Childhood Trauma and Premenstrual Symptoms: The Role of Emotion Regulation.

BACKGROUND: Women with Premenstrual Dysphoric Disorder (PMDD) are more likely to have a history of childhood trauma, and may experience more severe premenstrual symptomatology. However, the pathway in which childhood trauma affects the prevalence and severity of premenstrual symptoms remains largely unclear. OBJECTIVE: To determine whether childhood trauma is associated with increased premenstrual symptoms, and if so, whether emotional dysregulation mediates or moderates this relationship. PARTICIPANTS AND SETTINGS: A total of 112 women were recruited for the study among students at the Hebrew University of Jerusalem. METHODS: Participants completed the Premenstrual Symptoms Screening Tool (PSST), the Childhood Trauma Questionnaire (CTQ) and the Difficulties in Emotion Regulation Scale (DERS). To test the mediation hypothesis, direct and indirect effects of childhood trauma on premenstrual symptoms were calculated. To test moderation, we performed multiple regression, including the interaction term between childhood trauma and emotion dysregulation RESULTS: Twenty-two women (18.6%) met criteria for premenstrual syndrome (PMS) and sixteen (13.6 %) for PMDD. The number and severity of premenstrual symptoms increased with more childhood trauma (r = .282), and this relationship was completely mediated by emotion regulation difficulties. Specifically, exposure to Sexual abuse (r = .243) and Emotional neglect (r = .198) were significantly associated with premenstrual symptoms. Abuse predicted greater emotion dysregulation (r = .33), whereas, neglect did not. CONCLUSIONS: This study contributes to the current knowledge on the long-term effects of childhood trauma. Promoting use of adaptive emotion regulation strategies for women with a history of childhood trauma, could improve their capability to confront and adapt to premenstrual changes.

Cross-sectional survey on defensive practices and defensive behaviours among Israeli psychiatrists.

OBJECTIVE: Psychiatry is a low-risk specialisation; however, there is a steady increase in malpractice claims against psychiatrists. Defensive psychiatry (DP) refers to any action undertaken by a psychiatrist to avoid malpractice liability that is not for the sole benefit of the patient's mental health and well-being. The objectives of this study were to assess the scope of DP practised by psychiatrists and to understand whether awareness of DP correlated with defensive behaviours. METHODS: A questionnaire was administered to 213 Israeli psychiatry residents and certified psychiatrists during May and June 2015 regarding demographic data and experience with malpractice claims, medicolegal literature and litigation. Four clinical scenarios represented defensive behaviours and reactions (feelings and actions) to malpractice claims. RESULTS: Forty-four (20.6%) certified psychiatrists and four (1.9%) residents were directly involved in malpractice claims, while 132 (62.1%) participants admitted to practising DP. Residents acknowledged the practice of DP more than did senior psychiatrists (p=0.038).Awareness of DP correlated with unnecessary hospitalisation of suicidal patients, increased unnecessary follow-up visits and prescribing smaller drug dosages than required for pregnant women and elderly patients. CONCLUSIONS: This study provides evidence that DP is well established in the routine clinical daily practice of psychiatrists. Further studies are needed to reveal whether DP effectively protects psychiatrists from malpractice suits or, rather, if it impedes providing quality psychiatric care and represents an economic burden that leads to more harm for the patient.

The MCP-4/MCP-1 ratio in plasma is a candidate circadian biomarker for chronic post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is psychiatric disease, which can occur following exposure to traumatic events. PTSD may be acute or chronic, and can have a waxing and waning course of symptoms. It has been hypothesized that proinflammatory cytokines and chemokines in the cerebrospinal fluid (CSF) or plasma might be mediators of the psychophysiological mechanisms relating a history of trauma exposure to changes in behavior and mental health disorders, and medical morbidity. Here we test the cytokine/chemokine hypothesis for PTSD by examining levels of 17 classical cytokines and chemokines in CSF, sampled at 0900 hours, and in plasma sampled hourly for 24 h. The PTSD and healthy control patients are from the NIMH Chronic PTSD and healthy control cohort, initially described by Bonne et al. (2011), in which the PTSD patients have relatively low comorbidity for major depressive disorder (MDD), drug or alcohol use. We find that in plasma, but not CSF, the bivariate MCP4 (CCL13)/ MCP1(CCL2) ratio is ca. twofold elevated in PTSD patients compared with healthy controls. The MCP-4/MCP-1 ratio is invariant over circadian time, and is independent of gender, body mass index or the age at which the trauma was suffered. By contrast, MIP-1ß is a candidate biomarker for PTSD only in females, whereas TARC is a candidate biomarker for PTSD only in males. It remains to be discovered whether these disease-specific differences in circadian expression for these specific immune signaling molecules are biomarkers, surrogates, or drivers for PTSD, or whether any of these analytes could contribute to therapy.

