthy controls (HC) were in executive function, attention span and verbal memory. Deficits in TLE compared to HC were in executive function and memory. In the pre- to post-surgical comparisons, verbal memory in left temporal lobe (LTL) and, less consistently, visuospatial memory in right temporal lobe (RTL) epilepsy declined following surgery. BD-I studies used comprehensive test batteries in well-defined euthymic patients compared to matched HC groups. TLE studies used convenience samples pre- to post-surgery, comparing LTL and RTL subgroups, few included comparisons to HC (5 studies). TLE studies typically examined a narrow range of known temporal lobe-mediated neuropsychological functions, particularly verbal and visuospatial memory.

CONCLUSION

Both disorders exhibit deficits in executive function and verbal memory suggestive of both frontal and temporal lobe involvement. However, deficits in TLE are measured pre- to post-surgery and not controlled at baseline pre-surgery. Further research involving a head-to-head comparison of the two disorders on a broad range of neuropsychological tests is needed to clarify the nature and extent of cognitive deficits and potential overlaps.

Impact of Serum Cytokine Levels on EEG-Measured Arousal Regulation in Patients with Major Depressive Disorder and Healthy Controls

BACKGROUND

In major depressive disorder (MDD), findings include hyperstable regulation of brain arousal measured by electroencephalography (EEG) vigilance analysis and alterations in serum levels of cytokines. It is also known that cytokines affect sleep-wake regulation. This study investigated the relationship between cytokines and EEG vigilance in participants with MDD and nondepressed controls, and the influence of cytokines on differences in vigilance between the two groups.

METHODS

In 60 patients with MDD and 129 controls, 15-min resting-state EEG recordings were performed and vigilance was automatically assessed with the VIGALL 2.0 (Vigilance Algorithm Leipzig). Serum levels of the wakefulness-promoting cytokines interleukin (IL)-4, IL-10, IL-13 and somnogenic cytokines tumor necrosis factor-α, interferon-x03B3; and IL-2 were measured prior to the EEG.

RESULTS

Summed wakefulness-promoting cytokines, but not somnogenic cytokines, were significantly associated with the time course of EEG vigilance in the MDD group only. In both groups, IL-13 was significantly associated with the course of EEG vigilance. In MDD compared to controls, a hyperstable EEG vigilance regulation was found, significant for group and group × time course interaction. After controlling for wakefulness-promoting cytokines, differences in vigilance regulation between groups remained significant.

CONCLUSIONS

The present study demonstrated a relationship between wakefulness-promoting cytokines and objectively measured EEG vigilance as an indicator for brain arousal. Altered brain arousal regulation in MDD gives support for future evaluation of vigilance measures as a biomarker in MDD. Since interactions between cytokines and EEG vigilance only moderately differed between the groups and cytokine levels could not explain the group differences in EEG vigilance regulation, cytokines and brain arousal regulation are likely to be associated with MDD in independent ways.

Serum concentrations of TNF-α and its soluble receptors during psychotherapy in German soldiers suffering from combat-related PTSD

BACKGROUND

Changes in serum concentrations of tumor necrosis factor-α (TNF-α) and its soluble receptors (sTNF-R) p55 and p75 have been shown to be associated with various psychiatric treatments.

SUBJECTS AND METHODS

Before and after treatment, serum levels of TNF-α, sTNF-R p55 and sTNF-R p75 were measured in 38 German soldiers who had been deployed abroad and suffered from combat-related post-traumatic stress disorder (PTSD). Patients were randomized either to inpatient psychotherapy (N=21) including eye movement desensitization and reprocessing (EMDR) or to outpatient clinical management (N=17). Symptoms of PTSD were measured using the Post-traumatic Stress Diagnostic Scale (PDS).

RESULTS

The PDS score significantly decreased across time in both groups. Serum concentrations of TNF-α increased, while sTNF-R p55 and sTNF-R p75 levels decreased significantly. After the treatment period, we could not detect any significant difference regarding TNF-α, sTNF-R p55 or sTNF-R p75 levels between the inpatient psychotherapy group and the outpatient clinical management control group.

CONCLUSIONS

This relatively small clinical study suggests that specific inpatient psychotherapy but also non-specific supportive outpatient treatment for PTSD are associated with changes in the TNF-α system. This may represent an immunological effects or side effects of psychotherapy.

