Anxiety disorders in children and adolescents in the first six months after traumatic brain injury

The study's objective was to assess the nature, rate, predictive factors, and neuroimaging correlates of novel (new-onset) definite anxiety disorders and novel definite/subclinical anxiety disorders (in a broader group of children with at least subclinical anxiety disorders) after traumatic brain injury (TBI). Children with TBI from consecutive admissions to five trauma centers were enrolled and studied with psychiatric interviews soon after injury (baseline) and again 6 months post-injury. Novel definite anxiety disorder and novel definite/subclinical anxiety disorders were heterogeneous and occurred in 8.5% (N=12) and 17% (N=24) of participants, respectively, in the first 6 months after injury. Novel definite anxiety disorder was significantly associated with younger age at injury and tended to be associated with novel depressive disorder, as well as lesions of the superior frontal gyrus. Novel definite/subclinical anxiety disorder was significantly associated with concurrent psychiatric problems of personality change due to TBI and novel definite/subclinical depressive disorder, as well as with lesions of the superior frontal gyrus and a trend-association with frontal lobe white-matter lesions. These findings suggest that anxiety after childhood TBI may be part of a broader problem of affective dysregulation related to damaged dorsal frontal lobe and frontal white-matter systems, with younger children being at greatest risk for developing novel anxiety disorder after TBI.     

Pathological laughing and crying following traumatic brain injury

The authors examined the prevalence and clinical correlates of pathological laughing and crying (PLC) using the Pathological Laughter and Crying Scale (PLAC) in 92 consecutive patients with acute symptoms 3, 6, and 12 months after traumatic brain injury (TBI). The prevalence of PLC during the first year after TBI was 10.9%. Compared to patients without PLC, patients with PLC had significantly more depressive, anxious, and aggressive behaviors and had poorer social functioning. Additionally, PLC was associated with the presence of anxiety disorder, and focal frontal lobe lesions, especially in the lateral aspect of the left frontal lobe. Findings revealed that prefrontal regulation of limbic circuits may be involved in the pathophysiology of this disturbed emotional expression.     

The relationship between risk factors for affective disorder and poststroke depression in hospitalised stroke patients.

The influence of psychiatric risk factors on the development of depression following stroke was examined in 88 patients undergoing inpatient rehabilitation. In this sample, 34 patients (38%) had a diagnosis of major or minor depression. Older age and a personal or family history of affective or anxiety disorder were associated significantly with major depression. Minor depression was more common among males and those patients with greater physical disability. Severity of depressive symptoms was associated with a personal or family history of affective or anxiety disorder and higher pre-stroke personality neuroticism. We conclude that certain psychiatric risk factors for affective disorder are strongly associated with poststroke depression. The implications of these findings for anticipating and managing poststroke depression are discussed.     

Major depression following traumatic brain injury

BACKGROUND: Major depression is a frequent psychiatric complication among patients with traumatic brain injury (TBI). To our knowledge, however, the clinical correlates of major depression have not been extensively studied. OBJECTIVE: To determine the clinical, neuropsychological, and structural neuroimaging correlates of major depression occurring after TBI. DESIGN: Prospective, case-controlled, surveillance study conducted during the first year after the traumatic episode occurred.Settings University hospital level I trauma center and a specialized rehabilitation unit. METHODS: The study group consisted of 91 patients with TBI. In addition, 27 patients with multiple traumas but without evidence of central nervous system injury constituted the control group. The patients' conditions were evaluated at baseline and at 3, 6, and 12 months after the traumatic episode. Psychiatric diagnosis was made using a structured clinical interview and DSM-IV criteria. Neuropsychological testing and quantitative magnetic resonance imaging were performed at the 3-month follow-up visit. RESULTS: Major depressive disorder was observed in 30 (33%) of 91 patients during the first year after sustaining a TBI. Major depressive disorder was significantly more frequent among patients with TBI than among the controls. Patients with TBI who had major depression were more likely to have a personal history of mood and anxiety disorders than patients who did not have major depression. Patients with major depression exhibited comorbid anxiety (76.7%) and aggressive behavior (56.7%). Patients with major depression had significantly greater impairment in executive functions than their nondepressed counterparts. Major depression was also associated with poorer social functioning at the 6-and 12-month follow-up, as well as significantly reduced left prefrontal gray matter volumes, particularly in the ventrolateral and dorsolateral regions. CONCLUSIONS: Major depression is a frequent complication of TBI that hinders a patient's recovery. It is associated with executive dysfunction, negative affect, and prominent anxiety symptoms. The neuropathological changes produced by TBI may lead to deactivation of lateral and dorsal prefrontal cortices and increased activation of ventral limbic and paralimbic structures including the amygdala.     

Depression in patients with acute traumatic brain injury.

