The multifactorial aetiology and management of premenstrual dysphoric disorder with leuprorelin acetate.

Up to 18% of women of reproductive age may experience symptoms during the luteal phase of the menstrual cycle known as premenstrual syndrome (PMS) or its more severe form, premenstrual dysphoric disorder (PMDD). A plethora of symptoms have been described, but both are commonly associated with other mood-related disorders such as major depression causing significant life impairment. Originally known as late luteal phase dysphoric disorder in the DSM-III-R (American Psychiatric Association 1987), the syndrome was renamed PMDD in the DSM-IV (American Psychiatric Association 1994). Between 3% and 8% of women meet the diagnostic criteria for PMDD. Currently, there is no consensus on its aetiology although it is thought to be multifactorial. Biological, genetic, psychological, environmental and social factors have all been suggested. However, an altered sensitivity to the normal hormonal fluctuations that influence functioning of the central nervous system is thought most likely. PMDD is identified in the DSM-5 by the presence of at least five symptoms accompanied by significant psychosocial or functional impairment. During evaluation, it is recommended that clinicians confirm symptoms by prospective patient mood charting for at least two menstrual cycles. Management options include psychotropic agents, ovulation suppression and dietary modification. Selective serotonin reuptake inhibitors (SSRIs) are considered primary therapy for psychological symptoms. Ovulation suppression is another option with the combined oral contraceptive pill (COCP) or GnRH (gonadotropin-releasing hormone) agonists. Rarely symptoms warrant a bilateral oophorectomy and a 6-month trial of GnRH agonists prior to surgery may be prudent to determine its potential efficacy. The authors present the case of a multiparous woman in her mid-30s experiencing severe symptoms during the luteal phase of her menstrual cycle. A trial of the contraceptive pill and SSRIs were unsuccessful. Treatment with leuprorelin acetate (Prostap) improved her symptoms. She therefore elected to undergo a bilateral oophorectomy with resolution of her symptoms. She started hormone replacement therapy (HRT). This case demonstrates the multifactorial aetiology of PMDD and the challenges in its management. Women with PMDD suffer functional impairments comparable with other depressive disorders and yet PMDD and its impact remain under-recognised. As the psychological nature and consequences of PMDD often seem indistinguishable from symptoms of other mental health difficulties, this condition presents distinct diagnostic challenges for healthcare professionals. It is crucial to establish the correct diagnosis using clearly defined criteria because if it is left untreated, it can cause considerable impairment to the woman's quality of life.

Abdominal ectopic pregnancy.

An ectopic pregnancy (EP) accounts for 1-2% of all pregnancies, of which 90% implant in the fallopian tube. An abdominal ectopic pregnancy (AEP) is defined as an ectopic pregnancy occurring when the gestational sac is implanted in the peritoneal cavity outside the uterine cavity or the fallopian tube. Implantation sites may include the omentum, peritoneum of the pelvic and abdominal cavity, the uterine surface and abdominal organs such as the spleen, intestine, liver and blood vessels. Primary abdominal pregnancy results from fertilisation of the ovum in the abdominal cavity and secondary occurs from an aborted or ruptured tubal pregnancy. It represents a very rare form of an EP, occurring in <1% of cases. At early gestations, it can be challenging to render the diagnosis, and it can be misdiagnosed as a tubal ectopic pregnancy. An AEP diagnosed >20 weeks' gestation, caused by the implantation of an abnormal placenta, is an important cause of maternal-fetal mortality due to the high risk of a major obstetric haemorrhage and coagulopathy following partial or total placental separation. Management options include surgical therapy (laparoscopy±laparotomy), medical therapy with intramuscular or intralesional methotrexate and/or intracardiac potassium chloride or a combination of medical and surgical management. The authors present the case of a multiparous woman in her early 30s presenting with heavy vaginal bleeding and abdominal pain at 8 weeks' gestation. Her beta-human chorionic gonadotropin (bHCG) was 5760 IU/L (range: 0-5), consistent with a viable pregnancy. Her transvaginal ultrasound scan suggested an ectopic pregnancy. Laparoscopy confirmed an AEP involving the pelvic lateral sidewall. Her postoperative 48-hour bHCG was 374 IU/L. Due to the rarity of this presentation, a high index of clinical suspicion correlated with the woman's symptoms; bHCG and ultrasound scan is required to establish the diagnosis to prevent morbidity and mortality.

Neurocomputational mechanisms underlying cross-modal associations and their influence on perceptual decisions.

When exposed to complementary features of information across sensory modalities, our brains formulate cross-modal associations between features of stimuli presented separately to multiple modalities. For example, auditory pitch-visual size associations map high-pitch tones with small-size visual objects, and low-pitch tones with large-size visual objects. Preferential, or congruent, cross-modal associations have been shown to affect behavioural performance, i.e. choice accuracy and reaction time (RT) across multisensory decision-making paradigms. However, the neural mechanisms underpinning such influences in perceptual decision formation remain unclear. Here, we sought to identify when perceptual improvements from associative congruency emerge in the brain during decision formation. In particular, we asked whether such improvements represent 'early' sensory processing benefits, or 'late' post-sensory changes in decision dynamics. Using a modified version of the Implicit Association Test (IAT), coupled with electroencephalography (EEG), we measured the neural activity underlying the effect of auditory stimulus-driven pitch-size associations on perceptual decision formation. Behavioural results showed that participants responded significantly faster during trials when auditory pitch was congruent, rather than incongruent, with its associative visual size counterpart. We used multivariate Linear Discriminant Analysis (LDA) to characterise the spatiotemporal dynamics of EEG activity underpinning IAT performance. We found an 'Early' component (∼100-110 ms post-stimulus onset) coinciding with the time of maximal discrimination of the auditory stimuli), and a 'Late' component (∼330-340 ms post-stimulus onset) underlying IAT performance. To characterise the functional role of these components in decision formation, we incorporated a neurally-informed Hierarchical Drift Diffusion Model (HDDM), revealing that the Late component decreases response caution, requiring less sensory evidence to be accumulated, whereas the Early component increased the duration of sensory-encoding processes for incongruent trials. Overall, our results provide a mechanistic insight into the contribution of 'early' sensory processing, as well as 'late' post-sensory neural representations of associative congruency to perceptual decision formation.

