Response to methylphenidate by adult and pediatric patients with attention-deficit/hyperactivity disorder: the Spanish multicenter DIHANA study.

BACKGROUND: The purpose of this multicenter Spanish study was to evaluate the response to immediate-release methylphenidate by children and adults diagnosed with attention-deficit/hyperactivity disorder (ADHD), as well as to obtain information on current therapy patterns and safety characteristics. METHODS: This multicenter, observational, retrospective, noninterventional study included 730 patients aged 4-65 years with a diagnosis of ADHD. Information was obtained based on a review of medical records for the years 2002-2006 in sequential order. RESULTS: The ADHD predominantly inattentive subtype affected 29.7% of patients, ADHD predominantly hyperactive-impulsive was found in 5.2%, and the combined subtype in 65.1%. Overall, a significant lower Clinical Global Impression (CGI) score and mean number of DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision) symptoms by subtype were found after one year of treatment with immediate-release methylphenidate; CGI decreased from 4.51 to 1.69, symptoms of inattention from 7.90 to 4.34, symptoms of hyperactivity from 6.73 to 3.39, and combined subtype symptoms from 14.62 to 7.7. Satisfaction with immediate-release methylphenidate after one year was evaluated as "very satisfied" or "satisfied" by 86.90% of the sample; 25.75% of all patients reported at least one adverse effect. At the end of the study, 41.47% of all the patients treated with immediate-release methylphenidate were still receiving it, with a mean time of 3.80 years on therapy. CONCLUSION: Good efficacy and safety results were found for immediate-release methylphenidate in patients with ADHD.

[Swallowing phobia: symptoms, diagnosis and treatment]. / Fobia a tragar: clínica, diagnóstico y tratamiento.

INTRODUCTION: Choking phobia (or swallowing phobia) is characterized by a fear of swallowing foods, liquids or pills, sometimes after an episode of choking on food. METHODS: Forty-one case reports on swallowing phobia from 1978 to 2005 were studied. Clinical and therapeutic variables of the disorder were studied. RESULTS: It appears to occur more often in females (two-thirds of the cases) and has a high comorbidity with anxiety disorders (panic disorder, 41 %; obsessive conditions, 22 %, and separation anxiety, 15 %). Life-events and eating traumatic antecedents are frequently present (44% and 56% cases, respectively). Cognitive-behavioral treatments have been of proven efficacy, as well as anti-panic drugs (alprazolam, lorazepam, bromazepan, imipramine, clomipramine, fluoxetine, paroxetine) with a remission rate of 58.5%. Gender and treatment differences are also analyzed.

[Evolutionary aspects of affective disorders, critical review and proposal of a new model]. / Aspectos evolucionistas de los trastornos afectivos, revisión crítica y propuesta de un nuevo modelo.

Evolutionary psychopathology incorporates psychiatry into biology via theory of evolution, generating new etiological hypothesis for mental disorders. For evolutionary psychopathology emotions are a response system or a genetically programmed, specialized state of functioning, formed by natural selection, that allows us to adapt to the environment, increasing the ability to cope with threats and opportunities. Emotions exert their function by coordinated physiological, psychological and behavioral changes. Many functions have been suggested for low mood or depression, including communicating a need for help, signaling yielding in a hierarchy conflict, fostering disengagement for commitments to unreachable goals, regulating patterns of investment, parallelism with despair phase of separation from mother situation in monkeys, hibernation, etc. Despite other evolutionary models, our model not only tries to explain depression but mania, hypomania and other affective disorders as well. For us, most affective disorders are pathological states (and not adaptive ones), due to dysfunction of an innate precipitating mechanism (IPM). IPM function is to regulate energy and activity levels according to intensity and duration of light (namely IPM-A). This IPM-A is responsible for vegetative, endocrine and behavioral responses that are present in humans and more ancient phylogenetic animals. More recently in the phylogeny, other mechanisms (IPM-AA) have coupled to this IPM-A. In the human being, the precipitating factors of IPM-AA are predominately social. IPM-AA add new responses (such as mood) to the older responses of IPM-A.

Violence in mental disorders and community sample: an evolutionary model related with dominance in social relationships.

