The Limbic System in Youth Depression: Brain Structural and Functional Alterations in Adolescent In-patients with Severe Depression.

Adolescent-onset major depressive disorder (MDD) is associated with an increased risk of recurrent depressive episodes, suicidal behaviors, and psychiatric morbidity throughout the lifespan. The objective of the present study was to investigate brain structural and functional changes in adolescent patients with MDD. Furthermore, we aimed to clarify the influence of early-life stress on brain function and structure. The study investigated adolescent patients with severe MDD (n=20, mean age=16.0, range=15-18 years) and a control sample of matched healthy adolescents (n=21, mean age=16.6, range=15-18 years). Functional MRI data were obtained using a face-matching paradigm to investigate emotion processing. Structural MRI data were analyzed using voxel-based morphometry (VBM). In line with previous studies on adult MDD, adolescent patients showed elevated amygdala activity to negative and reduced amygdala activity to positive emotional stimuli. Furthermore, MDD patients showed smaller hippocampal volumes compared to healthy adolescents. Higher levels of childhood maltreatment were associated with smaller hippocampal volumes in both depressed patients and healthy controls, whereby no associations between amygdala reactivity and childhood maltreatment were found. Our results suggest that hippocampal alterations in youth MDD patients may at least partly be traced back to higher occurrence of early-life adverse experiences. Regarding the strong morphometric impact of childhood maltreatment and its distinctly elevated prevalence in MDD populations, this study provides an alternative explanation for frequently observed limbic structural abnormalities in depressed patients.

[Attachment Patterns and their Relation to the Development of Anxiety Symptoms in Childhood and Adolescence]. / Der Zusammenhang von Bindungsmustern und der Entwicklung von Angstsymptomen im Kindes- und Jugendalter.

From the perspective of attachment theory, insecure attachment can be seen as a key risk factor for the development of anxiety symptoms and anxiety disorders. This systematic review addresses the current state of empirical research on the relationship between attachment status and anxiety symptoms respective anxiety disorders in childhood and adolescence. 21 current international studies published between 2010 and 2014 were included in this systematic review. These studies were heterogeneous in target populations, methods and study design. The majority of studies supported the assumed correlation between insecure attachment and anxiety symptoms or anxiety disorders. These findings are more evident in studies with school-age children than with preschool children or adolescents. Furthermore, the disorganized-disoriented type of attachment seems to be a particular risk factor for the development of anxiety symptoms and anxiety disorders. Results were discussed in relation to attachment theory and with reference to the results of previous relevant reviews.

Psychiatric treatment outcomes of preschool children in a family day hospital.

This study describes the treatment outcomes of preschoolers with severe mental health problems who were treated at the child psychiatric family day hospital for preschool children in Münster, Germany. The eclectic multi-modal treatment combines behavioral and psychodynamic techniques for both parents and children in various settings within an intermittent attendance structure provided by a multi-disciplinary team. This study evaluated 185 children with the Caregiver-Teacher Report Form (C-TRF/1.5-5), which was completed by therapists, and the Child Behavior Checklist (CBCL/1.5-5), which was completed by mothers, at admission and discharge. The mothers' ratings of their children were statistically adjusted for the distortion caused by their own psychopathology. After treatment, the patients showed significant improvement on the C-TRF/CBCL Total Problem score with an average Cohen's d = -0.50 based on therapists' ratings, d = -0.97 for the non-adjusted maternal ratings, and d = -0.68 for the adjusted maternal ratings. We conclude that specialized family day hospitals may successfully treat preschool psychiatric patients.

[Multiprofessional intermittent psychiatric treatment of children in preschool age and their parents in a family day clinic]. / Multiprofessionelle Intervallbehandlung psychisch kranker Kinder im Vorschulalter und ihrer Eltern in einer Familientagesklinik.

Psychiatric treatment of children in preschool age (0-6 years) and their parents is an expanding field of research due to its high clinical significance. Specific family psychiatric treatment programs have been developed to meet the demands of this young age group, but are little known. A multiprofessional intermittent treatment approach sensitive to developmental and family context has been established in the Preschool Family Day Hospital for Infants, Toddlers and Preschoolers and their Families at Münster University Hospital, Germany. Group and individual therapeutic interventions for both children and parents, video-based parent-child-interaction therapy, psychiatric and psychotherapeutic treatments of parents and family therapeutic interventions integrating siblings are supporting and enhancing each other in an innovative and integrated family psychiatric program. First results of evaluation studies are reported that show that this treatment is effective.

