The need for a unified framework: How Tulving's framework of memory systems, memory processes, and the SPI-model can guide and sharpen the understanding of déjà vu and involuntary autobiographical memories and add to conceptual clarity.

Barzykowski and Moulin link déjà vu and involuntary autobiographical memories to the process of retrieval. They make no reference to Tulving's SPI-model. In this, it is proposed that information is acquired serially (S), stored in parallel (P), and retrieved independently (I). This model offers an alternative, elegant, view of involuntary autobiographical memory retrieval, as well as of déjà vus.

A prospective international multi-center study on safety and efficacy of deep brain stimulation for resistant obsessive-compulsive disorder.

Deep brain stimulation (DBS) has been proposed for severe, chronic, treatment-refractory obsessive-compulsive disorder (OCD) patients. Although serious adverse events can occur, only a few studies report on the safety profile of DBS for psychiatric disorders. In a prospective, open-label, interventional multi-center study, we examined the safety and efficacy of electrical stimulation in 30 patients with DBS electrodes bilaterally implanted in the anterior limb of the internal capsule. Safety, efficacy, and functionality assessments were performed at 3, 6, and 12 months post implant. An independent Clinical Events Committee classified and coded all adverse events (AEs) according to EN ISO14155:2011. All patients experienced AEs (195 in total), with the majority of these being mild (52% of all AEs) or moderate (37%). Median time to resolution was 22 days for all AEs and the etiology with the highest AE incidence was 'programming/stimulation' (in 26 patients), followed by 'New illness, injury, condition' (13 patients) and 'pre-existing condition, worsening or exacerbation' (11 patients). Sixteen patients reported a total of 36 serious AEs (eight of them in one single patient), mainly transient anxiety and affective symptoms worsening (20 SAEs). Regarding efficacy measures, Y-BOCS reduction was 42% at 12 months and the responder rate was 60%. Improvements in GAF, CGI, and EuroQol-5D index scores were also observed. In sum, although some severe AEs occurred, most AEs were mild or moderate, transient and related to programming/stimulation and tended to resolve by adjustment of stimulation. In a severely treatment-resistant population, this open-label study supports that the potential benefits outweigh the potential risks of DBS.

Preventing COVID-19 outbreaks through surveillance testing in healthcare facilities: a modelling study.

BACKGROUND: Surveillance testing within healthcare facilities provides an opportunity to prevent severe outbreaks of coronavirus disease 2019 (COVID-19). However, the quantitative impact of different available surveillance strategies and their potential to decrease the frequency of outbreaks are not well-understood. METHODS: We establish an individual-based model representative of a mental health hospital yielding generalizable results. Attributes and features of this facility were derived from a prototypical hospital, which provides psychiatric, psychosomatic and psychotherapeutic treatment. We estimate the relative reduction of outbreak probability for three test strategies (entry test, once-weekly test and twice-weekly test) relative to a symptom-based baseline strategy. Based on our findings, we propose determinants of successful surveillance measures. RESULTS: Entry Testing reduced the outbreak probability by 26%, additionally testing once or twice weekly reduced the outbreak probability by 49% or 67% respectively. We found that fast diagnostic test results and adequate compliance of the clinic population are mandatory for conducting effective surveillance. The robustness of these results towards uncertainties is demonstrated via comprehensive sensitivity analyses. CONCLUSIONS: We conclude that active testing in mental health hospitals and similar facilities considerably reduces the number of COVID-19 outbreaks compared to symptom-based surveillance only.

[Treatment of obsessive-compulsive disorders: recommendations of the revised S3 guidelines on obsessive-compulsive disorders]. / Therapie der Zwangsstörungen: Empfehlungen der revidierten S3-Leitlinie Zwangsstörungen.

In 2022, the first revised version of the S3 guidelines on obsessive-compulsive disorder will be published under the auspices of the German Society for Psychiatry, Psychotherapy and Psychosomatics (DGPPN). This article contains a summary of the most important recommendations for therapy in a condensed form. There were no major changes in the central basic therapy recommendations compared with the first version of the guidelines, as the evidence base has not fundamentally changed since then. Cognitive behavioral therapy (CBT) with exposure and response management is the most effective form of therapy for this clinical picture and therefore the therapy of first choice. Regarding pharmacotherapy, selective serotonin reuptake inhibitors are the first-line medications. They are indicated when CBT with exposure is not available or has not been effective, when CBT is rejected by the patient and in the patient's personal preference for medication, or to increase the readiness for CBT with exposure. New recommendations include, e.g., the use of Internet therapy, and recommendations for the use of CBT and exposure, e.g., also in group format, including video conferencing if appropriate as well as in intensive format.