Pro- and anti-inflammatory cytokines, but not CRP, are inversely correlated with severity and symptoms of major depression

To clarify findings of elevated cytokine levels in major depression (MD), this study aimed to investigate the relationship between serum levels of cytokines, symptoms of MD and antidepressant treatment outcome. At baseline (T0) and 4 weeks following initiation of antidepressant treatment (T1), levels of tumor necrosis factor (TNF)-α, interferon (IFN)-γ, interleukin (IL)-2, IL-4, IL-5, IL-10, IL-12, IL-13, granulocyte-macrophage-colony-stimulating-factor (GM-CSF), CRP and depression ratings HAMD-17 and BDI-II were assessed in 30 patients with MD and 30 age-and sex-matched controls. At T0, in the patient group, cytokines, but not CRP, negatively correlated with individual BDI-II-items, factors and severities and showed both negative and positive correlations with HAMD-17 items. At T1 and within the controls, no such relationships were observed. At T0 and T1, levels of both pro- and anti-inflammatory cytokines were significantly higher in treatment responders (ΔHAMD-17T0-T1≥50%,n=15) compared to non-responders. When controlled for baseline BDI, differences between groups were only found significant for IL-2 at T0. The results suggest cytokines are not generally pro-depressive but rather relate to more specific regulation of symptoms and severities in MD. Together with the association between cytokines and treatment responder status, these data support cytokines as a promising but still controversial biomarker of depression.

The Historical Development of Immunoendocrine Concepts of Psychiatric Disorders and Their Therapy

Relationships between the central nervous, immune and endocrine systems are a focus of psychiatric research, particularly in depression and schizophrenia. The field has long antecedents. Observed phenomena attributable to these relationships date back to the Neolithic era. Immunoendocrine theories in the broadest sense are recorded in antiquity. In the 19th century, Kraepelin and Wagner-Jauregg reported pioneering clinical observations in psychiatric patients. Von Basedow, Addison and Cushing described psychiatric symptoms in patients suffering from endocrine diseases. The 20th century opened with the identification of hormones, the first, adrenaline, chemically isolated independently by Aldrich und Takamine in 1901. Berson and Yalow developed the radioimmunoassay (RIA) technique in 1959 making it possible to measure levels of hormones and cytokines. These developments have enabled great strides in psychoimmunoendocrinology. Contemporary research is investigating diagnostic and therapeutic applications of these concepts, for example by identifying biomarkers within the endocrine and immune systems and by synthesizing and testing drugs that modulate these systems and show antidepressant or antipsychotic properties.

Weight Gain and Metabolic Changes During Treatment with Antipsychotics and Antidepressants

Weight gain and metabolic disturbances are common side effects during psychopharmacological treatment with specific antipsychotics and antidepressants. The antipsychotics clozapine and olanzapine, and antidepressants tricyclics and mirtazapine have a high risk of inducing weight gain. Recently discovered pathophysiological mechanisms include antihistaminergic effects, activation of hypothalamic adenosine monophosphate-activated protein kinase (AMPK), modulation of hormonal signaling of ghrelin and leptin, changes in the production of cytokines such as tumor necrosis factor-alpha (TNF)-alpha and adipokines such as adiponektin, and the impact of genes, in particular the melanocortin 4 receptor (MC4R), serotonin 2C receptor (HTR2C), leptin, neuropeptide Y (NPY) and cannabinoid receptor 1 (CNR1) genes. Metabolic changes associated with weight gain include disturbances of glucose and lipid metabolism. Clozapine and olanzapine may, in addition to mechanisms resulting from weight gain, impair glucose metabolism by blockade of the muscarinic M3 receptor (M3R). Antidepressants associated with weight gain appear to have fewer unfavourable effects on glucose and lipid metabolism than the second-generation antipsychotics clozapine and olanzapine. To assess the risk of weight gain and its consequences for the patient's health, assessing body weight changes and metabolic monitoring in the first week of treatment as well as in long-term treatment is recommended.

Symbolic online exposure for spider fear: habituation of fear, disgust and physiological arousal and predictors of symptom improvement

BACKGROUND AND OBJECTIVES

This research compared the effects of real versus hyper-real images on anxiety, disgust, and physiological arousal during internet-delivered exposure in high spider-fearfuls. Hyper-real images were digitally altered to highlight fearful aspects. A further aim was to examine self-reported and behavioural therapeutic outcomes and exposure-related predictors of these outcomes.