Rates and predictors of anti-depressant prescribing in Northern Ireland 2011-2015: a data linkage study using the Administrative Data Research Centre (NI).

OBJECTIVES: Research indicates that anti-depressant prescribing is higher in Northern Ireland (NI) than in the rest of the UK, and that socio-economic and area-level factors may contribute to this. The current study provides comprehensive population-based estimates of the prevalence of anti-depressant prescription prescribing in NI from 2011 to 2015, and examined the associations between socio-demographic, socio-economic, self-reported health and area-level factors and anti-depressant prescription. METHODS: Data were derived from the 2011 NI Census (N = 1 588 355) and the Enhanced Prescribing Database. Data linkage techniques were utilised through the Administrative Data Research Centre in NI. Prevalence rates were calculated and binary logistic analysis assessed the associations between contextual factors and anti-depressant prescription. RESULTS: From 2011 to 2015, the percentages of the population in NI aged 16 or more receiving anti-depressant prescriptions were 12.3%, 12.9%, 13.4%, 13.9% and 14.3%, respectively, and over the 5-year period was 24.3%. The strongest predictors of anti-depressant prescription in the multivariate model specified were 'very bad' (OR = 4.02) or 'Bad' general health (OR = 3.98), and self-reported mental health problems (OR = 3.57). Other significant predictors included social renting (OR = 1.67) and unemployment (OR = 1.25). Protective factors included Catholic religious beliefs, other faith/philosophic beliefs and no faith/philosophic beliefs in comparison to reporting Protestant/other Christian religious beliefs (ORs = 0.78-0.91). CONCLUSION: The prevalence of anti-depressant prescription in NI appears to be higher than the prevalence of depressive disorders, although this may not necessarily be attributable to over-prescribing as anti-depressants are also prescribed for conditions other than depression. Anti-depressant prescription was linked to several factors that represent socio-economic disadvantage.

Neural correlates of multisensory reliability and perceptual weights emerge at early latencies during audio-visual integration.

To make accurate perceptual estimates, observers must take the reliability of sensory information into account. Despite many behavioural studies showing that subjects weight individual sensory cues in proportion to their reliabilities, it is still unclear when during a trial neuronal responses are modulated by the reliability of sensory information or when they reflect the perceptual weights attributed to each sensory input. We investigated these questions using a combination of psychophysics, EEG-based neuroimaging and single-trial decoding. Our results show that the weighted integration of sensory information in the brain is a dynamic process; effects of sensory reliability on task-relevant EEG components were evident 84 ms after stimulus onset, while neural correlates of perceptual weights emerged 120 ms after stimulus onset. These neural processes had different underlying sources, arising from sensory and parietal regions, respectively. Together these results reveal the temporal dynamics of perceptual and neural audio-visual integration and support the notion of temporally early and functionally specific multisensory processes in the brain.

Illusory Increases in Font Size Improve Letter Recognition.

Visual performance of human observers depends not only on the optics of the eye and early sensory encoding but also on subsequent cortical processing and representations. In two experiments, we demonstrated that motion adaptation can enhance as well as impair visual acuity. Observers who experienced an expanding motion aftereffect exhibited improved letter recognition, whereas observers who experienced a contracting motion aftereffect showed impaired letter recognition. We conclude that illusory enlargement and shrinkage of a visual stimulus can modulate visual acuity.

Long-term effects of psychological trauma on psychosocial functioning.

BACKGROUND: Most studies of the effects of trauma on mental health have generally not separately assessed psychosocial functioning, and in those that have key issues have received little attention, such as the relation between the time courses of the two kinds of outcome, and detailed assessment of social functioning in a range of domains. The present study made separate assessments with a view to testing four hypotheses. First, that the experience of trauma itself (independently of effects on mental health) has a negative effect on psychosocial functioning; second, that psychopathology following trauma is associated with poorer psychosocial functioning; third, that psychosocial functioning recovers when psychiatric conditions remit; fourth, that post-traumatic stress and depression have different associations with impairments of psycho-social functioning. METHOD: One hundred and fifteen young adults who had survived a shipping disaster (the sinking of the Jupiter in 1988) between 5 and 8 years previously, and 50 control participants were assessed for psychopathology, and for psychosocial functioning using the Adolescent to Adult Personality Functioning Assessment (ADAPFA). RESULTS: Results did not support the first hypothesis: survivors who, although experiencing a traumatic event, did not develop Post Traumatic Stress Disorder or other psychopathology warranting diagnosis, when compared with Controls who had no psychopathology since the time of the disaster, showed no significant differences on any ADAPFA domains or on total score. There was partial support for the second hypothesis: survivors with diagnosable disorder during the rating period showed poorer psychosocial functioning in total ADAPFA score and in the domains of Education/Work, Love Relationships, and Non-specific Social Contacts, though not in other domains. The third hypothesis was supported: recovered Survivors showed no psychosocial impairments compared with unaffected Controls. Results also supported the fourth hypothesis, showing differential effects of post traumatic stress and depression in relation to the extent and kind of psycho-social impairments. CONCLUSIONS: The results lend support to the general model that effects on psychosocial functioning following traumatic experience are mediated by psychopathology, though further research is needed to establish whether the present pattern of findings applies to other kinds of trauma.