The major risk determinants of violence are to be young and male, to have low socioeconomic status and suffering substance abuse. This is true whether it occurs in the context of a concurrent mental illness or not; i.e., mental disorders are neither necessary, nor sufficient causes for violence. Intense motivation is a facilitating factor for violence in clinical and non clinical samples. This explains why 'normal' people, are implicated in planned violence at higher rates than mentally ill (e.g. in criminal acts against property). However mentally ill patients are more easily implicated in impulsive violence or in violence without obvious cause due to veiled motivation fuelled by unidentified symptoms. Subjective or real awareness of competitive disadvantage increases motivation for violence (e.g. paranoid, narcissistic symptoms, etc.). Many psychiatric disorders as antisocial disorder, borderline, schizophrenia, have most of the factors that facilitate the appearance of violence. Antisocial disorder is a good model to study determinants of violence in normal samples as it is present in young males that do not have any psychotic symptom, have stable symptomatology, self control under scrutiny, and their motivations are similar to normal samples. Our evolutionary model suggests that there is a non random association of genetic factors (genes, pseudogenes, promoting areas, etc.), that is, a genetic cluster (cluster DO), whose phylogenetic function is to motivate to be the dominant in social relationships. To be the dominant is a major psychological feature present in many social groups of animals, included primates. DO cluster have sense from an evolutionary viewpoint: when expressed in no pathological way it increases inclusive fitness (transmission of the genes of a person genotype whether by oneself or by relatives reproduction). Features of cluster DO in humans are expressed differently according to sex, age, moral education, level of intelligence, etc. Cluster DO has higher phenotypical expression in males and young people. Primary antisocial personality disorder and other related disorders (cluster B personality disorders, disocial, defiant disorder, etc.), are a pathological manifestation of this cluster DO. Some other genetic clusters that causes the genetic liability to some disorders (e.g. attention deficit disorder) are non random associated with cluster DO, thus explaining clinical comorbidity. According to our model, motivation for dominance usually prevails over motivation for material benefit or antinormative behaviour, this explains some incongruent behaviour in antisocial patients not elucidated by other models. Along with the primary expressed feature of dominance of cluster DO there are other secondary features that have been identified by psychobiological studies: novelty seeking, intolerance for frustration, impulsiveness, fearless, aggressiveness, higher threshold for activation of the sympathetic system, lack of empathy, egoism, non acceptance of rules, defiant and rebellious behaviour, manipulation in social interactions, selfishness and deficits in altruism or in social co-operation.

[Treatment of Tourette syndrome and its comorbidity: experience with 17 cases]. / Tratamiento del síndrome de Tourette y su comorbilidad: presentación de 17 casos.

INTRODUCTION: Clinical characteristics and comorbid disorders of Tourette syndrome (TS) are reviewed along with a presentation of our experience with 17 cases. MATERIAL AND METHODS: We carried out a retrospective study of pediatric patients with TS admitted from 1998 to 2004 in Fundación Hospital Alcorcón. RESULTS: Seventeen patients were obtained, 16 of whom were men and there was only 1 woman. Present age ranged from 7 to 17 years old. Most frequent comorbid disorders were attention deficit disorder (ADD) in 9 patients, (53%), obsessive-compulsive disorder in 8 (48%) and anxiety in 7 (41%). Learning disorders were found in 7 patients (41%), 5 of whom have concurrent ADD and 1 severe obsessive compulsive disorder. Psychopharmacological treatment was withdrew in the 2 cases treated with halloperidol due to the presence of severe extrapyramidal symptoms (EPS) and in 3 of the 7 cases treated with pimozide (one of them was withdrawn due to EPS). No EPS was found with atypical neuroleptics, but sedation and weight gain was common. Methylphenidate was administered to 7 patients without an increase in tics. CONCLUSIONS: In our sample the most common comorbid disorders were ADD, obsessive-compulsive disorders, anxiety and learning disorders. Atypical neuroleptics were better tolerated than classic ones, although the incidence of side effects is elevated. Methylphenidate was not associated with tic worsening.