METHODS

Twenty-eight females were randomised to real (n = 14) or hyper-real (n = 14) treatment groups and nine participants were subsequently allocated to a wait-list control group. Treatment groups viewed an 8-stage exposure hierarchy of real or hyper-real spider images. Subjective anxiety and disgust ratings were taken during each stage (0, 60, 120, 180 s) with heart rate and skin conductance recorded throughout.

RESULTS

Anxiety, disgust and physiological arousal habituated within each exposure stage, with no differential effect of real compared to hyper-real images. Both treatment groups but not controls demonstrated significant reductions in behavioural avoidance and self-reported phobic symptoms from pre-treatment to post-treatment with large effect sizes noted. The change in within-stage habituation of anxiety, disgust and heart rate, between the first and last stage, predicted improvement in behavioural avoidance at post-treatment. This suggests that generalisation of habituation to multiple images is an important predictor of improvement.

LIMITATIONS

While findings in relation to therapeutic outcome should be considered preliminary, clear relationships were found between exposure-related variables and outcome among those who undertook treatment.

CONCLUSIONS

Findings provide evidence in support of the efficacy of online image-based exposure and have implications for informing further research into the underlying mechanisms of image-based exposure treatment.

Impact of antidepressants on cytokine production of depressed patients in vitro

The interplay between immune and nervous systems plays a pivotal role in the pathophysiology of depression. In depressive episodes, patients show increased production of pro-inflammatory cytokines such as interleukin (IL)-1β and tumor necrosis factor (TNF)-α. There is limited information on the effect of antidepressant drugs on cytokines, most studies report on a limited sample of cytokines and none have reported effects on IL-22. We systematically investigated the effect of three antidepressant drugs, citalopram, escitalopram and mirtazapine, on secretion of cytokines IL-1β, IL-2, IL-4, IL-6, IL-17, IL-22 and TNF-α in a whole blood assay in vitro, using murine anti-human CD3 monoclonal antibody OKT3, and 5C3 monoclonal antibody against CD40, to stimulate T and B cells respectively. Citalopram increased production of IL-1β, IL-6, TNF-α and IL-22. Mirtazapine increased IL-1β, TNF-α and IL-22. Escitalopram decreased IL-17 levels. The influence of antidepressants on IL-2 and IL-4 levels was not significant for all three drugs. Compared to escitalopram, citalopram led to higher levels of IL-1β, IL-6, IL-17 and IL-22; and mirtazapine to higher levels of IL-1β, IL-17, IL-22 and TNF-α. Mirtazapine and citalopram increased IL-22 production. The differing profile of cytokine production may relate to differences in therapeutic effects, risk of relapse and side effects.

Cytokines as biomarkers in depressive disorder: current standing and prospects

The frequently observed co-occurrence of depressive disorders and inflammatory diseases suggests a close connection between the nervous and the immune systems. Increased pro-inflammatory and type 1 cytokines, such as interleukin (IL)-1, tumour necrosis factor (TNF)-α and interferon (IFN)-γ, appear to be an important link. Cytokines are synthesized by immune cells in the blood and peripheral tissues and by glial cells in the central nervous system (CNS). Evidence suggests that the blood-brain barrier (BBB) is permeable to cytokines and immune cells, and that afferent nerves, e.g. the vagus nerve, mediate the communication between peripheral inflammatory processes and CNS. Cytokines such as IL-1ß, TNF-α and IFN-γ seem to contribute to the pathophysiology of depression by activating monoamine reuptake, stimulating the hypothalamic-pituitary-adrenocortical (HPA) axis and decreasing production of serotonin due to increased activity of indolamine-2,3-dioxygenase (IDO). However, critical appraisal of these hypotheses is required, because cytokine elevation is not specific to depression. Moreover, several effective antidepressants such as amitriptyline and mirtazapine have been shown to increase cytokine production. When applying immunomodulatory therapies, these drugs may increase the risk of specific side effects such as infections or interact with antidepressant drugs on important functions of the body such as the coagulation system.