Risk factors for suicide in the Israeli army between the years 1992-2012: A case-control study.

OBJECTIVE: Young age, availability of weapons, and stressful life events, increase the risk of suicide. The aim of the present study was to assess additional risk factors for suicide in the Israeli army. METHODS: We conducted a case-control study, to assess risk factors for suicide. The cases comprised soldiers who died by suicide during their military service (n=462; 0.039% of all soldiers in the cohort). The control group consisted of soldiers who did not commit suicide but were in active service during the investigated period (n=1,170,895; 99.96%). Predictor variables, including socio-demographic and psychiatric diagnoses, were considered. RESULTS: Using a Generalized Linear Model with a Binary Logistic dependent variable to predict suicide, while controlling the effect of intervening variables, we found the following variables enhanced the risk for committing suicide: male (RR=6.703; P<0.001), country of origin: Ethiopia (RR=4.555; P=0.014), low socioeconomic status (RR=1.448; P=0.016) and low adjustment difficulties (RR=2.324; P<0.001). In addition, we found that in males only, Cluster B Personality Disorder (RR=2.548; P=0.027), low (RR=1.657; P=0.002), to average motivation to serve in a combat unit (RR=1.322; P=0.046) increased the risk for suicide. CONCLUSIONS: IDF Soldiers bearing a psychiatric diagnosis or severe adjustment difficulties remained tightly monitored through their military service, and were found to be at a lower risk for suicide. However, those enlisted with mild (low) difficulties, were found to be at greater risk for suicide, as well as soldiers whose country of origin is Ethiopia. Suicide prevention program should focus on monitoring soldiers with these risk factors, together with soldiers' guidance regarding help seeking and de-stigmatizing suicide.

Deterioration of mental health in bariatric surgery after 10 years despite successful weight loss.

BACKGROUND/OBJECTIVE: The present study evaluated the mental health and psychological functioning of bariatric patients before surgery, and after 1 year and 10 year follow-ups, and compared them with participants in a dietary program. Such long follow-up is rare, but strongly recommended by the American Association of Bariatric Surgeons. SUBJECTS/METHODS: Thirty-six bariatric surgery patients and 34 participants of a weight loss program were weighed and assessed at all 3 points in time. Participants were administered the mental health inventory, neuroticism, sense of control and fear of intimacy scales. Along with these mental and psychological measurements, the medical outcome short form (SF-36) was used. RESULTS: The surgery group achieved successful weight loss outcomes (27% reduction of pre-operative weight) after 10 years and better than baseline health-related quality-of-life scores. However, their general mental health, neuroticism, sense of control and fear of intimacy scores showed significant deterioration in comparison to pre-operative levels after 10 years. The dietary group participants remained psychologically stable among all three points in time. CONCLUSIONS: This study highlights the importance of identifying a risk group among bariatric patients for which the dietary and psychological follow-up may be of special significance.

Well being, psychopathology and coping strategies in psoriasis compared with atopic dermatitis: a controlled study.