Mirtazapine versus paroxetine in panic disorder: an open study.

Introduction Open studies suggest that mirtazapine has efficacy in panic disorder treatment. We designed an open study that evaluates changes induced by mirtazapine compared with paroxetine in panic disorder. Methodology Patients 18-65 years old consecutively referred to a psychiatry liaison service with panic disorder (DSM-IV criteria) were offered either mirtazapine or paroxetine treatment. Results There were statistically significant reductions from baseline to week 3 and from week 3 to 8 for mirtazapine and paroxetine groups for: number of panic attacks, Beck Anxiety or Depression Inventory (BAI, BDI) Clinical Global Impresion (CGI) of panic disorder severity and CGI of panic disorder response (these variables were evaluated by the patient, the clinician or a blind evaluator). Responders at week 3 (BAI decrease of 50%) were 83% for the mirtazapine group and 84% for the paroxetine group. Responders at week 8 (number of panic attacks equal to 0) were 77% for the mirtazapine group and 73% for the paroxetine group Statistically significant differences between mirtazapine and paroxetine were found for number of panic attacks at weeks 3 and 8 and BAI at week 3, suggesting a faster response for mirtazapine. Responders at week 8 maintained a no recurrence figure of 95% at follow-up 6 months later. Panic disorder either with or without comorbid depression improved in both groups of treatment. Discussion Our study supports the hypothesis that mirtazapine has efficacy in the treatment of panic disorder either with or without comorbid depression.

[Assessment of Machiavellian intelligence in antisocial disorder with the MACH-IV Scale]. / Valoración de la Inteligencia maquiavélica en el trastorno antisocial mediante la Escala MACH-IV.

INTRODUCTION: The objective is to evaluate the presence of Machiavellian intelligence with the MACH-IV Scale in antisocial patients versus community controls. MATERIAL AND METHODS: Categorical diagnosis and dimensional evaluation program according to IPDE were obtained from 26 controls from the community and 40 patients from a methadone program. Both groups were evaluated on cooperation with TCI and on Machiavellian intelligence with MACH-IV. RESULTS: Higher figures in MACH-IV Global Score, Tactics subscale (to manipulate others), Visions subscale (interpretations on Machiavellian behavior of others) were found in the 20 antisocial patients compared with the 26 community controls achieving statistical significance. No statistical differences were found for Morality subscale scores (abstract morality) between groups. Dimensional evaluation of antisocial disorder according to IPDE shows statistically significant positive correlations for Tactics subscale, Visions subscale and Global Score of MACH-IV scale, but no statistically significant correlation was found for Morality subscale. There is a statistically significant negative correlation between MACH-IV Tactics subscale and TIC altruism subscale. CONCLUSIONS: Antisocial patients have the same level of abstract moral attitudes as controls but are prone to use Machiavellian intelligence to interpret the actions of others, rationalize their own conduct and manipulate the behavior of others to get a benefit. These data support the hypothesis that many of the features of the antisocial syndrome may be explained by an abnormal development of an innate predisposition to be dominant in social relationships.

[Antisocial personality disorder evaluation with the prisoner's dilemma]. / Evaluación del trastorno antisocial de personalidad con el dilema del prisionero.

INTRODUCTION: The aim of this study is to evaluate cooperation problems in antisocial disorder with the prisoner's dilemma game, which, in mathematical game theory, is the paradigm of the <> games (mutual benefit from cooperation). METHODS: We have designed a computer version of the prisoner's dilemma (CDT-BD) that confronts the patient to a simulation of a reciprocal exchange situation. IPDE provided us a categorical and dimensional evaluation of 26 controls from the community and 40 methadone patients. Only methadone patients obtained an antisocial diagnosis: 20 in the category of positive antisocial and 10 in the probable antisocial category. Patients also fullfilled TCI and MACH-IV. RESULTS: CDT-BD is, according to the parent's opinion (mothers), a good correlation of real life behavior. CDT-BD shows a statistically significant poorer cooperation of antisocial patients this is catego rical evaluation (ve rsus in controls) and in dimensional evaluation true both for variables that measure non-cooperation due to the patient's initiative and those as a response to the computer provocation. This may be due to a tendency of antisocials to use interchange situations <> strategies (you win what the other player loses) instead of non-zero games strategies. Non-cooperative responses are correlated to high scores on the MACH-IV scale (manipulative behavior and cognition) and revengeful in Treatment and Character Inventory (TCI). CONCLUSIONS: CDT-BD allows us to generate and test new hypotheses on the causes of the cooperation problems in antisocial patients using game theory paradigms.