Stress-induced cytokine changes in rats

Stress-induced cytokine changes may be the link between stress and the pathogenesis of psychiatric disorders such as depression, and organic diseases such as infections, autoimmune diseases and cancer. We tested the effect of stress on interleukin (IL)-2, IL-4, IL-6, IL-10, IL-22, tumour necrosis factor (TNF)-α and interferon (IFN)-γ serum levels in male Wistar rats. Rats underwent either acute stress by forced swimming (N = 8), chronic restraint stress (N = 8), or were not subjected to any stress (N = 8). IL-2 serum levels were significantly higher in forced swimming, but not in restraint stress rats, compared to non-stressed rats. IL-4, IL-6, IL-10 and TNF-α levels were higher in both forced swimming and restraint stress compared to non-stressed rats. IFN-γ production was significantly decreased by restraint stress, but not by forced swimming. IL-22 was not affected significantly by either stress condition. Alterations in the pro-inflammatory cytokines IL-6 and TNF-α may indicate a pathophysiological pathway from acute and chronic stress to the development of depression. Changes in IL-4 and IL-10 may link acute and chronic stress to autoimmune disorders, allergies or cancer. The reported changes in IFN-γ could provide an explanation for the higher susceptibility to infection seen in life periods associated with sustained levels of stress.

Event-related potentials indicating impaired emotional attention in cerebellar stroke--a case study

The cerebellum has been implicated in affective and attentional processes, but little is known about corresponding neural signatures. We investigated early and late components of event-related potentials (ERPs) to emotionally arousing pictures, with and without competing attentional tasks, in a patient with an ischemic right posterior cerebellar infarction, at two months post infarct and two year follow-up. The early posterior negativity (EPN) response to highly arousing emotional cues in the competing visual attention condition revealed that the augmentation over occipital areas, as typically seen in normals, was absent post-infarct but was restored after two years. The late positive potentials (LPP) response to highly arousing emotional cues showed augmentation over frontal areas post-infarct, and over centro-parietal regions after two years. These ERP findings suggest a specific pattern of disruption of neural function associated with emotional-behavioral disturbances following cerebellar lesions, which can revert to normal with long term recovery.

Australia's mental health legislation

Australia has a generally progressive approach to mental health law, reflective of international trends in human rights. Responsibility for most legislation is vested in the six States and two Territories, a total of eight jurisdictions, such that at any given time several new mental health acts are in preparation. In addition there is a model mental health act that promotes common standards. Transfer of orders between jurisdictions relies on Memoranda of Understanding between them, and is patchy. State and Territory legislation is generally cognisant of international treaty obligations, which are themselves the preserve of the Federal Parliament and legislature. UK legislation has had a key influence in Australia, the 1959 Mental Health Act in particular, with its strong emphasis on voluntary hospitalisation, prefacing deinstitutionalisation.

Australia's mental health legislation

Australia has a generally progressive approach to mental health law, reflective of international trends in human rights. Responsibility for most legislation is vested in the six States and two Territories, a total of eight jurisdictions, such that at any given time several new mental health acts are in preparation. In addition there is a model mental health act that promotes common standards. Transfer of orders between jurisdictions relies on Memoranda of Understanding between them, and is patchy. State and Territory legislation is generally cognisant of international treaty obligations, which are themselves the preserve of the Federal Parliament and legislature. UK legislation has had a key influence in Australia, the 1959 Mental Health Act in particular, with its strong emphasis on voluntary hospitalisation, prefacing deinstitutionalisation.

[Schizophrenic disorders. The development of immunological concepts and therapy in psychiatry]

Immunological changes reported in patients with schizophrenia may play an aetiological role in these disorders. Further, immunomodulatory medications can influence the symptoms of psychiatric disorders. Antipsychotic agents such as clozapine may act therapeutically through the modulation of the immune system and also lead to side effects in that domain.Both the understanding and factual foundations of immunological concepts and immunological therapies of schizophrenic disorders have changed throughout the history of medicine. These are important considerations in psychiatry where diagnostic, nosological and therapeutic complexity is the norm. The article exemplarily presents publications of the psychiatrists such as Julius Wagner von Jauregg, Lewis Campbell Bruce and Friedrich Ostmann as well as neuropathologist Hermann Lehmann-Facius and haematologist William Dameshek.

Three Versus Six Sessions of Computer-aided Vicarious Exposure Treatment for Spider Phobia

Thirty participants diagnosed with specific phobia (spiders) were randomly allocated to receive a treatment dose of either three or six 45-minute sessions of a computer-aided vicarious exposure (CAVE) for spider phobia. Phobic symptom severity was measured at pretreatment, posttreatment and at one-month follow-up on a range of subjective and behavioural measures. Results showed that participants in both groups improved significantly across the majority of outcome measures from pre- to posttreatment and pretreatment to follow-up assessment. There were no significant differences between the three- and six-session groups. Process measures indicated that the six-session treatment group performed approximately twice as much vicarious exposure, however, competence on the program was reached by the end of three sessions. These results suggest that rehearsal of CAVE, beyond the level at which skill learning is consolidated, is not of therapeutic value. Further research is required to ascertain whether other forms of dosage effect may operate in computer-delivered behaviour therapy. For example, delivery of a wider range, rather than amount, of CAVE scenarios, or the delivery of a hierarchy of exposure stimuli on the screen, without a vicarious component, may show a dose-response relationship.

