Increased tobacco and alcohol use among women with joint hypermobility: a way to cope with anxiety?

Joint hypermobility (JH) is a common trait of heritable disorders of the connective tissue which has been identified as a risk factor for anxiety states. Anxiety and other negative emotions lead some people to use tobacco and alcohol as a coping strategy. The purpose of this study was to examine JH in relation to the consumption of these psychoactive substances and the associated anxiety and coping strategies. A cross-sectional sample of 305 female college students completed self-administered questionnaires on JH, tobacco and alcohol use, state and trait anxiety, and coping strategies. The prevalence of JH in the final sample (N = 301) was 51.8 %. The percentage of smokers, smokers using tobacco to calm anxiety, at-risk drinkers, tobacco and alcohol users, and the number of standard drinks consumed per week were significantly higher among females with JH than among those without it. The percentage of participants with severe state anxiety was significantly higher in the JH group, as were the emotion-focused coping score. The results of the logistic regression analysis showed that the odds of being assessed with JH were greater in those who consume tobacco and alcohol. This study provides evidence that women with JH report higher levels of state anxiety than non-JH women and use emotion-focused coping (i.e., efforts to regulate affect) more than any other coping strategies to deal with stress. These factors may help explain the increase in tobacco and alcohol use observed in this population.

Brain regions related to fear extinction in obsessive-compulsive disorder and its relation to exposure therapy outcome: a morphometric study.

BACKGROUND: The size of particular sub-regions within the ventromedial prefrontal cortex (vmPFC) has been associated with fear extinction in humans. Exposure therapy is a form of extinction learning widely used in the treatment of obsessive-compulsive disorder (OCD). Here we investigated the relationship between morphometric measurements of different sub-regions of the vmPFC and exposure therapy outcome in OCD. METHOD: A total of 74 OCD patients and 86 healthy controls underwent magnetic resonance imaging (MRI). Cortical thickness and volumetric measurements were obtained for the rostral anterior cingulate cortex (rACC), the medial orbital frontal cortex and the subcallosal cortex. After MRI acquisition, patients were enrolled in an exposure therapy protocol, and we assessed the relationship between MRI-derived measurements and treatment outcome. Baseline between-group differences for such measurements were also assessed. RESULTS: Compared with healthy controls, OCD patients showed a thinner left rACC (p = 0.008). Also, left rACC thickness was inversely associated with exposure therapy outcome (r - 0.32, p = 0.008), and this region was significantly thinner in OCD patients who responded to exposure therapy than in those who did not (p = 0.006). Analyses based on regional volumetry did not yield any significant results. CONCLUSIONS: OCD patients showed cortical thickness reductions in the left rACC, and these alterations were related to exposure therapy outcome. The precise characterization of neuroimaging predictors of treatment response derived from the study of the brain areas involved in fear extinction may optimize exposure therapy planning in OCD and other anxiety disorders.

Striatal volume deficits in children with ADHD who present a poor response to methylphenidate.

Methylphenidate (MPH) is the first choice of medical treatment for attention-deficit/hyperactivity disorder (ADHD). Its mechanism of action is to inhibit the reuptake of dopamine and noradrenaline mainly in the region of the striatum. It has been estimated that 10-30 % of patients with ADHD do not respond adequately to MPH. The aim of this study was to evaluate whether striatal differences exist between good and poor responders to MPH. The sample included 27 treatment-naïve children with ADHD between the ages of 6 and 14. MPH administration started 1 day after the MRI acquisition. After a month, psychiatrists established the good or poor response to treatment according to clinical criteria. MRI images were analyzed using a technique based on regions of interest applied specifically to the caudate and accumbens nuclei. Sixteen patients showed good response to MPH and 11 a poor one. Regions of interest analysis showed that good responders had a higher concentration of gray matter in the head of both caudate nuclei and the right nucleus accumbens. Furthermore, a significant correlation was found between caudate and accumbens nuclei volume and the Conners' Parent Rating Scale and Continuous Performance Test improvement. These results support the hypothesis of the involvement of the caudate and accumbens nuclei in MPH response and in ADHD pathophysiology.

Concurrent Koro and Cotard syndromes in a Spanish male patient with a psychotic depression and cerebrovascular disease.