Joint Effects of the Epigenetic Alteration of Neurotrophins and Cytokine Signaling: A Possible Exploratory Model of Affective Symptoms in Alcohol-Dependent Patients?

AIMS: Neurotrophins have been linked to the symptomatology of alcohol dependence. We aimed to investigate a possible association between the methylation of the promoters of both neurotrophins, the serum levels of the cytokines and core symptoms of alcohol dependence as withdrawal severity and anxiety. METHODS: In this study we investigated a possible association between alterations in the methylation of the BDNF IV/NGF I gene promoter and the cytokines tumor necrosis factor α (TNF-α) and interleukin-6 (IL-6) in 55 male alcohol-dependent patients. RESULTS: Mean methylation of the promoter of the BDNF gene was significantly associated with the TNF-α serum levels and the CIWA-score during withdrawal (P < 0.001). Moreover, mean methylation of the NGF I promoter was significantly associated with the IL-6 serum levels and STAI-I score during withdrawal (P < 0.001). CONCLUSION: Our results suggest an association between the epigenetic regulation of both neurotrophins, BDNF and NGF, cytokine release and the symptomatology of alcohol dependence. They imply that changes in the methylation of neurotrophins may contribute to the symptomatology of alcohol dependence by affecting relevant downstream signaling cascades.

[Hoarding as a Disorder of the Obsessive-Compulsive Spectrum]. / Pathologisches Horten und Sammeln als Erkrankung des Zwangsspektrums.

Hoarding often occurs without obsessive-compulsive disorder (OCD), it shows distinguishable neuropsychological and neurobiological correlates and a distinct comorbidity spectrum. Further, it occurs secondarily to other psychiatric and neurobiological disorders. Therefore hoarding disorder has been included as a distinct diagnosis in DSM-5.Neuroimaging studies point to functional and structural abnormalities of networks subserving decision making, attention, action planning and emotional regulation.The cognitive-behavioral model outlines the most important characteristics of pathological hoarding, comprising deficits of information processing, maladaptive beliefs about information processing deficits, maladaptive beliefs about posessions as well as emotional attachment to them accompanied with emotional distress and avoidance.Because of a low willingness for therapy plus a high rate of discontinuation of therapy, a manualized cognitive-behavioral therapy approach for pathological hoarding has been established. It builds on observational learning, cognitive strategies, graduated exposure, response prevention, training/coaching to sort out, and relapse prevention are key components of the treatment. Particularily in case of lacking motivation for any kind of behavioral therapy or other psychological treatments, a pharmacotherapy with SSRIs is recommended.

Decreased limbic and increased fronto-parietal connectivity in unmedicated patients with obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is characterized by recurrent intrusive thoughts and ritualized, repetitive behaviors, or mental acts. Convergent experimental evidence from neuroimaging and neuropsychological studies supports an orbitofronto-striato-thalamo-cortical dysfunction in OCD. Moreover, an over excitability of the amygdala and over monitoring of thoughts and actions involving the anterior cingulate, frontal and parietal cortex has been proposed as aspects of pathophysiology in OCD. We chose a data driven, graph theoretical approach to investigate brain network organization in 17 unmedicated OCD patients and 19 controls using resting-state fMRI. OCD patients showed a decreased connectivity of the limbic network to several other brain networks: the basal ganglia network, the default mode network, and the executive/attention network. The connectivity within the limbic network was also found to be decreased in OCD patients compared to healthy controls. Furthermore, we found a stronger connectivity of brain regions within the executive/attention network in OCD patients. This effect was positively correlated with disease severity. The decreased connectivity of limbic regions (amygdala, hippocampus) may be related to several neurocognitive deficits observed in OCD patients involving implicit learning, emotion processing and expectation, and processing of reward and punishment. Limbic disconnection from fronto-parietal regions relevant for (re)-appraisal may explain why intrusive thoughts become and/or remain threatening to patients but not to healthy subjects. Hyperconnectivity within the executive/attention network might be related to OCD symptoms such as excessive monitoring of thoughts and behavior as a dysfunctional strategy to cope with threat and uncertainty.