OBJECTIVE: This study was undertaken to examine patients with closed head injuries for the presence of depressive disorders. METHOD: A consecutive series of 66 patients with closed head injuries but no significant spinal cord or other organ system injury were examined by means of a semistructured psychiatric interview. The Hamilton Rating Scale for Depression as well as scales measuring impairment in activities of daily living, intellectual functioning, and social functioning were administered. The patients' CT scans were also examined. RESULTS: Seventeen patients had major depression and two had minor depression. The presence of left dorsolateral frontal lesions and/or left basal ganglia lesions and, to a lesser extent, parietal-occipital and right hemisphere lesions was associated with an increased probability of developing major depression. Compared to the nondepressed group, the group with major depression had a higher frequency of previous psychiatric disorder and showed evidence of poorer social functioning. CONCLUSIONS: Major depression occurs in about one-quarter of patients after traumatic brain injury. This is the same frequency as in other major disorders such as stroke. Major depression appears to be provoked by one or more factors that include poor premorbid social functioning and previous psychiatric disorder or injury to certain critical brain locations.     

Relationship between anxiety disorders and depressive disorders in patients with cerebrovascular injury

The interaction between anxiety disorder and major depressive disorder in patients with cerebrovascular lesions was examined in a controlled, 2 x 2 study design. A consecutive series of 24 patients who met criteria for major depression only were compared with 6 patients who met criteria for both major depression and generalized anxiety disorder, and 45 patients who did not meet criteria for either major depression of generalized anxiety. Among patients with positive computed tomographic scans, the anxious-depressed group (n = 19) showed a significantly higher frequency of cortical lesions, while patients with major depression only (n = 15) had a significantly higher frequency of subcortical (basal ganglia) strokes. No significant between-group differences were found in other variables, such as demographic variables, familial and personal history of psychiatric disorders, and neurologic deficits. These findings suggest that, in this mostly black, low-socioeconomic-status population, cortical vs subcortical lesion location may play an important role in determining whether severe anxiety occurs in patients with post-stroke major depression.     

Predictors of attention-deficit/hyperactivity disorder within 6 months after pediatric traumatic brain injury

OBJECTIVE: To assess the phenomenology and predictive factors of attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (SADHD). METHOD: Children without preinjury ADHD 5-14 years old with TBI from consecutive admissions (n = 143) to five trauma centers were observed prospectively for 6 months (baseline and 6 months), with semistructured psychiatric interviews. Injury severity, lesion characteristics, and preinjury variables including psychiatric disorder, family psychiatric history, family psychiatric history of ADHD, family function, socioeconomic status, psychosocial adversity, and adaptive function were assessed with standardized instruments. RESULTS: SADHD in the first 6 months after injury occurred in 18 of 115 (16%) of returning participants. All subtypes of ADHD occurred. Socioeconomic status (p = .041) and orbitofrontal gyrus lesions (p = .005) independently significantly predicted SADHD. CONCLUSIONS: These findings are consistent with research on developmental ADHD that implicate psychosocial factors and prefrontal structural and functional differences between those with and without the disorder.     

The utility of the REM latency test in psychiatric diagnosis: a study of 81 depressed outpatients

To examine the utility of the REM (rapid eye movement) latency test in identifying outpatient primary depressions, 81 consecutive referrals to a sleep disorders center were evaluated in a phenomenologic, sleep polygraphic, and psychometric study. Modified Feighner (St. Louis) diagnoses were definite primary depression (n = 19), probable primary depression (n = 30), depression chronologically secondary to preexisting psychiatric disorders (n = 19), and nonaffective psychiatric disorder (n = 13). There were 18 nonpsychiatric controls. REM latency less than 70 minutes on 2 consecutive nights detected 62% of primary depressions, discriminating them from the other diagnostic groups with 88% specificity. There were no false positives among controls. These data provided a 90% confidence for the diagnosis of primary depression in this outpatient sample. Requiring 2 consecutive nights of shortened REM latency appears to improve significantly the specificity of a test previously considered to have high sensitivity but relatively low specificity for depressive disorders.     