Koro and Cotard syndromes are uncommon conditions described in a variety of psychiatric and medical disorders. The authors report the third case of a simultaneous presentation of both syndromes, in a 62-year-old inpatient Spanish male with major depressive disorder with psychotic features, parkinsonism and cognitive impairment. A discussion of the literature and the possible relationship between both syndromes and other neuropsychiatric disorders are presented.

Gray matter volume deficits and correlation with insight and negative symptoms in first-psychotic-episode subjects.

OBJECTIVE: To determine brain areas reduced in first episode of psychotic subjects and its association with lack of insight and negative symptoms. METHOD: Twenty-one drug naive first-episode subjects and 20 controls underwent a structural MRI scan and were clinically assessed. Optimized voxel-based-morphometry analysis (VBM) was implemented to find between-group differences and correlations between GM volume and: (i) lack of insight and (ii) negative symptoms. RESULTS: Patients showed GM reduction in prefrontal and left temporal areas. A significant correlation was found between insight and GM volume in the cerebellum (corrected P = 0.01), inferior temporal gyrus (corrected P = 0.022), medial superior frontal gyrus (corrected P < 0.001), and inferior frontal gyrus (corrected P = 0.012), as the insight decreased, the volume decreased. Negative symptoms correlated with decreased GM volume at cerebellum (corrected P = 0.037) and frontal inferior regions (corrected P < 0.001), the more negative symptoms, the less volume. CONCLUSION: Our findings support an association between prefrontal, temporal, and cerebellar deficits and lack of insight in schizophrenia and confirm previous findings of GM deficits in patients since the first episode of psychosis.

Impact of psychiatric and neuropsychological sequelae of traumatic brain injury on the duration of legal time periods.

INTRODUCTION: In the forensic setting, diagnosis of sequels and determination of the legal periods are central to the assessment of traumatic brain injury (TBI). The analysis of the relationship between descriptors of TBI and legal periods is undertaken. METHOD: Retrospective study of 50 TBI. Demographic information, severity and characteristics of the TBI, neuroimaging data, treatments, legal periods and sequels were gathered. Descriptive statistics and correlational analysis were performed. RESULTS: Glasgow Comma Scale was available in 47 cases but coma duration and posttraumatic amnesia only in 21. There was information on early TAC in 48 cases and followup neuroimaging (after three months) was available in 46. 26 patients received the diagnosis organic personality disorder and this correlated with longer legal periods. Affective disorder (N=6), anxiety disorder (N=5) and postconcussional syndrome (N=5) were less prevalent. Average "time in hospital" was longer than two months. "Healing time" and "disability time" were on average longer than a year. "Healing time" and "time in hospital" were longer with left sided lesions. CONCLUSION: In the forensic assessment of TBI, availability of information regarding the duration of coma and posttraumatic amnesia should be improved. Left sided lesions and the presence of organic personality disorder predict longer legal periods. Understanding of these facts requires a more detailed analysis.

Immigrants and borderline personality disorder at a psychiatric emergency service.

BACKGROUND: Several studies have suggested that immigrants have higher rates of psychiatric emergency service use and a higher risk of mental disorders such as schizophrenia than indigenous populations. AIMS: To compare the likelihood that immigrants (immigrant group) v. indigenous population (indigenous group) will be diagnosed with borderline personality disorder in a psychiatric emergency service and to determine differences according to area of origin. METHOD: A total of 11 578 consecutive admissions over a 4-year period at a tertiary psychiatric emergency service were reviewed. The collected data included socio-demographic and clinical variables and the Severity of Psychiatric Illness rating score. Psychiatric diagnosis was limited to information available in the emergency room given that a structured interview is not usually feasible in this setting. The diagnosis of borderline personality disorder was based on DSM-IV criteria. Immigrants were divided into five groups according to region of origin: North Africa, sub-Saharan Africa, South America, Asia and Western countries. RESULTS: Multivariate statistical logistic regression analysis showed that all subgroups of immigrants had a lower likelihood of being diagnosed with borderline personality disorder than the indigenous population independently of age and gender. Furthermore, the rates of borderline personality disorder diagnosis were considerably lower in Asian and sub-Saharan subgroups than in South American, North African, Western or native subgroups. CONCLUSIONS: Our results showed that in the psychiatric emergency service borderline personality disorder was diagnosed less frequently in the immigrant group v. the indigenous group. Our results do not support the concept of migration as a risk factor for borderline personality disorder.