Urbach-Wiethe disease in a young patient without apparent amygdala calcification.

Urbach-Wiethe disease is an extremely rare genetically-based syndrome which usually leads to dermatological and neurological changes. Neurologically, the amygdaloid region is primarily bilaterally affected. Therefore, several functions modulated by the amygdala are changed in patients with Urbach-Wiethe disease. As the neurological alterations evolve only gradually, it is particularly important to determine the cognitive and brain status of a juvenile. The patient described here was seen briefly at age 9 and tested neuropsychologically at age 19; furthermore, computer tomography and magnetic resonance imaging of his head was done. There were no important abnormalities in the brain, which is unusual in the light of previous data from other patients. On the cognitive level, the patient was generally within normal limits. However, he had mild problems in attention and concentration, and more prominent problems in emotional processing domain, and in personality dimensions. It is concluded that amygdala calcifications in Urbach-Wiethe disease take place progressively-possibly underpinned by genetic and gender variables; this can subsequently allow psychosocial-social factors (such a proper education and socialization) and biological factors (compensatory neuroplasticity) to retard and diminish the development of socio-emotional and cognitive deteriorations, though the outcome of questionnaires indicates that such patients may develop substantial concerns as to their future life and well-being.

Relevance of orbitofrontal neurochemistry for the outcome of cognitive-behavioural therapy in patients with obsessive-compulsive disorder.

Since the advent of non-invasive methods such as proton magnetic resonance spectroscopy ((1)H-MRS), obsessive-compulsive disorder (OCD) has been increasingly associated with an altered composition of neurometabolites and neurotransmitters in several brain areas. Particularly, Inositol has not only been implicated in OCD pathophysiology, but also shown effective in pilot studies in therapy-refractory OCD patients. However, the relevance of regional brain neurochemistry for therapy outcome has not yet been investigated. Whereas numerous neuroimaging findings support a dysfunction of the orbitofrontal cortex (OFC) in OCD, MR-spectroscopic investigations of this region are missing. (1)H-MRS and psychometric measurements were obtained from twenty unmedicated patients with OCD, subsequently enrolled in a 3-month structured inpatient cognitive-behavioural therapy programme, and from eleven matched control subjects. Multiple regression of symptom score changes (Y-BOCS) on (myo-)inositol concentrations in three areas (right orbitofrontal cortex (OFC), right striatum and anterior cingulate cortex) was performed. The concentration of (myo-)inositol in the OFC only predicted the outcome of subsequent CBT regarding Y-BOCS score reduction (Spearman's r(s) = .81, P < 0.003, corrected). The (myo-)inositol concentration did not differ between OCD patients and healthy controls and did not change during therapy. We provide preliminary evidence for a neurochemical marker that may prove informative about a patient's future benefit from behaviour therapy. Inositol, a metabolite involved in cellular signal transduction and a spectroscopic marker of glial activity, predicted the response to CBT selectively in the OFC, adding to the evidence for OFC involvement in OCD and highlighting neurobiological underpinnings of psychotherapy.

Electrophysiological correlates of mindfulness in patients with major depressive disorder.

Objectives: Mindfulness-based interventions (MBI) can reduce both stress and depressive symptoms. However, the impact of mindfulness on stress level in depressed subjects remains unclear. This study aims to assess electrophysiological correlates of mindfulness in patients with major depressive disorder (MDD) at baseline, under stress exposure, and in relaxation following stress exposure. Methods: Perceived mindfulness was assessed with the Freiburger Mindfulness Inventory (FMI) in 89 inpatients (mean age 51) with MDD [mean Beck Depression Inventory (BDI) 30]. Electrophysiological parameters [resting heart rate (RHR), heart rate variability (HRV), respiration rate, skin conductance, and skin temperature] were recorded at 5-min baseline, 1-min stress exposure, and 5-min self-induced relaxation. Results: Freiburger Mindfulness Inventory was strongly inversely correlated with symptom severity measured by BDI (r = -0.53, p < 0.001). No correlations between FM score and electrophysiological parameters in any of the three conditions (baseline, stress exposure, relaxed state) could be found. The factor openness was associated with higher VLF (very low frequency of HRV) in the baseline condition. However, this correlation was no more significant after regression analysis when corrected for respiratory rate, age, and sex. Conclusion: Autonomous nervous reactivity in depression was not associated with perceived mindfulness as measured by FMI score and presented electrophysiological parameters, despite the strong inverse correlation between state mindfulness and symptom severity.