[Swallowing phobia: a case report]. / Fobia a tragar: a propósito de un caso.

Choking phobia is characterized by fear and avoidance of swallowing food, fluids or pills. It often appears in women after an episode of choking on food. We present the case of an adolescent beginning her phobia after a mononucleosis with severe dysphagia. Patient's solid restriction raised concerns about differential diagnosis with eating disorders. She was treated with psychoeducation, cognitive restructuring and graduated exposure in vivo, achieving a total recovery.

[Efficacy of gabapentin in a sample of bipolar patients]. / Eficacia de gabapentina en una muestra de trastornos bipolares.

INTRODUCTION: Field studies support the idea of gabapentin being helpful in the maintenance, and in the treatment of some symptoms in bipolar patients. Our study evaluates relapse rates previous and after gabapentin administration in severe bipolar patients. METHODOLOGY: Gapabentine was administered to all consecutive bipolar patients from a relapse prevention program who could not be given lithium, valproic acid or carbamacepin because of his current medical condition or his past history of secondary effects or lack of response to those treatments. Number and severity of relapses were evaluated before and after gabapentin administration. RESULTS: Seven patients were included in the study. Medium maintenance period with gabapentine was 9 months. In the gabapentin period, relapses per month increased from 0.18 in the previous three years to 0.29. This may be due because six patients interrupted abruptly previous treatment in less than 1 week. Relapses severity, evaluated by measuring length and number of hospitalisations, and number of interviews by month, was similar to the three previous years, and better than the period from the beginning of the condition. Clinical Global Impression evaluated gabapentin as similar to previous mood stabilizers in five patients and better in two. Irritability and dysphoria improved in all the patients. CONCLUSION: Although gabapentin may be helpful in some patients, a clinical essay that shows its efficacy as add-on treatment is need.

[Psychotic syndrome after withdrawal of cyproheptadine: remission with olanzapine]. / Síndrome psicótico tras suspensión de ciproheptadina: remisión con olanzapina.

Cyproheptadine is a drug with direct antimuscarinic, antihistaminic (H1) and antiseronergic (5HT2) effects. In spite of its use as an orexigenic agent in normal or anorectic subjects, little is known about its effect in affective, anxiety or psychotic disorders. We present the case of a 14-year patient beginning with a psychotic syndrome after the sudden withdrawal cyproheptadine, achieving a total control of the symptoms with olanzapine at low dose, besides a good family, school and social adaptation.

[Obsessive psychotic disorder in adolescence]. / Trastorno obsesivo psicótico en la adolescencia.

Relationship between obsessive-compulsive disorder (OCD) and psychotic pathology is a controversial one. Case reports indicate that OCD with psychotic features is generally more severe and antidepressant-refractory than neurotic OCD. Behaviour therapy is shown to be ineffective in OCD patients with psychotic features. One of the subtypes includes reactive paranoid forms, with fluctuating clinical course, in obsessive patients with delusional thoughts that improve with neuroleptic augmentation of the serotonin reuptake inhibitor (SRI) treatment for OCD. We present the case of a 17-year-old woman with family history of OCD, starting with panic symptoms after cannabis use, but suddenly developing OCD with avoidant behavior and delusional ideas of self-reference and persecution. Response to behavior therapy and SRI and neuroleptics is analyzed.

[Compulsive buying: a new disorder?]. / Compra compulsiva: un nuevo trastorno?

Despite its high frequency and its severe financial, social and personal complications, compulsive buying is rarely described in the psychiatric literature. We reviewed all the published papers on this syndrome to describe its clinical features, epidemiology and response to drug or psychological treatment. Psychiatric comorbidity is also reviewed and nosologic implications are analyzed.