Computer-Delivered Behavioural Avoidance Tests for Spider Phobia

Behavioural avoidance tests (BATs) are a cornerstone of objective assessment of phobias. However, live BATs have several disadvantages. They are practically difficult and time-consuming to set up and are not standardised. This study examined two computer-delivered BATs (using slide and video presentations of phobic stimuli respectively): first, in respect to their ability to discriminate fearfuls from nonfearfuls, and second, in terms of convergent validity with a live BAT and the Spider Phobia Questionnaire (SPQ). Sixty-four low (n = 32) and high (n = 32) spider-fearful undergraduate participants were administered the three BATs in counterbalanced order. Results showed that subjective anxiety on all BATs was highly discriminative of low and high spider-fearfuls. The number of steps completed did not discriminate between phobics and nonphobics on the computer BATs. However, there was good convergent validity between the live BAT, the SPQ and both computer-delivered BATs on subjective anxiety. Overall, the live BAT gives a clearer indication of avoidance behaviour while the video BAT assesses subjective anxiety across a wider range of steps. The development of computer-delivered BATs that reliably measure avoidance is necessary before contemplating them as an alternative to a live BAT.

Controlled Comparison of Single-session Treatments for Spider Phobia: Live Graded Exposure Alone versus Computer-aided Vicarious Exposure

The efficacy of prolonged single sessions of live graded exposure (LGE) and computer-aided vicarious exposure (CAVE) for spider phobia was examined in a single-blind, controlled trial. Forty participants diagnosed with specific phobia (spiders) received a prolonged single-session treatment of either therapist-aided LGE comprising exposure only or CAVE, or were assigned to a waiting list. Phobic symptomatology was measured at pre- and post-treatment, and at 1-month follow-up on a range of behavioural and subjective assessments. The results showed that the single-session therapist-aided LGE was superior to both CAVE and the waiting-list control. In contrast with previous findings of comparability between LGE and CAVE, and superiority of CAVE over placebo, the present study found no significant differences between the CAVE and waiting-list groups, with the exception of subjective units of distress, providing little support for single-session CAVE treatment.

Danger Expectancies, Self-efficacy and Subjective Anxiety as Mediators of Avoidance Behaviour in Spider Phobia

Forty-five participants diagnosed with specific phobia (spiders) gave ratings of subjective anxiety, self-efficacy and the probability of being bitten or injured by a spider while completing a behavioural avoidance test involving exposure to a live spider. Testing was performed before and after treatment and at a 3-month follow-up. Results indicated that subjective anxiety was a more useful predictor of avoidance behaviour than self-efficacy. Danger expectancies in relation to being bitten and/or injured by a spider were not found to be a significant cognitive symptom in the majority of spider phobia sufferers during the behavioural avoidance test with a live spider. Methodological factors that may account for the low reporting of danger-related cognitions in the present study are discussed.

Internet delivered images for exposure in specific phobia, design considerations for self-directed therapy

Exposure to phobic stimuli in subjects with specific phobia typically results in increased anxiety, ranging from mild to severe, followed by gradual habituation. The Internet is a candidate medium for the delivery of phobic stimuli to phobic subjects, such as pictures, video clips or computer animations. Delivery of such images in home settings warrants careful attention to the range and time course of anxiety responses elicited, and to tailoring of progression through hierarchies of images. The agency of the user is paramount, they need to have the final say at all stages of exposure as to whether to proceed or not. We have incorporated solutions to these requirements in the design of an internet-based exposure program (FEARDROP). This employs a database repository of pictures and videos of phobic stimuli. Images are called up by the user engaging a tracking circle with their mouse and following it around the screen. The image fades out if the circle is not followed, a form of 'dead man's brake'. Anxiety responses are measured at intervals on a visual analogue scale and graphed for the user. Initial results show substantial habituation to spider pictures within minutes, with a controlled comparison to video images in progress.