Heart Rate Variability Changes in Patients With Major Depressive Disorder: Related to Confounding Factors, Not to Symptom Severity?

BACKGROUND: The aim of this study was to assess the electrophysiological and other influencing factors correlating with symptom severity in patients with major depressive disorder (MDD) under three different conditions: baseline, stress exposure, and relaxation following stress exposure. METHODS: Symptom severity was assessed using the Beck Depression Inventory (BDI-II) in 89 inpatients (37 women; mean age 51 years) with MDD. Resting heart rate (RHR), heart rate variability (HRV), respiration rate (RR), skin conductance (SC), and skin temperature (ST) were recorded at baseline for 300 s, under stress exposure for 60 s, and under self-induced relaxation for 300 s. Age, nicotine consumption, body mass index, and blood pressure were evaluated as influencing factors. RESULTS: The BDI-II mean score was 29.7 points. Disease severity correlated positively with SC elevation under stress exposure and with a higher RR in the relaxed state, but no association was found between HRV and symptom severity. Age and higher blood pressure were both associated with lower HRV and higher RHR. CONCLUSION: The results indicate that, in patients with MDD, changes in the autonomic nervous system (ANS) are complex; and the assessment of ANS reactivity to stressors is useful. Elevated blood pressure might be underdiagnosed, although it is already relevant in patients with MDD in their early 50s.

Stress- and trauma-related blockade of episodic-autobiographical memory processing.

Memory disorders without a direct neural substrate still belong to the riddles in neuroscience. Although they were for a while dissociated from research and clinical arenas, risking becoming forgotten diseases, they sparked novel interests, paralleling the refinements in functional neuroimaging and neuropsychology. Although Endel Tulving has not fully embarked himself on exploring this field, he had published at least one article on functional amnesia (Schacter et al., 1982) and ignited a seminal article on amnesia with mixed etiology (Craver et al., 2014). Most importantly, the research of Endel Tulving has provided the researchers and clinicians in the field of dissociative or functional amnesia with the best framework for superiorly understanding these disorders through the lens of his evolving concept of episodic memory and five long term memory systems classification, which he developed and advanced. Herein we use the classification of long-term memory systems of Endel Tulving as well as his concepts and views on autonoetic consciousness, relationships between memory systems and relationship between episodic memory and emotion to describe six cases of dissociative amnesia that put a challenge for researchers and clinicians due to their atypicality. We then discuss their possible triggering and maintaining mechanisms, pointing to their clinical heterogeneity and multifaceted causally explanatory frameworks.

Quo vadis 'episodic memory'? - Past, present, and perspective.

The term 'episodic memory' was coined by Endel Tulving, who also created a classification in several memory systems. This classification is presented, and it is described which predecessors existed for the partition of memory into systems. The 'episodic memory system' is discussed as being in general equivalent with the 'episodic-autobiographical memory system'. It is seen as an emotionally colorized system. A special paragraph is devoted to the 'perceptual memory system', as this was not included in Tulving's previous schemes of memory systems. More recent sub-categorizations of the 'episodic memory system' are presented and a perspective on the future of the episodic memory system is developed.

Long-Term Follow-up of Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: Symptom Severity and the Role of Exposure 8-10 Years After Inpatient Treatment.

Obsessive-compulsive disorder (OCD) can be effectively treated by cognitive behavioral therapy (CBT) with exposure and response prevention (ERP). Yet, little is known about the long-term effects of inpatient CBT up to one decade after treatment. Thirty patients who had been treated with 12 weeks of intensive inpatient CBT with ERP were examined 8-10 years after their stay in hospital with regard to obsessive-compulsive symptoms, secondary outcomes, and use of healthcare services. Significant (p < .001) improvements in OC symptoms with medium and large effects compared to baseline on the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) and on the Obsessive-Compulsive Inventory (OCI-R) could still be observed, with 20% of the patients reaching remission status. Continuation of exposure exercises after the inpatient stay was the sole significant factor for improved scores at follow-up. The results suggest that OCD does not necessarily take a chronic course. However, maintenance of exposure training seems to be crucial for sustained improvement.

Angiogenic factors in patients with current major depressive disorder comorbid with borderline personality disorder.