Onset of mania after CPAP in a man with obstructive sleep apnea.

BACKGROUND: This short report presents the case of a man with chronic anergy and mild depressive symptoms probably due to obstructive sleep apnea (OAS). METHOD: The patient was treated with continuous positive airway pressure (CPAP). RESULT: He developed a first manic episode at an atypical age simultaneously with the beginning of treatment. DISCUSSION: Several possible connections between affective syndromes, OAS, and CPAP treatment are proposed and discussed relating to current literature.

Clinical characteristics and psychopathological profile of patients with vulvodynia: an observational and descriptive study.

BACKGROUND: Vulvodynia is a fairly common dermatological symptom that often interferes with the personal, social and working activities of affected women and results in a significant loss of their quality of life. It is a persistent and tedious clinical disorder which is often resistant to conventional treatments. OBJECTIVES: The aim of this study is to evaluate the main clinical signs, associated psychopathological disorders and outcome after antidepressant treatment of patients with vulvodynia. METHODS: Eighty patients were included. Clinical characteristics and psychopathological profiles were determined by appropriate instruments. The improvement of clinical symptoms after combined antidepressant drug therapy was also evaluated. RESULTS: Pain (70%), burning (63.7%), dyspareunia (57.5%) and stinging (56.2%) were the most commonly reported symptoms. Most patients (56.5%) showed anxiety, and 52.2% of them were reported as having a depression disorder. When evaluated by psychometric tools, 81.4% of patients scored >150 on the Life Event Scale, which means a risk >50% of suffering an illness in the near future, and patients' scores in the Dermatology Life Quality Index showed higher values than the mean of the Spanish validation group. After 6 months of combined treatment with escitalopram (10-20 mg/day), perfenazine (2-4 mg/day) and amytriptiline (10 mg/day), a complete remission of the clinical symptoms was achieved in 41% of patients. In contrast, only 12% of patients who did not follow drug treatment reported a complete resolution of the clinical symptoms. CONCLUSIONS: Our results seem to confirm that vulvodynia is associated with psychiatric co-morbidity such as stress and depression. The study highlights that the psychiatric treatment may be a useful option to improve clinical symptoms. Whether these patients should be evaluated for depression or be referred to a psychiatrist, remains to be investigated.

Spanish translation and analysis of the metric properties of inpatient satisfaction scale in psychiatry: The Satispsy-22-E.

The Satispsy-22 scale is an instrument created for the specific evaluation of psychiatric inpatient satisfaction. Therefore, the study aims to carry out the Satispsy-22 scientific translation to Spanish and to learn its psychometric properties. The Satipsy-22-E was administered to discharged patients from four units of acute psychiatric admission, a unit of dual pathology and two units of subacute psychiatric admission (N = 268). Cronbach's alpha was 0.886, which can be interpreted as good internal reliability. All the dimensions showed a good internal consistency with scores from 0.722 to 0.919. Test-retest offered scores of 0.752-0.951 showing good stability. Confirmatory factor analysis showed that all elements load in the estimated dimensions of the original scale and these were significant and the adjustment measures showed, in general, a rather good adjustment, Root Mean Square Error (RMSE) showed that the error between observations and actual data is small and acceptable. Satispsy-22-E is a specific scale in Spanish language for the assessment of psychiatric inpatient satisfaction. It is an easy to use tool that offers good psychometric properties. The availability of a validated survey in Spanish may help to improve the care provided by psychiatric wards in Spanish-speaking countries.

Cross validation with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Spanish: the 32 item hypomania symptom check list (HCL-32).