Insular and hippocampal gray matter volume reductions in patients with major depressive disorder.

BACKGROUND: Major depressive disorder is a serious psychiatric illness with a highly variable and heterogeneous clinical course. Due to the lack of consistent data from previous studies, the study of morphometric changes in major depressive disorder is still a major point of research requiring additional studies. The aim of the study presented here was to characterize and quantify regional gray matter abnormalities in a large sample of clinically well-characterized patients with major depressive disorder. METHODS: For this study one-hundred thirty two patients with major depressive disorder and 132 age- and gender-matched healthy control participants were included, 35 with their first episode and 97 with recurrent depression. To analyse gray matter abnormalities, voxel-based morphometry (VBM8) was employed on T1 weighted MRI data. We performed whole-brain analyses as well as a region-of-interest approach on the hippocampal formation, anterior cingulate cortex and amygdala, correlating the number of depressive episodes. RESULTS: Compared to healthy control persons, patients showed a strong gray-matter reduction in the right anterior insula. In addition, region-of-interest analyses revealed significant gray-matter reductions in the hippocampal formation. The observed alterations were more severe in patients with recurrent depressive episodes than in patients with a first episode. The number of depressive episodes was negatively correlated with gray-matter volume in the right hippocampus and right amygdala. CONCLUSIONS: The anterior insula gray matter structure appears to be strongly affected in major depressive disorder and might play an important role in the neurobiology of depression. The hippocampal and amygdala volume loss cumulating with the number of episodes might be explained either by repeated neurotoxic stress or alternatively by higher relapse rates in patients showing hippocampal atrophy.

Inter-rater reliability and aspects of validity of the parent-infant relationship global assessment scale (PIR-GAS).

BACKGROUND: The Parent-Infant Relationship Global Assessment Scale (PIR-GAS) signifies a conceptually relevant development in the multi-axial, developmentally sensitive classification system DC:0-3R for preschool children. However, information about the reliability and validity of the PIR-GAS is rare. A review of the available empirical studies suggests that in research, PIR-GAS ratings can be based on a ten-minute videotaped interaction sequence. The qualification of raters may be very heterogeneous across studies. METHODS: To test whether the use of the PIR-GAS still allows for a reliable assessment of the parent-infant relationship, our study compared a PIR-GAS ratings based on a full-information procedure across multiple settings with ratings based on a ten-minute video by two doctoral candidates of medicine. For each mother-child dyad at a family day hospital (N = 48), we obtained two video ratings and one full-information rating at admission to therapy and at discharge. This pre-post design allowed for a replication of our findings across the two measurement points. We focused on the inter-rater reliability between the video coders, as well as between the video and full-information procedure, including mean differences and correlations between the raters. Additionally, we examined aspects of the validity of video and full-information ratings based on their correlation with measures of child and maternal psychopathology. RESULTS: Our results showed that a ten-minute video and full-information PIR-GAS ratings were not interchangeable. Most results at admission could be replicated by the data obtained at discharge. We concluded that a higher degree of standardization of the assessment procedure should increase the reliability of the PIR-GAS, and a more thorough theoretical foundation of the manual should increase its validity.

The neural basis of cognitive change: reappraisal of emotional faces modulates neural source activity in a frontoparietal attention network.

Emotions can be regulated effectively via cognitive change, as evidenced by cognitive behavioural therapy. The neural correlates of cognitive change were investigated using reappraisal, a strategy that involves the reinterpretation of emotional stimuli. Hemodynamic studies revealed cortical structures involved in reappraisal and highlighted the role of the prefrontal cortex in regulating subcortical affective processing. Studies using event-related potentials elucidated the timing of reappraisal by showing effective modulation of the Late Positive Potential (LPP) after 300ms but also even earlier effects. The present study investigated the spatiotemporal dynamics of the cortical network underlying cognitive change via inverse source modelling based on whole-head magnetoencephalography (MEG). During MEG recording, 28 healthy participants saw angry and neutral faces and followed instructions designed to down- or up-regulate emotions via reappraisal. Differences between angry and neutral face processing were specifically enhanced during up-regulation, first in the parietal cortex during M170 and across the whole cortex during LPP-M, with particular involvement of the parietal and dorsal prefrontal cortex regions. Thus, our data suggest that the reappraisal of emotional faces involves specific modulations in a frontoparietal attention network.