BACKGROUND: There is a vast literature describing the association between psoriasis, atopic dermatitis (AD) and psychological distress. Some of these studies were uncontrolled and others used non-dermatological diseases as control, but only a few used chronic skin diseases as controls. OBJECTIVE: To compare well being, psychopathology and coping strategies of psoriatic, AD and healthy controls in a prospective case-control study. METHODS: Thirty-seven psoriatic patients and 31 AD patients were recruited from the Hadassah Ein Karem Hospital, Jerusalem, Israel, outpatient and inward clinic. The participants in the control group were 31 healthy workers and volunteers with no dermatological diseases from Kaplan Hospital, Rehovot, Israel. We used self-report questionnaires [Mental Health Inventory (MHI) and Adjustment to Chronic Skin Diseases Questionnaire (ACSD)], a projective technique (Hand Test) and assessment tools (Clinical Global Impression). RESULTS: Psoriatic patients experienced reduced well being (P = 0.007) and more anxiety and depression (P = 0.018) than normal controls. Psoriatic patients also displayed more severe psychopathology (P = 0.039) a more passive attitude towards life, and loss of meaning in life (P = 0.001) as measured by the projective technique compared with AD patients and normal controls. CONCLUSIONS: We propose two explanations, derived from the psychological and the psycho-neuro-immunological domains. First, greater mental distress in psoriasis is because of the greater stigma it bears compared with AD. Alternatively, we hypothesize that the psoriatic inflammatory process may possibly have a direct central nervous system effect.

Low early morning plasma cortisol in posttraumatic stress disorder is associated with co-morbid depression but not with enhanced glucocorticoid feedback inhibition.

BACKGROUND: Co-morbid major depressive disorder (MDD) in individuals with posttraumatic stress disorder (PTSD) confers a more severe clinical course and is associated with distinct biologic abnormalities. Although dysregulation in the hypothalamic pituitary adrenal (HPA) axis has been well established in PTSD, the impact of commonly co-occuring MDD has received scant attention. METHODS: Overnight (7p.m. to 7a.m.) plasma cortisol, adrenocorticotropic hormone (ACTH), dehydroepiandrosterone sulphate (DHEA-S) were measured at 30 min intervals in 9 participants with PTSD with MDD (PTSD+MDD), 9 with PTSD without MDD (PTSD-MDD) and 16 non-traumatized healthy controls. A low-dose dexamethasone suppression test was administered to evaluate feedback sensitivity to glucocorticoids. Linear mixed models with body mass index (BMI) and age as covariates and Bonferroni corrected post hoc tests assessed group differences. RESULTS: Compared to healthy controls, subjects with PTSD+MDD, but not those subjects with PTSD-MDD, exhibited lower basal plasma cortisol levels between 1:30 a.m. and 3:30 a.m. and at 4:30 a.m. and 6:30 a.m. (effect size d=0.75). Despite similar plasma ACTH levels between the three groups, the ACTH/cortisol ratio was higher in PTSD+MDD patients compared to controls. We obtained similar results when the patient and control groups were re-studied 1 week later, and when men and current smokers were excluded. Basal plasma DHEA-S levels, and cortisol and ACTH response to a low-dose dexamethasone suppression test were similar in all three groups. CONCLUSIONS: Lower early morning plasma cortisol levels and a high ACTH/cortisol ratio in subjects with PTSD and co-morbid MDD may not be due to enhanced peripheral sensitivity to glucocorticoids. A central abnormality in glucocorticoid regulation could explain HPA axis dysfunction in this subgroup.

Biased emotional attention in post-traumatic stress disorder: a help as well as a hindrance?

BACKGROUND: From a cognitive neuroscience perspective, the emotional attentional bias in post-traumatic stress disorder (PTSD) could be conceptualized either as emotional hyper-responsiveness or as reduced priming of task-relevant representations due to dysfunction in 'top-down' regulatory systems. We investigated these possibilities both with respect to threatening and positive stimuli among traumatized individuals with and without PTSD. METHOD: Twenty-two patients with PTSD, 21 trauma controls and 20 non-traumatized healthy participants were evaluated on two tasks. For one of these tasks, the affective Stroop task (aST), the emotional stimuli act as distracters and interfere with task performance. For the other, the emotional lexical decision task (eLDT), emotional information facilitates task performance. RESULTS: Compared to trauma controls and healthy participants, patients with PTSD showed increased interference for negative but not positive distracters on the aST and increased emotional facilitation for negative words on the eLDT. CONCLUSIONS: These findings document that hyper-responsiveness to threat but not to positive stimuli is specific for patients with PTSD.

Longitudinal MRI study of hippocampal volume in trauma survivors with PTSD.