BACKGROUND: The detection and diagnosis of present or past hypomanic episodes is of key importance for the differential diagnosis between depressive disorders and type II bipolar disorder. However, there are few instruments available to satisfactorily screen for the latter condition. The Hypomania Symptom Checklist-32 (HCL-32) is a self-applied questionnaire with 32 hypomania items and 8 severity and functional impact items which is being developed in several European countries for this purpose. Our aim was to develop and validate the psychometric properties of the HCL-32 scale in Spain in patients with bipolar disorder and to compare its properties with other instruments available for the detection of bipolar II disorder. METHODS: Patients were selected from 15 psychiatric outpatient departments, diagnosed with type I or type II bipolar disorder (BDI and BDII) and unipolar major depression (MD) according to DSM-IV-TR criteria. A control group of healthy subjects (HS) was likewise assessed. The patient selection criteria included a well-established diagnosis and a stable disorder and pharmacological treatment. The HCL-32 was administered to 237 subjects distributed among the above groups, on two occasions four weeks apart. We analysed the internal consistency, test-retest reliability and discriminative capacity of the HCL-32. RESULTS: The internal consistency of the Spanish version of the HCL-32, evaluated by Cronbach's alpha, was 0.94. Mean of affirmative questions by group were 21.2 (SD 5.8) for BDI, 19.3 (SD 6.2) for BDII, 8.6 (SD 6.6) for MD and 6.6 (SD 6.1) for HS, with statistically significant differences between them (Kruskal-Wallis test, p<0.001). Concurrent validity using the diagnosis variable was 0.72. Test-retest reliability was 0.90. We analysed the best cut-off point by means of a ROC curve analysis; for 14 affirmative responses, a sensitivity of 0.85 95%CI (0.78, 0.91) and specificity of 0.79, 95%CI (0.72, 0.87) were obtained. The positive and negative probability ratios were 4.1 and 5.3 (1/0.19 respectively). HCL-32 shows a dual factor structure of items, one as an energy-activity factor and another one as a factor involving items related to disinhibition and problems with self-control and attention. LIMITATIONS: The sample size of bipolar patients (particularly type BDII) should be increased in further studies. CONCLUSIONS: The Spanish version of the HCL-32 has good psychometric properties and sufficient sensitivity and specificity, detecting 8 out of every 10 patients with BD. The HCL-32 is a useful screening tool of patients with bipolar disorder in clinical settings. In its present form it adequately discriminates between bipolar and unipolar or healthy subjects, but not between BD I and BII.

Depression in internal medicine inpatients at the time of hospital discharge and referral to primary care

Background and objectives. This is the first multi-center study intended to document the prevalence, characteristics, and associations of depression in Medicine patients at the time of hospital discharge and their referral to Primary Care (PC). Methods. Adult patients randomly selected among consecutive admissions to Medicine wards in 8 hospitals in Spain, covering health districts, were examined in a two-phase 'case-finding' procedure. Standardized, Spanish versions of instruments were used, including the Standardized Polyvalent Psychiatric Interview (SPPI) and Cumulative Illness Rating Scale (CIRS). Cases of depression were diagnosed according to ICD-10 general hospital research criteria. Results. Three hundred and twelve patients with treatable depression and 777 non-depressed controls were identified. In a conservative estimate, the global prevalence of major depression was 7.1%, dysthymia 4.2% and adjustment depression 7.1%, and 51.9% of cases were of moderate/ severe intensity. Depression was more frequent in women, the differences being significant in all categories of depression. The prevalence of depression was lower in individuals aged 85 or more years, the differences being significant in cases of both dysthymia and adjustment depression. A clear pattern of decreasing prevalence with age was observed in women. The depressed had as an average five medical systems affected, and higher CIRS scores compared with the controls, the differences being significant in cases of both major depression and dysthymia. Conclusions. This is the first report showing a considerable prevalence of treatable cases of depression in Medicine patients at the time of hospital discharge and referral to PC. Depression is associated with the severity of the medical condition, and differences observed by age and sex have clinical implications. Paper read at the 3rd Annual Meeting of the European Association of Psychosomatic Medicine, Nuremberg 2015.

Global and regional gray matter reductions in ADHD: a voxel-based morphometric study.