Implementing psychiatric day treatment for infants, toddlers, preschoolers and their families: a study from a clinical and organizational perspective.

BACKGROUND: An increasing number of empirical studies indicate that infants, toddlers and preschoolers may suffer from non-transient mental illnesses featuring developmental psychopathology. A few innovative child psychiatric approaches have been developed to treat infants, toddlers and preschoolers and their families, but have not yet been conceptually presented and discussed in the framework of different healthcare systems. The organizational and clinical experience gained while developing specific approaches may be important across disciplines and guide future developments in psychiatric treatment of infants, toddlers, preschoolers and their families. RESULTS: This article introduces the Preschool Family Day Hospital for Infants, Toddlers and Preschoolers and their Families at Münster University Hospital, Germany. This hospital is unique in the German healthcare system with regard to its social-service institution division of labor. Specifically, it uses an intermittent treatment approach and an integrated interactional family psychiatric approach to treat children and their parents as separate patients. This multidisciplinary, developmentally and family-oriented approach includes components of group treatments with children and separate treatments with parents. Specific techniques include video-assisted treatments of the parent-child interaction, psychiatric and psychotherapeutic treatments for parents, and conjoint family therapies that include both parents and siblings. CONCLUSIONS: The Family Day Hospital for infants, toddlers and preschoolers and their families offers innovative family-oriented treatments for those who suffer from a wide range of severe child psychiatric disorders that cannot be sufficiently treated in outpatient settings. Treatment is based on the need for family-oriented approaches to the early psychiatric treatment of infants, toddlers and preschoolers. Family day hospitals are an innovative approach to preschool child psychiatry that requires further evaluation.

Beyond the blues: towards a cross-cultural phenomenology of depressed mood.

BACKGROUND: There is a great cultural variety in the social phenomenology of depressed mood. The aim of this qualitative study was to compare English and Laotian Hmong semantic and pragmatic differences in depressed mood and to assess their relevance for cross-cultural psychiatric research and practice. SAMPLING AND METHOD: The first author conducted long-term ethnographic fieldwork from 2000 to 2002 among the Hmong in Laos. Methods included participant observation, interviews and focus group interviews in the Hmong language. The semantic and pragmatic context of Hmong depressed mood tu siab, literally translated as 'broken liver', is compared to that of 'sadness' in Western contexts. RESULTS: Hmong 'broken liver' and English 'sadness' are deeply shaped by culture-specific premises concerning notions of social interaction, morality, interiority, socialisation, and cosmology. CONCLUSIONS: Critical attention has to be paid when assessing depressed mood cross-culturally. A social phenomenology combining qualitative and quantitative methods should be developed to analyse important semantic and pragmatic differences of depressed mood across cultural contexts.

Prognosis and continuity of child mental health problems from preschool to primary school: results of a four-year longitudinal study.

In a four-year longitudinal study, changes in and continuity of behavioral and emotional problems were examined in 814 subjects from kindergarten to primary school. Mental health problems were assessed by means of the Child Behavior Checklist (CBCL). The distribution of the CBCL broadband groups revealed a high level of continuity of internalizing symptoms over the four-year period and a shift from externalizing symptoms at baseline towards a combination of internalizing and externalizing symptoms at follow-up. The presence of mental health problems at follow-up was correlated with gender (higher amongst boys), pre-existing mental health problems at baseline, and separation or divorce of the parents, but not with single-family status or the age and educational level of the mother. The increasing number of children with a combination of internalizing and externalizing symptoms demonstrates the increasing complexity of child mental health problems in the developmental span from preschool age to school age.

Regulatory disorders in early childhood: Correlates in child behavior, parent-child relationship, and parental mental health.