Follow-up and family study of anxious depression

OBJECTIVE: The failure of the concept of anxious depression to find its way into DSM-III-R led the authors to conclude that a further report on the occurrence of anxiety symptoms in depressed subjects is indicated. METHOD: The subjects were 327 consecutively evaluated inpatients and outpatients with primary unipolar depressive disorder at five university medical centers participating in the National Institute of Mental Health Collaborative Program on the Psychobiology of Depression--Clinical Studies. The authors restricted their sample selection to patients with primary depressive disorder so that patients with other preexisting psychiatric disorders, especially anxiety disorders, would not contaminate the symptom picture, family studies, or follow-up. The examined six anxiety symptoms and derived a new anxiety summary score to show the effect of anxiety in depression on family data and 5-year outcome. RESULTS: Depressed subjects with higher ratings for anxiety took longer to recover. There was also a significant relationship between anxiety in depressed probands and the risk for primary unipolar depressive disorder, but not anxiety disorders or alcoholism, among 832 blindly interviewed first-degree relatives. CONCLUSIONS: These data confirm the usefulness of subdividing depressed patients according to anxiety symptoms: psychic and somatic symptoms of anxiety, taken together, significantly predict family illness and course. The data also emphasize the wisdom of requiring that generalized anxiety disorder not be diagnosed in the presence of a mood disorder. Clearly, symptoms of anxiety coexist with depression and need to be recognized for the effective treatment of the underlying depressive disorder.     

A diagnostic and family study of posttraumatic stress disorder

A family history study of 36 patients with chronic posttraumatic stress disorder revealed a positive history of familial psychopathology in 66% of the patients. Alcoholism, depression, and anxiety disorders were the disorders most commonly found. The patients also had a higher prevalence of alcoholic siblings than did a retrospectively derived control group of depressed and anxious male patients. With respect to the proportion of familial anxiety to familial depression, the probands with posttraumatic stress disorder more closely resembled probands with generalized anxiety than probands with depression. Every patient had experienced at least one significant psychiatric illness during his lifetime, most commonly alcohol abuse or depression.     

ANXIOUS FORMS OF DEPRESSION

Previous research has described distinctive features for anxious and nonanxious forms of major depression. The concept of “mixed anxiety depression disorder” (MADD) refers to a milder degree of the anxious form of depression, since the depressive symptoms fall short of the number required for a diagnosis of major depression. It is argued that this can be thought of as a subclinical form of anxious depression, rather than a separate disorder in its own right. In view of its substantial prevalence in general medical settings, its associated disability and its public health importance, it deserves to be recognized, and seen as being continuous with the more severe forms of anxious depression. It will therefore be included in the Field Trials of the version of the ICD‐11 (where ICD is the International Classification of Disease) intended for primary care. It is argued that current anxiety, depression (without anxiety), and anxious depression would cover most of the psychologically distressed patients seen in general medical settings, using a pseudodimensional system.     

Delineation of social phobia in Saudia Arabians

Summary Eighty Saudi Arabian males with social phobia who met DSMIIIR criteria, were evaluated psychiatrically and socially according to the MMPI social withdrawal scale standardized to the Saudi population. They were empirically grouped as mild, moderate or severe cases. They were also evaluated symptomatically according to the Leeds anxiety-depression scale to give ratings of depression and anxiety, separately and in combination. Thirty-seven and a half percent and 55% of the patients were mild-moderately and severely anxious respectively; 55% and 34% were mild-moderately and significantly depressed respectively. There was, however, no linear correlation between the level of anxiety or depression and the severity of social phobia. Social withdrawal ratings were matched with demographic variables, age of onset, perceived childhood adjustment, perceived parental behaviour, work adjustment, family history of psychiatric disorder, and the presence of other phobia. There was a negtive correlation between social withdrawal scale and all of these variables except work adjustment, family history of psychiatric disorder and presence of other phobias. These results are discussed.     

Obsessive-compulsive disorder after traumatic brain injury

Traumatic brain injury ( TBI) neuropsychiatric sequelae are a significant cause of morbidity in TBI victims. Among the recognized sequelae are anxiety, obsessions, compulsions and obsessive-compulsive disorder (OCD). This review addresses the emergence of OCD and OCD symptoms after TBI with an emphasis on neural circuits that underlie OCD symptom expression that may be affected by the injury. Current studies suggest that post-TBI emergent psychopathology, including OCD, is influenced by underlying sub-clinical diathesis, brain injury lesions sites, environmental stressors and the rehabilitation process. Pre-morbid status can be obtained by structured psychiatric interviews, and TBI brain lesions can be defined with advanced neuroimaging techniques. This information along with the management of family and environmental stressors and the enhanced clinical identification of symptoms of anxiety and OCD can be used in the rehabilitation process to improve prognosis after TBI.     

Obsessive-compulsive disorder after traumatic brain injury

Traumatic brain injury (?TBI) neuropsychiatric sequelae are a significant cause of morbidity in TBI victims. Among the recognized sequelae are anxiety, obsessions, compulsions and obsessive-compulsive disorder (OCD). This review addresses the emergence of OCD and OCD symptoms after TBI with an emphasis on neural circuits that underlie OCD symptom expression that may be affected by the injury. Current studies suggest that post-TBI emergent psychopathology, including OCD, is influenced by underlying sub-clinical diathesis, brain injury lesions sites, environmental stressors and the rehabilitation process. Pre-morbid status can be obtained by structured psychiatric interviews, and TBI brain lesions can be defined with advanced neuroimaging techniques. This information along with the management of family and environmental stressors and the enhanced clinical identification of symptoms of anxiety and OCD can be used in the rehabilitation process to improve prognosis after TBI.     