Attention deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by inattentiveness, motor hyperactivity and impulsivity. According to neuroimaging data, the neural substrate underlying ADHD seems to involve fronto-striatal circuits and the cerebellum. However, there are important discrepancies between various studies, probably due to the use of different techniques. The aim of this study is to examine cerebral gray (GM) and white (WM) matter abnormalities in a group of ADHD children using a voxel-based morphometry protocol. The sample consisted of 25 children/adolescents with DSM-IV TR diagnosis of ADHD (medicated, aged 6-16 years) who were compared with 25 healthy volunteer children/adolescents. ADHD brains on an average showed a global volume decrease of 5.4% as compared to controls. Additionally, there were regionally specific effects in the left fronto-parietal areas (left motor, premotor and somatosensory cortex), left cingulate cortex (anterior/middle/posterior cingulate), parietal lobe (precuneus bilaterally), temporal cortices (right middle temporal gyrus, left parahippocampal gyrus), and the cerebellum (bilateral posterior). There were no differences in WM volume between ADHD children and control subjects. The results are consistent with previous studies that used different techniques, and may represent a possible neural basis for some of the motor and attentional deficits commonly found in ADHD.

Emotion processing in joint hypermobility: A potential link to the neural bases of anxiety and related somatic symptoms in collagen anomalies.

BACKGROUND: Joint hypermobility syndrome (JHS) has repeatedly been associated with anxiety and anxiety disorders, fibromyalgia, irritable bowel syndrome and temporomandibular joint disorder. However, the neural underpinnings of these associations still remain unclear. This study explored brain responses to facial visual stimuli with emotional cues using fMRI techniques in general population with different ranges of hypermobility. METHODS: Fifty-one non-clinical volunteers (33 women) completed state and trait anxiety questionnaire measures, were assessed with a clinical examination for hypermobility (Beighton system) and performed an emotional face processing paradigm during functional neuroimaging. RESULTS: Trait anxiety scores did significantly correlate with both state anxiety and hypermobility scores. BOLD signals of the hippocampus did positively correlate with hypermobility scores for the crying faces versus neutral faces contrast in ROI analyses. No results were found for any of the other studied ROIs. Additionally, hypermobility scores were also associated with other key affective processing areas (i.e. the middle and anterior cingulate gyrus, fusiform gyrus, parahippocampal region, orbitofrontal cortex and cerebellum) in the whole brain analysis. CONCLUSIONS: Hypermobility scores are associated with trait anxiety and higher brain responses to emotional faces in emotion processing brain areas (including hippocampus) described to be linked to anxiety and somatic symptoms. These findings increase our understanding of emotion processing in people bearing this heritable variant of collagen and the mechanisms through which vulnerability to anxiety and somatic symptoms arises in this population.

Differential effect of haloperidol and clozapine on plasma homovanillic acid in elderly schizophrenic patients with or without tardive dyskinesia.

BACKGROUND: Plasma homovanillic acid (HVA) changes in response to a challenge of several days with haloperidol have been found to be predictive of the therapeutic response to haloperidol over a longer period of treatment. METHODS: Twenty-six elderly women who gave informed consent were divided into two groups, with or without tardive dyskinesia, and subjected to an 80-day washout, after which both the dyskinetic and nondyskinetic group was divided, and half of each group given haloperidol or clozapine. CONCLUSIONS: The nondyskinetic group had a brief rise in plasma HVA, then a decline. The dyskinetic group had no change in plasma HVA. Neither group challenged with clozapine had any change in plasma HVA.

Association between joint hypermobility syndrome and panic disorder.

OBJECTIVE: The purpose of this study was to assess whether joint hypermobility syndrome is more frequent in patients with panic disorder, agoraphobia, or both than in control subjects and, if so, to determine whether mitral valve prolapse modifies or accounts in part for the association. METHOD: A case-control study was conducted in a general teaching hospital outpatient clinic. Subjects were 99 patients, newly diagnosed and untreated, with panic disorder, agoraphobia, or both and two groups of age- and sex-matched control subjects: 99 psychiatric patients and 64 medical patients who had never suffered from any anxiety disorder. Measures consisted of the Structured Clinical Interview for DSM-III-R, Beighton's criteria for joint hypermobility syndrome, and two-dimensional and M-mode echocardiogram. The presence of mitral valve prolapse and joint hypermobility syndrome was explored by raters who were blind to subjects' psychiatric status. RESULTS: Joint hypermobility syndrome was found in 67.7% of patients with anxiety disorder but in only 10.1% of psychiatric and 12.5% of medical control subjects. On the basis of statistical analysis, patients with anxiety disorder were over 16 times more likely than control subjects to have joint laxity. These findings were not altered after the presence of mitral valve prolapse was taken into account. Of the patients with anxiety disorder, those who had joint hypermobility syndrome were younger and more often women and had an earlier onset of the disorder than those without joint hypermobility syndrome. CONCLUSIONS: Joint laxity is highly prevalent in patients with panic disorder, agoraphobia, or both and may reflect a constitutional disposition to suffer from anxiety. Mitral valve prolapse plays a secondary role in the association between joint hypermobility and anxiety.