BACKGROUND: Major depression has been associated with endocrine and immune alterations, in particular a dysregulation of the hypothalamus-pituitary-adrenal system with subsequent hypercortisolism and an imbalance of pro- and anti-inflammatory cytokines. Recent studies suggest that vascular endothelial growth factor (VEGF), a cytokine involved in angiogenesis and neurogenesis, may also be dysregulated during stress and depression. These observations prompted us to examine VEGF and other angiogenic factors in patients with major depressive disorder. METHODS: Twelve medication-free female patients with a major depressive episode in the context of borderline personality disorder (MDD/BPD) and twelve healthy women were included. Concentrations of VEGF, VEGF receptors 1 and 2, basic fibroblast growth factor-2 (FGF-2), hepatocyte growth factor (HGF), angiopoetin-2, interleukin-8 (IL-8) and transforming growth factor-beta1 (TGF-beta1) were determined from serum profiles. RESULTS: Increased concentrations of VEGF and FGF-2 were found in MDD/BPD patients compared to the healthy comparator group. No group differences were found concerning the other angiogenic factors examined. CONCLUSION: Depressive episodes in the context of borderline personality disorder may be accompanied by increased serum concentrations of VEGF and FGF-2. Similar findings have been observed in patients with major depression without a borderline personality disorder. A dysregulation of angiogenic factors may be another facet of the endocrine and immunologic disturbances frequently seen in patients with depressive episodes.

Is repetitive negative thinking a transdiagnostic process? A comparison of key processes of RNT in depression, generalized anxiety disorder, obsessive-compulsive disorder, and community controls.

BACKGROUND AND OBJECTIVES: The transdiagnostic view of repetitive negative thinking (RNT) claims that different forms of RNT are characterized by identical processes that are applied to disorder-specific content. The purpose of the study was to test whether the processes of RNT differ across major depression disorder (MDD), generalized anxiety disorder (GAD), and obsessive-compulsive disorder (OCD). METHODS: Forty-two individuals diagnosed with MDD, 35 individuals with GAD, 41 individuals with OCD, and 35 community controls were asked to think of a typical RNT episode and to rate its processes (core processes; use of mental capacity, unproductivity, abstractness, verbal quality, duration). Ratings were compared across groups using planned contrasts and analysis of variance. RESULTS: All individuals with a clinical diagnosis rated the key processes of RNT and avoidance function of RNT as higher than healthy controls. There were no differences between individuals diagnosed with MDD, GAD or OCD on key processes and avoidance function of RNT. LIMITATIONS: Results are based on retrospective self-reports, which might restrict validity of the measurements. CONCLUSIONS: Data support the transdiagnostic hypothesis of RNT. Transdiagnostic prevention and intervention techniques seem highly recommendable given these findings.

Quetiapine addition to serotonin reuptake inhibitors in patients with severe obsessive-compulsive disorder: a double-blind, randomized, placebo-controlled study.

OBJECTIVE: Although many patients with obsessive-compulsive disorder (OCD) benefit from treatment with serotonin reuptake inhibitors (SRIs), it is estimated that 40% to 60% of them do not respond. The objective of the present study was to evaluate the efficacy of quetiapine added to baseline treatment with SRIs for the treatment of OCD in severely ill adult subjects. METHOD: Forty patients (21 men, 19 women) with primary OCD according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria participated in a 12-week, double-blind, placebo-controlled trial. They were randomly assigned to dosages of quetiapine titrated up to 400 mg/d (n = 20) or to placebo (n = 20) in addition to their SRI treatment. During the continuation phase (weeks 6-12), subjects received different dosages between 400 and 600 mg/d depending on clinical response. At entry, all patients were unresponsive to at least 1 course of at least 12 weeks of treatment with SRIs at defined doses. The total Yale-Brown Obsessive-Compulsive Scale score was the primary efficacy parameter. RESULTS: Intention-to-treat, last-observation-carried-forward analysis demonstrated a mean +/- SD decrease in Yale-Brown Obsessive-Compulsive Scale score of 5.2 +/- 5.4 in the quetiapine group and 3.9 +/- 4.9 in the placebo group. The analysis of treatment effects between the 2 groups showed no significant difference. There were no significant group differences in any of the other self-rating scales or clinician-administered rating scales. CONCLUSIONS: In this study, augmentation of SRI treatment with quetiapine in severe OCD had no additional effect.

Psychological causes of autobiographical amnesia: A study of 28 cases.