OBJECTIVE: The authors prospectively explored whether a reduction in the volume of the hippocampus occurs in recent trauma survivors who develop posttraumatic stress disorder (PTSD). METHOD: Thirty-seven survivors of traumatic events were assessed within a week of the traumatic event and 6 months later. The assessment included magnetic resonance imaging of the brain (including 124 coronal slices of 1.5-mm thickness), psychometric testing, and structured clinical interviews. The Clinician-Administered PTSD Scale conferred PTSD diagnoses at 6 months. RESULTS: Ten subjects (27%) had PTSD at 6 months. The subjects with PTSD did not differ from those without PTSD in hippocampal volume (right or left) at 1 week or 6 months. There was no reduction in hippocampal volume in the PTSD subjects between 1 week and 6 months. CONCLUSIONS: Smaller hippocampal volume is not a necessary risk factor for developing PTSD and does not occur within 6 months of expressing the disorder. This brain abnormality might occur in individuals with chronic or complicated PTSD.

Cerebral activation associated with sexual arousal in response to a pornographic clip: A 15O-H2O PET study in heterosexual men.

This study attempted to use PET and 15O-H2O to measure changes in regional cerebral blood flow (rCBF) during sexual arousal evoked in 10 young heterosexual males while they watched a pornographic video clip, featuring heterosexual intercourse. This condition was compared with other mental setups evoked by noisy, nature, and talkshow audiovisual clips. Immediately after each clip, the participants answered three questions pertaining to what extent they thought about sex, felt aroused, and sensed an erection. They scored their answers using a 1 to 10 scale. SPM was used for data analysis. Sexual arousal was mainly associated with activation of bilateral, predominantly right, inferoposterior extrastriate cortices, of the right inferolateral prefrontal cortex and of the midbrain. The significance of those findings is discussed in the light of current theories concerning selective attention, "mind reading" and mirroring, reinforcement of pleasurable stimuli, and penile erection.

Separation-induced body weight loss, impairment in alternation behavior, and autonomic tone: effects of tyrosine.

We have investigated the effects of tyrosine on alternation behavior and hippocampal adrenergic and cholinergic tone in a model of self-induced weight loss caused by separation stress. Separation decreased body weight in mice (P < .001) and spontaneous alternations in the T-maze (P < .001). This impairment was associated with depletion of both norepinephrine (NE, P < .001) and dopamine (P < .01) while increasing MHPG (P < .05) and the ratio of MHPG/NE (P < .05). Increasing tyrosine availability restored performance to control levels (P < .001) and repleted dopamine (P < .05) and presumably also NE (indicated by increases in both MHPG, P < .001, and MHPG/NE, P < .05). Stress increased adrenergic alpha(2)-receptor density (P < .001) without changing its K(d) and the B(max) and K(d) of beta-receptors, suggesting that it decreased NE transmission through action on alpha(2)-receptors. The balance between beta- and alpha(2)-receptors appeared to be related to alternation behavior as shown by the decrease (P < .01) and increase (P < .05) in their ratios induced by stress and tyrosine, respectively. With regard to cholinergic tone, separation stress increased M1 receptor density (P < .05) and its mRNA signal (P < .001). Tyrosine further increased M1 receptor density of stressed mice (P < .05). Tyrosine might be a potential therapy for cognitive and mood problems associated with the maintenance of a reduced body weight in the treatment of obesity and in the extreme case of anorexia nervosa.

Diet restriction in mice causes a decrease in hippocampal choline uptake and muscarinic receptors that is restored by administration of tyrosine: interaction between cholinergic and adrenergic receptors influencing cognitive function.