Predictors of antidepressant treatment outcome in melancholia: psychosocial, clinical and biological indicators.

Predictive variables of response to imipramine and to phenelzine at 6 weeks and 6 months were studied in 116 patients suffering from major depression with melancholia (DSM-III). Several sociodemographic, clinical, and biological variables were studied. For imipramine-treated patients, high social support predicted a better response at 6 weeks, while development of hypomania during follow-up was associated with a better response at 6 weeks; absence of life events during the 6-month follow-up and initial non-suppression of dexamethasone predicted a better outcome at 6 months. For phenelzine-treated patients, development of hypomania during follow-up was associated with a better outcome at 6 months and absence of life events prior to the onset of the episode was associated with a worse outcome at 6 months.

A validation study of the hospital anxiety and depression scale (HADS) in a Spanish population.

The present study aims to validate the Spanish version of the Hospital Anxiety and Depression Scale (HADS) and to determine the use of this tool for screening mood and anxiety disorders. Psychometric properties of the HADS were assessed in different groups of general medical outpatients attending the Hospital Clínic in Barcelona (N=385), and psychiatric diagnoses were made using DSM-IV criteria. A two-factor solution corresponding to the original two subscales of the HADS was found. The Spanish version of the HADS had good internal consistency and external validity, with favorable sensitivity and specificity in identifying cases of psychiatric disorder as defined by the Structured Clinical Interview for DSM-IV (SCID-I). The psychometric properties of the HADS and its brevity make it useful for screening for psychiatric disorders in the medically ill.

Anxiety disorders in the joint hypermobility syndrome.

A case-control study was designed to test the association between joint hypermobility syndrome (JHS), an inherited disorder of collagen synthesis, and anxiety and phobic disorders. One hundred fourteen cases of JHS diagnosed at the rheumatology outpatient clinic of the Hospital del Mar (Barcelona) were compared to 59 control subjects randomly selected from patients seen at the same clinic. Both cases and controls were examined by a psychologist who used the Structured Clinical Interview for DSM-III-R and who was unaware of their medical diagnoses. DSM-III-R diagnoses of panic disorder, agoraphobia, and simple phobia, but not generalized anxiety disorder, dysthymic disorder, or major depression were found to be highly associated with JHS (age- and sex-adjusted odds ratio = 10.7). Mitral valve prolapse (MVP) was present only among JHS cases. Among cases of JHS, subjects with MVP were almost three times more likely to suffer from anxiety than subjects without MVP (odds ratio = 2.95), although the association was not statistically significant. The strong association between panic anxiety and JHS appears to occur at a higher level than the association between panic and MVP, and provides a new basis for further studies on the genetic background of panic-anxiety.

Prevalence and correlates of respiratory and non-respiratory panic attacks in the general population.

BACKGROUND: Panic attacks are heterogeneous with regards to symptom profile. Subtypes of panic attacks have been proposed, of which the most investigated is respiratory panic attacks (RPA). Limited information exists about RPA in the general population. METHOD: The prevalence and correlates of RPA and non-respiratory panic attacks (NRPA) were examined in a subsample (n=8.796) of individuals participating in a cross-sectional survey of the adult general population of six European countries. Panic attacks, mental disorders, and chronic physical conditions were assessed with the Composite International Diagnostic Interview (CIDI) 3.0. Data on use of health services and disability were obtained. RESULTS: The lifetime prevalence of RPA was 6.77 and the 12-month prevalence was 2.26. No robust associations of RPA with sociodemographic characteristics, mental disorders or physical conditions were found as compared to NRPA. RPA were associated with increased use of health services but similar disability in comparison to NRPA. LIMITATIONS: Few direct data are available on the validity of the CIDI to assess RPA. Other definitions of RPA exist in the literature. CONCLUSIONS: Our findings suggest that there are very few differences between RPA and NRPA and do not support the need of subtyping panic attacks in current classification systems.