A genome screen of 35 bipolar affective disorder pedigrees provides significant evidence for a susceptibility locus on chromosome 15q25-26

Bipolar affective disorder is a heritable, relatively common, severe mood disorder with lifetime prevalence up to 4%. We report the results of a genome-wide linkage analysis conducted on a cohort of 35 Australian bipolar disorder families which identified evidence of significant linkage on chromosome 15q25-26 and suggestive evidence of linkage on chromosomes 4q, 6q and 13q. Subsequent fine-mapping of the chromosome 15q markers, using allele frequencies calculated from our cohort, gave significant results with a maximum two-point LOD score of 3.38 and multipoint LOD score of 4.58 for marker D15S130. Haplotype analysis based on pedigree-specific, identical-by-descent allele sharing, supported the location of a bipolar susceptibility gene within the Z(max-1) linkage confidence interval of 17 cM, or 6.2 Mb, between markers D15S979 and D15S816. Non-parametric and affecteds-only linkage analysis further verified the linkage signal in this region. A maximum NPL score of 3.38 (P=0.0008) obtained at 107.16 cM (near D15S130), and a maximum two-point LOD score of 2.97 obtained at marker D15S1004 (affecteds only), support the original genome-wide findings on chromosome 15q. These results are consistent with four independent positive linkage studies of mood and psychotic disorders, and raise the possibility that a common gene for susceptibility to bipolar disorder, and other psychiatric disorders may lie in this chromosome 15q25-26 region.

Psychiatric networks in Asia

With over 60% of the world's population, the two most widely spoken global languages, rapid economic growth and high uptake of information communications technology, the Asian region is poised to make a major contribution to psychiatric networks. These networks comprise a matrix of professional associations, regional development frameworks, clinical services, consumer and carer organizations, research collaborations and population interventions. Notable developments include the rise of supranational associations centred on or active in the Asian region, regional and international conference activity, information exchanges between services, research funding networks, and disease awareness campaigns with a strong Internet base. Such activities form a supportive and collaborative milieu for professionals, administrators, and members of the community, who are seeking practical ways to raise the standards of mental healthcare in diverse health settings, economic conditions and cultures.

FMR1 alleles in Tasmania: a screening study of the special educational needs population

The distribution of fragile X mental retardation-1 (FMR1) allele categories, classified by the number of CGG repeats, in the population of Tasmania was investigated in 1253 males with special educational needs (SEN). The frequencies of these FMR1 categories were compared with those seen in controls as represented by 578 consecutive male births. The initial screening was based on polymerase chain reaction analysis of dried blood spots. Inconclusive results were verified by Southern analysis of a venous blood sample. The frequencies of common FMR1 alleles in both samples, and of grey zone alleles in the controls, were similar to those in other Caucasian populations. Consistent with earlier reports, we found some (although insignificant) increase of grey zone alleles in SEN subjects compared with controls. The frequencies of predisposing flanking haplotypes among grey zone males FMR1 alleles were similar to those seen in other Caucasian SEN samples. Contrary to expectation, given the normal frequency of grey zone alleles, no premutation (PM) or full mutation (FM) allele was detected in either sample, with only 15 fragile X families diagnosed through routine clinical admissions registered in Tasmania up to 2002. An explanation of this discrepancy could be that the C19th founders of Tasmania carried few PM or FM alleles. The eight to ten generations since white settlement of Tasmania has been insufficient time for susceptible grey zone alleles to evolve into the larger expansions.

Social context and health consequences of the antipsychotics introduction

BACKGROUND

From the vantage point of fifty years after the introduction of antipsychotics to clinical practice, this article examines the social context and health consequences of their introduction.

METHODS

Historical review of literature sources with commentary.

CONCLUSIONS

The availability of antipsychotics over nearly half a century has powerfully influenced concepts of mental illness, dominant models of care versus control, health outcomes and side effect burdens. The large demand and economic success of antipsychotic medications is an important driver for research and development as well as sophistication in marketing. Regulatory agencies, funders and clinicians are faced with a moving target as indications for use of antipsychotics move well beyond the traditional core of schizophrenia and acute mania into depression, anxiety, behavioral disturbance with dementia and some forms of personality disturbance. The history of antipsychotics and mental illness is arguably being written as forcefully now, in an environment of rapid scientific change, as was the case in the 1960s era of rapid social change when chlorpromazine prompted a shift of emphasis from asylum to community. Psychosis is a challenge to how we interpret and approach our inner experiences and societal structures. Accordingly, it is not surprising that the history of antipsychotic drugs resonates with a lively interplay of social, health and economic issues and an ongoing quest to comprehend mental phenomena and their variants.