According to the guidelines published by the German Society of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (2007), regulatory disorders of early childhood are characterized by a symptom triad, including (a) behavioral symptoms such as excessive crying, sleeping, or feeding problems; (b) a disturbed parent-child relationship; and (c) parental psychopathology. On the basis of a clinic-referred sample of 162 children, we examined whether children with and without regulatory symptoms differed in the quality of parent-child relationship and parental mental health, and how often the criteria of the symptom triad were fulfilled in the group of children with regulatory symptoms. In addition, emotional and behavior problems were compared in children with and without regulatory symptoms. Children with regulatory symptoms and children with other psychiatric symptoms did not differ with respect to child-parent relationship quality. However, parents of children with regulatory symptoms scored higher on the Symptom Checklist 90 Items-Revised (G.H. Franke, 2002) than did the other parents. On the Child Behavior Checklist (T.M. Achenbach & L.A. Rescorla, 2000), children with regulatory symptoms tended to show more somatic problems, but they showed significantly less withdrawn behavior than did the other children. Of the 67 children with regulatory symptoms, only 11 (16.4%) fulfilled all three criteria of a regulatory disorder.

Limbic scars: long-term consequences of childhood maltreatment revealed by functional and structural magnetic resonance imaging.

BACKGROUND: Childhood maltreatment represents a strong risk factor for the development of depression and posttraumatic stress disorder (PTSD) in later life. In the present study, we investigated the neurobiological underpinnings of this association. Since both depression and PTSD have been associated with increased amygdala responsiveness to negative stimuli as well as reduced hippocampal gray matter volume, we speculated that childhood maltreatment results in similar functional and structural alterations in previously maltreated but healthy adults. METHODS: One hundred forty-eight healthy subjects were enrolled via public notices and newspaper announcements and were carefully screened for psychiatric disorders. Amygdala responsiveness was measured by means of functional magnetic resonance imaging and an emotional face-matching paradigm particularly designed to activate the amygdala in response to threat-related faces. Voxel-based morphometry was used to study morphological alterations. Childhood maltreatment was assessed by the 25-item Childhood Trauma Questionnaire (CTQ). RESULTS: We observed a strong association of CTQ scores with amygdala responsiveness to threat-related facial expressions. The morphometric analysis yielded reduced gray matter volumes in the hippocampus, insula, orbitofrontal cortex, anterior cingulate gyrus, and caudate in subjects with high CTQ scores. Both of these associations were not influenced by trait anxiety, depression level, age, intelligence, education, or more recent stressful life events. CONCLUSIONS: Childhood maltreatment is associated with remarkable functional and structural changes even decades later in adulthood. These changes strongly resemble findings described in depression and PTSD. Therefore, the present results might suggest that limbic hyperresponsiveness and reduced hippocampal volumes could be mediators between the experiences of adversities during childhood and the development of emotional disorders.

Moral agency, identity crisis and mental health: an anthropologist's plight and his Hmong ritual healing.

During anthropological fieldwork, the author had a serious accident on the outskirts of a Hmong village in the highland of Laos. However, this dramatic incident turned out to be the occasion of his ritual initiation into the local village community. An analysis of narratives of the incident reveals Hmong conceptions of the anthropologist's physical, mental and moral affliction, its causative concomitants and his ritual healing. Hmong mental health and identity are situated in a moral space of exchange relationships to significant others, challenging basic assumptions of concepts of the person widely held in psychiatry and beyond. The healing ritual transformed the author's being from indeterminate "other," in a life-threatening state of identity crisis, to a wholesome Hmong "self," in a state of health and moral agency. This exemplary rite de passage highlights the affinity of ritual healing and constitution of self in a moral space. The underlying relational concept of the person is in sharp contrast to psychiatry's concepts of the person, which are deeply shaped by values of individualism. Psychiatric services must accommodate substantial differences in the concepts of the person when treating Hmong migrants from Laos.

Five systems of psychiatric classification for preschool children: do differences in validity, usefulness and reliability make for competitive or complimentary constellations?

DSM-IV and ICD-10 have limitations in the diagnostic classification of psychiatric disorders at preschool age (0-5 years). The publication of the Diagnostic Classification 0-3 (DC:0-3) in 1994, its basically revised second edition (DC:0-3R) in 2005 and the Research Diagnostic Criteria-Preschool Age (RDC-PA) in 2004 have provided several modifications of these manuals. Taking into account the growing empirical evidence highlighting the need for a diagnostic classification system for psychiatric disorders in preschool children, the main categorical classification systems in preschool psychiatry will be presented and discussed. The paper will focus on issues of validity, usefulness and reliability in DSM-IV, ICD-10, RDC-PA, DC:0-3, and DC:0-3R. The reasons for including or excluding postulated psychiatric disorder categories for preschool children with variable degrees of empirical evidence into the different diagnostic systems will be discussed.