Autobiographical amnesia is found in patients with focal or diffuse brain damage ("organic amnesia"), but also without overt brain damage (at least when measured with conventional brain imaging methods). This last condition is usually named dissociative amnesia at present, and was originally described as hysteria. Classically and traditionally, dissociative amnesia is seen as a disorder that causes retrograde amnesia in the autobiographical domain in the aftermath of incidents of major psychological stress or trauma. In the present study one of the probably largest published collections of patients (28) with psychogenically caused autobiographical amnesia, who were assessed with comprehensive neuropsychological tests, will be described and documented in order to identify variables which are central for the occurrence of dissociative amnesia. The presented cases demonstrate that autobiographical amnesia without direct brain damage can have very mixed clinical presentations, causes and consequences. The described cases of psychogenic amnesia are clustered according to a number of manifestations and features, which include a reduced effort to perform cognitively at a normal level, a forensic background, anterograde (instead of retrograde) autobiographical amnesia, the fugue condition, concurrent somatic diseases, and their appearance in childhood and youth. It is concluded that autobiographical amnesia of a psychogenic origin may occur within a variety of symptom pictures. For all patients, it probably serves a protective function by offering them a mechanism to exit a life situation which appears to them unmanageable or adverse.

Vegetative symptoms and behaviour of the therapy-accompanying dog of a chronically suicidal patient.

We herein present a 51-year-old single female inpatient with treatment-resistant recurrent depressive disorder. Her most recent depressive episode has been severe and followed a chronic course, lasting for longer than 2 years. During the exacerbation of the patient's suicidal thoughts and plans, we repeatedly and independently observed vegetative and behavioural changes of the therapy-accompanying dog of the patient. Our findings suggest a role for dog-assisted therapy for augmenting treatment as well as for enhancing and developing novel adjunctive strategies for risk assessment in patients with chronic depression and suicidality. Possible social-biological mechanisms and underpinnings are discussed, by drawing on the available literature and comparative psychology. Collaboration with animal behaviourists and animal welfare scientists, in order to improve behavioural and physiological data interpretation and humaneness of dog-assisted therapy, is emphasised as a crucial component of future research.

Nicotine and alcohol dependence in patients with comorbid attention-deficit/hyperactivity disorder (ADHD).

AIMS: Several studies have shown that attention-deficit/hyperactivity disorder (ADHD) represents a significant risk factor for the onset and development of an addiction. Thirty-five per cent of adult ADHD patients are known to be addicted to alcohol. Many ADHD patients also have an increased nicotine consumption, which typically, leads to an improvement of attention, ability to concentrate and control of impulses. There may be pathophysiological connections here. On the other hand, it can also be assumed that there is a high prevalence of addicted patients with undiagnosed ADHD. METHODS: Ninety-one adult alcohol-dependent patients were examined for ADHD in this study, using the Wender Utah Rating Scale (WURS-k), Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) symptom check-list for ADHD and the Conners' Adult ADHD Rating Scales (CAARS, Long Version). The patients were divided into diagnostic sub-groups according to DSM-IV (inattentive type, impulsive type, combined type). Nicotine consumption was investigated using the Fagerström Test of Nicotine Dependence (FTND) and then graded as 'minimal', 'average' or 'high' nicotine dependence. RESULTS: There were 20.9% (WURS-k) or 23.1% (DSM-IV diagnostic criteria) of the patients addicted to alcohol, who showed evidence of ADHD in childhood. With the help of CAARS, it could be demonstrated that 33.3% of the patients who fulfilled the diagnostic criteria of ADHD, according to DSM-IV, had persisting ADHD in adulthood. The FTND showed a statistically significant difference in nicotine dependence between alcohol-dependent patients with and without ADHD in childhood. Patients numbering 76.2% with ADHD, demonstrated an 'average to high' level of nicotine dependence compared to 45.7% of those patients without ADHD. Furthermore, the number of patients not addicted to nicotine (19%) was significantly lower than among those without ADHD (36.6%) (P = 0.029). CONCLUSIONS: The results of this investigation reveal that a large number of ADHD patients suffer from alcohol dependence, and an even greater number from excessive nicotine dependence. The outcome indicates that there are most likely pathophysiological connections with alcohol and nicotine dependence, and that this substance abuse is probably a form of 'self-medication'. The results clearly underline the great importance of early and adequate diagnosis and therapy of ADHD, in order to prevent exacerbation of addictive illness.