Course and outcome of child and adolescent major depressive disorder

Major depressive disorder (MDD) is a familial recurrent illness that significantly interferes with the child's normal development and is associated with increased risk for suicidal behaviors and psychiatric and psychosocial morbidity. Although most children and adolescents recover from their first depressive episode, 30-70%, in particular those with familial history of MDD, comorbid psychiatric disorders, dysthymia, subsyndromal symptoms of depression, anxiety, negative cognitive style, and exposure to negative life events (e.g., family conflicts and abuse) will experience one or more depressive recurrences during their childhood, adolescence, and adulthood. Depressed youth who present with psychosis, psychomotor retardation, pharmacological induced hypomania/mania, and/or family history of bipolar disorder are at high risk to develop bipolar disorder.     

Prevalence and course of depressive disorders in hospitalized stroke patients

In a sample of ninety-nine patients seen two months post-stroke, 18 percent were diagnosed as having minor depression and 14 percent major depression. At follow-up, fifteen months later, the prevalence of depressive disorder had declined substantially, to 12 percent overall. Major depression was characterized by an average duration of thirty-nine weeks, a mortality rate of 23 percent and was associated with positive family history of affective or anxiety disorder. Among patients with left hemisphere lesions, major depression was associated with cognitive impairment. Minor depression had a shorter average duration (twelve weeks) and was more common in males. These two syndromes may define distinct types of post-stroke depression with implications for treatment interventions.     

Thyroid function in anxious and depressed patients

We measured serum thyroid hormone levels, and pre- and post-TRH administration serum thyrotropin (TSH) in 46 psychiatric inpatients with major depression (n = 20), anxiety disorder (n = 9), and anxious depression (n = 17), and in 56 healthy subjects. Basal serum triiodothyronine was lower in female patients with major depression and anxious depression than in healthy women (P less than 0.05). Basal serum thyroxine was lower in female patients with anxious depression than in controls; all patients showed lower basal serum TSH than controls. In healthy subjects, basal triiodothyronine and thyroxine, basal TSH, and delta TSH (the increment of TSH after TRH administration) correlated, whereas no correlation was found between triiodothyronine and thyroxine in male patients with major depression, or between TSH and delta TSH in female patients with major depression or anxious depression. In female patients, 45% with major depression, 25% with anxiety disorder, and 35% with anxious depression showed a blunted TSH response. We also investigated pre- and post-dexamethasone administration cortisol levels in these patients. The sensitivity obtained by the combination of the results of the TRH and dexamethasone suppression tests for major depression, anxiety disorder, and anxious depression was 45%, 55%, and 65%, respectively.     

Comorbid Depressive Disorders in Anxiety-disordered Youth: Demographic,Clinical, and Family Characteristics

Research indicates that depression and anxiety are highly comorbid in youth. Little is known, however, about the clinical and family characteristics of youth with principal anxiety disorders and comorbid depressive diagnoses. The present study examined the demographic, clinical, and family characteristics of 200 anxiety-disordered children and adolescents (aged 7–17) with and without comorbid depressive disorders (major depressive disorder or dysthymic disorder), seeking treatment at a university-based anxiety clinic. All participants met DSM-IV diagnostic criteria for a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia). Of these, twelve percent (n = 24) also met criteria for a comorbid depressive disorder. Results suggest that anxiety-disordered youth with comorbid depressive disorders (AD-DD) were older at intake, had more severe anxious and depressive symptomotology, and were more impaired than anxiety-disordered youth without comorbid depressive disorders (AD-NDD). AD-DD youth also reported significantly more family dysfunction than AD-NDD youth. Future research should examine how this diagnostic and family profile may impact treatment for AD-DD youth.     

The relationship of anxiety and depression to symptoms of hyperthyroidism using operational criteria

Twenty-six females and seven males with newly diagnosed, untreated hyperthyroidism were administered a structured questionnaire designed to identify anxiety and depression using operational criteria. By DSM III criteria, 10 patients were found to have depression and 15 anxiety. The number of anxiety symptoms paralleled the number of hyperthyroid symptoms whereas depressive symptoms did not. Prior history of psychiatric disease and family history of psychiatric disease did not predict anxiety or depression in patients with hyperthyroidism. The number with depression and anxiety was felt to be artificially inflated by the concurrent presence of somatic thyroid symptoms. Psychiatric practitioners should be careful to exclude patients with hyperthyroidism before a primary psychiatric diagnosis is made.