We have studied the effects of diet restriction (DR) to 60% and 40% of daily requirements, and tyrosine administration on cognitive function in mice, to define the nutritional-neurochemical interactions on autonomic tone involved in behavior and energy regulation. Cognitive function in the Morris Water maze was significantly impaired after 40% DR compared to both control and 60% DR. It was restored after tyrosine in association with increased M1 cholinergic and beta-adrenergic receptor function, and decreased alpha-adrenergic function. DR to 40% significantly decreased choline uptake (p <.05) and M1 receptor number (Bmax) (p <.05), without changes in affinity (Kd), choline acetyl transferase (ChAT) or acetyl cholinesterase (AChE) activity. Tyrosine administration significantly increased choline uptake (Bmax) (p <.05) and M1 density in the 40% DR (p <.01) without changes in affinity. ChAT activity was decreased after tyrosine--significantly after 40% DR (p <.05) while AChE was not affected. Both M1 mRNA and protein were not influenced by DR or tyrosine administration. Tyrosine hydroxylase mRNA was decreased significantly by 40% DR (p <.01). The effect of DR and tyrosine appeared to be both pre- and post-synaptic, indicating modulation of cholinergic activity by adrenergic tone. Nutritional effect on behavior and autonomic tone may have implications for the treatment of mood changes associated with weight loss and semi-starvation.

The impact of parental death versus separation from parents on the mental health of Israeli adolescents.

Early research suggested that the loss of a parent during childhood can lead to depression and other psychopathology in children and adults. More recent research has differentiated between loss due to death and separation from parents and has questioned the link between early parental death and psychopathology. We examined the hypothesis that separation from parents has a more detrimental effect than the death of a parent on the mental health of adolescents in the community. Israeli adolescents (N = 844) with a mean age of 16.7 +/- 1.0 years (mean +/- SD) participated in this study. Seventy reported that a parent did not live at home during one of three 5-year periods until they reached the age of 15; 37 reported the death of a parent and 777 were from intact families. All participants completed the Brief Symptom Inventory (BSI), General Well Being Schedule (GWB), Parental Bonding Instrument (PBI), and Perceived Social Support Family/ Friends Scales (PSS-Fam and PSS-Fr). Adolescents who had experienced separation from parents had more psychiatric symptoms (BSI), expressed a lower sense of well-being (GWB), experienced less support from their family (PSS-Fam), and felt less cared for and more controlled by their parents (PBI) compared with those belonging to intact families. The death of a parent was not associated with significantly different scores on these variables. When we controlled for parental bonding (PBI) and perceived social support from family (PSS-Fam), the differences between the separation group and the intact family group were no longer significant. The psychological impact of separation from parents involves a greater risk for psychopathology than the death of a parent. The quality of the relationship with the parents moderates the negative impact of separation from them.

Childhood imaginary companionship and mental health in adolescence.

An imaginary companion (IC) is a frequently encountered childhood fantasy, invisible to anyone but the child, who may be named, addressed or played with. Whether the presence of an IC is a normal developmental feature has not been determined. We examined psychometric measures and the presence/absence of childhood IC in a sample of 850 mentally healthy adolescents. 17.6% of our subjects, more often females, reported having had such a companion. Subjects who reported having had an IC in childhood exhibited higher levels of distress and emotional discontrol, displayed prolonged transitional object attachment and immature modes of coping with stress. Thus, although childhood imaginary companionship is not indicative of psychopathology, it may denote a vulnerability for adolescent perturbation and difficulty in coping with emotionally laden situations.

Clinical doses of fluoxetine and cerebral blood flow in healthy volunteers.

RATIONALE: Of the specific serotonin reuptake inhibitors (SSRIs), fluoxetine is perhaps the most widely used. Anecdotal reports, mostly in the non-medical press, have suggested that it may positively affect psychological functioning and enhance quality of life in the absence of overt psychiatric disorder. Such wide-spread use in not supported by scientific data. OBJECTIVE: This prospective single blind study examined the effects of long term administration of clinical doses of fluoxetine on cerebral blood flow (CBF) in healthy volunteers. METHODS: Fifteen healthy subjects were examined by Tc99m HMPAO SPECT after 2 weeks of placebo administration and then after 6 weeks of fluoxetine, administered at 20 mg per day. Blood for fluoxetine and norfluoxetine plasma levels was drawn to ensure compliance. Tc99m HMPAO uptake was analyzed by the region of interest approach, normalized to the cerebellum, and by statistical parametric mapping (SPM). RESULTS: No statistically significant differences between the two conditions were detected by both techniques. Correlation analysis between fluoxetine and norfluoxetine plasma levels and rCBF yielded no statistically significant values. CONCLUSION: Our findings suggest a differential effect of fluoxetine on CBF under the following conditions: (i) mental health versus psychiatric illness; (ii) acute versus long term administration. Our findings further emphasize the importance of longitudinal studies in elucidating the physiology of the normal brain as well as the pathophysiology of psychiatric disorders.