Heterogeneity of admission history among patients with bipolar disorder

BACKGROUND

Patients on a first admission for bipolar disorder often have a history of other psychiatric diagnoses for previous admissions.

AIMS

The current study examines the time course and diagnoses of psychiatric admissions prior and subsequent to a first hospitalisation for a diagnosis of bipolar disorder.

METHOD

The prior admission histories (over the period 1965-1989) of 1167 patients who had been hospitalised in state mental health facilities with their first admission with diagnosis of bipolar disorder between 1983 and 1989 were examined.

RESULTS

A total of 542 (46.4%) patients had at least one previous hospitalisation with a psychiatric diagnosis other than bipolar disorder. Two prominent groups emerged; one group which had primarily a history of prior admissions with diagnoses of depression over 1-3 years, and a second which mainly had previous admissions for schizophrenia, over a period longer than for those with a primarily depressive history. The group with a history of schizophrenia was significantly younger and had a greater number of admissions prior to the first bipolar disorder diagnosis than the depression group.

LIMITATIONS

This was a record-based study which did not examine cases which were not hospitalised.

CONCLUSIONS

There appeared to be three distinct patterns of prior presentations in those patients admitted with a diagnosis of bipolar disorder.

Attitudes toward psychiatry among students entering medical school

OBJECTIVE

To survey the attitudes of Australian medical students to determine their views about the relative attractiveness of psychiatry as a career compared with other specialties, and against findings from a North American study.

METHOD

We surveyed 655 first-year medical students attending six Australian Universities.

RESULTS

Responses indicated that Australian medical students view psychiatry as distinctly less 'attractive' than other career options, as reported in the North American sample. In comparison with other disciplines, psychiatry was regarded as more interesting and intellectually challenging, but also as lacking a scientific foundation, not being enjoyable and failing to draw on training experiences.

CONCLUSION

Our findings suggest that psychiatry has an image problem that is widespread, reflecting community perceptions and the specialist interests of medical students on recruitment. If psychiatry is to improve its 'attractiveness' as a career option, identified image problems need to be corrected and medical student selection processes re-considered.

Genetic refinement and physical mapping of a 2.3 Mb probable disease region associated with a bipolar affective disorder susceptibility locus on chromosome 4q35

A susceptibility locus for bipolar affective disorder has been mapped to chromosome 4q35 in a large multigenerational pedigree. We have expanded this analysis to include 55 pedigrees (674 individuals, 214 affecteds). The evidence for linkage to 4q35 was strengthened in this larger cohort, with a maximum two-point LOD score of 3.2 for marker D4S1652. Several other markers in the region gave LOD scores greater than 1.5. Non-parametric analysis provided additional support for linkage to the 4q35 region. To further refine this region, haplotype analysis was carried out in 16 of the 55 pedigrees that showed evidence of linkage. As there is no evidence for an ancestral haplotype, nor a one-to-one correspondence between the disease and putative disease haplotype, we undertook an analysis based on pedigree-specific, identical-by-descent allele-sharing in order to define a probable disease region. This analysis indicated that the percentage sharing of alleles, identical-by-descent, in affecteds of all linked pedigrees increases from 60% at the centromeric markers to 75% for markers at the telomere. Maximal allele sharing occurred between markers D4S3051 and 4qTEL13 with this 24 cM region defining a probable disease region. We have constructed a physical map of the 4q35 interval consisting of a YAC contig and BAC clones. Based on this map the probable disease region between D4S3051 and 4qTEL13 corresponds to only 2.3 Mb. This region is very gene poor with only three known genes indicated from the YAC/BAC map. The small number of genes will facilitate systematic screening for variations associated with bipolar disorder.

The effects of single-dose lorazepam on memory and behavioural learning

To assess the influence of lorazepam on memory and behavioural learning, a non-clinical sample of undergraduate psychology students (n = 24), received lorazepam (2.5 mg) or placebo orally. Pre-drug and post-drug neuropsychological assessment comprised the Rey auditory verbal learning test, verbal fluency test, digit span and word stem completion. Relative to placebo, lorazepam induced a marked deficit in delayed free-recall, perceptual priming, and written word fluency, with preservation of digit span. Behavioural learning was assessed on a computer-aided vicarious exposure treatment for obsessive-compulsive disorder, administered post-drug, and repeated 1 week later, drug free. Compared to placebo, lorazepam treated participants enacted 51% less exposure activity on the behavioural learning task post-drug. Whilst both groups enacted increased exposure at the drug-free session, exposure activity was 49% less in the lorazepam group, indicating a carryover effect of the impaired learning under drug 1 week before. There were no significant differences between lorazepam and placebo on indices of overall activity on the program. These results suggest lorazepam-induced impairment in the ability to learn behavioural strategies, possibly due to impaired acquisition of information into long-term episodic memory. These findings suggest caution in the co-prescribing of benzodiazepines in people undergoing behavioural therapies in clinical populations.