Age-related changes in brain perfusion of normal subjects detected by 99mTc-HMPAO SPECT.

Previous functional imaging data generally show impairment in global cerebral blood flow (CBF) with age. Conflicting data, however, concerning age-related changes in regional CBF (rCBF) have been reported. We examined the relative rCBF in a sample of healthy subjects of various ages, to define and localize any age-related CBF reduction. Twenty-seven healthy subjects (17 male, 10 female; mean age 49 +/- 15, range 26-71, median 47 years) were studied by 99mTc-HMPAO brain SPECT. The younger age group consisted of subjects below, the older group above 47 years of age, respectively. Analysis was performed by applying three preformed templates, each containing delineated regions of interest (ROIs), to three transaxial brain slices at approximately 4, 6, and 7 cm above the orbitomeatal line (OML). The average number of counts for each ROI was normalized to mean uptake of the cerebellum and of the whole brain slice. Globally, 99mTc-HMPAO uptake ratio normalized to cerebellum was significantly decreased in older subjects, affecting both hemispheres. A slight left-to-right asymmetry was observed in HMPAO uptake of the whole study group. It did not, however, change with age. Regionally, both cortical and subcortical structures of older subjects were involved: uptake ratio to cerebellum was significantly lower (after correction for multiple testing) in the left basal ganglia and in the left superior temporal, right frontal and bilateral occipital cortices at 4 cm above the OML. At 6 cm above the OML, reduced uptake ratios were identified in the left frontal and bilateral parietal areas. At 7 cm, reduced uptake was detected in the right frontal and left occipital cortices. Most of these differences were reduced when uptake was normalized to whole slice, whereas an increase in uptake ratios was observed in the cingulate cortex of the elderly. An inverse correlation between age and HMPAO uptake ratios normalized to cerebellum was observed in a number of brain regions. These findings suggest that advancing age has a differential effect on cerebral perfusion reflected in brain 99mTc-HMPAO uptake.

Alprazolam reduces response to loud tones in panic disorder but not in posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) and panic disorder (PD) share several clinical features, and theory postulates that phasic arousal is similarly dysregulated in both. The modulation of phasic arousal can be probed by measuring the effect of pharmacologic agents on auditory startle. METHODS: Eyeblink electromyogram, heart rate, and skin conductance (SC) responses to 15 consecutive presentations of 1000-Hz, 95-dB, zero rise-time pure tones were measured, before and during treatment with alprazolam, in 9 PTSD and 9 PD patients. Concurrent anxiety was assessed by the Hamilton Anxiety Rating Scale. RESULTS: The groups did not differ in initial psychometric and physiological measures. Significant decrease in anxiety was observed in both groups during treatment. A decrease in response probability and a decrease in the SC responses were observed in PD, but not in PTSD. CONCLUSIONS: The results may reflect a difference in the modulation of phasic arousal between the disorders. They may also express an impaired between-session habituation or contextual sensitization in PTSD.

Pathophysiological significance of cerebral perfusion abnormalities in major depression-trait or state marker?

Considerable data support the existence of impaired regional cerebral blood flow in major depression. However, it is unclear whether the impairment in brain function in major depression is a "state" marker, reversible upon remission, or an enduring trait phenomenon. We have studied brain technetium-99m hexamethylpropyleneamineoxime (Tc-99m HMPAO) uptake ratios in healthy subjects of various ages, in depressed patients before and after electroconvulsive therapy (ECT) and in healthy subjects before and after administration of fluoxetine. Analysis of our findings, presented along with research data of other groups, strongly suggests that reduced cerebral perfusion in major depression is reversible by successful treatment. Furthermore, since fluoxetine had little effect on cerebral perfusion in healthy subjects, and ECT had little effect on cerebral perfusion in depressed patients who did not respond to treatment, we contend that increases in perfusion represent remission rather than treatment effect. Therefore, reduced perfusion in major depression appears to be a state marker and not a trait abnormality.