Effects of lorazepam and oxazepam on perceptual and procedural memory functions

RATIONALE

Lorazepam has been found to consistently impair performance on both episodic and perceptual priming tasks, whereas other benzodiazepines have shown perceptual priming to be preserved. However, it has recently been postulated that benzodiazepines may exert time-dependent effects on implicit memory processes after research findings indicated some benzodiazepines, other than lorazepam, impair performance on priming tasks when tested at the time of peak plasma concentration level after benzodiazepine administration.

OBJECTIVES

To compare time-dependent effects of lorazepam and oxazepam on implicit memory tasks, specifically perceptual priming and procedural learning.

METHODS

Thirty-three healthy female undergraduates were randomised to one of three time groups (pre-peak, peak, post-peak) and administered placebo, 2.5 mg lorazepam, and 30 mg oxazepam, in counterbalanced order, at 1-week intervals. Assessments included word-stem completion (perceptual priming) and rotary pursuit (procedural learning) tasks.

RESULTS

At all time intervals, lorazepam but not oxazepam significantly impaired perceptual priming but procedural learning was preserved under both drugs.

CONCLUSIONS

These findings are consistent with previous research showing a differential effect of lorazepam in impairing perceptual memory but the notion that benzodiazepines exert time-dependent effects on implicit memory processes was not supported.

Shrinking away from psychiatry? A survey of Australian medical students' interest in psychiatry

OBJECTIVE

We sought to examine the attitudes of newly recruited medical students towards psychiatry and other specialties to determine what factors influence their career choice options.

METHOD

We surveyed the attitudes of 655 medical students using a 31-item self-report questionnaire.

RESULTS

Australian medical students rated the ability to help patients as the most important aspect of a specialty in determining their choice. Attraction to psychiatry was based on the specialty being interesting and intellectually challenging,and providing a career that promised job satisfaction with good prospects and enjoyable work. Females expressed a greater interest in psychiatry and were more likely to consider pursuing it as a career, principally due to a greater interest in the subject matter and a stronger desire for interaction with patients. The least attractive aspects of psychiatry were its lack of prestige among the medical community and a perceived absence of a scientific foundation.

CONCLUSION

The attitudes of medical students can perhaps be modified and recruitment into psychiatry enhanced by presenting the reality of psychiatry today - namely the wide range of available therapeutic processes, the predominantly positive outcomes, the interesting and intellectually challenging nature of the subject and its nurturing and accommodating work environment.

Computer-aided vicarious exposure versus live graded exposure for spider phobia in children

The efficacy of computer-aided vicarious exposure (CAVE) for the treatment of spider phobia in children was evaluated in a single blind, randomised, controlled trial. Twenty-eight participants, aged 10-17 years, received three 45-min sessions of either Live graded exposure (LGE), CAVE or were assigned to a Waitlist. Phobic symptomatology was measured at pre- and post-treatment, and at one month follow-up on a range of behavioural and subjective assessments. The results showed the superiority of the LGE treatment over the CAVE and Waitlist conditions. Effect sizes support CAVE treatment as being superior to the Waitlist and resulting in reductions of phobic symptomatology.

Seasonal variation in hospital admission for bipolar disorder, depression and schizophrenia in Tasmania

OBJECTIVE

Seasonal variation has been reported for both affective disorders and schizophrenia. The current study examines seasonal variation in admissions in schizophrenia, depression and bipolar disorder in Tasmania, the southernmost state of Australia.

METHOD

All admissions with a diagnosis of schizophrenia, bipolar disorder and depression in Tasmania between 1983 and 1989 were examined for evidence of seasonal variation in admission patterns.

RESULTS

Using the modified Kolmogorov-Smirnov statistic defined by Freedman no significant seasonal variation was found in admissions with diagnoses of mania, depression or schizophrenia. There was a significant seasonal variation in admissions with schizoaffective disorder (winter peak).

CONCLUSION

There is no significant seasonal variation in admissions with schizophrenia, depression or bipolar disorder in Tasmania. This may be due to a combination of geographical location and the stringent test of seasonal variation used in the current study.