Psychiatric symptoms of noradrenergic dysfunction: A pathophysiological view

What psychiatric symptoms are caused by central noradrenergic dysfunction? The hypothesis considered in this review is that noradrenergic dysfunction causes the abnormalities in arousal level observed in functional psychoses. In this review, the psychiatric symptoms of noradrenergic dysfunction were inferred pathophysiologically from the neuroscience literature. This inference was examined based on the literature on the biology of psychiatric disorders and psychotropics. Additionally, hypotheses were generated as to the cause of the noradrenergic dysfunction. The central noradrenaline system, like the peripheral system, mediates the alarm reaction during stress. Overactivity of the system increases the arousal level and amplifies the emotional reaction to stress, which could manifest as a cluster of symptoms, such as insomnia, anxiety, irritability, emotional instability and exaggerated fear or aggressiveness (hyperarousal symptoms). Underactivity of the system lowers the arousal level and attenuates the alarm reaction, which could result in hypersomnia and insensitivity to stress (hypoarousal symptoms). Clinical data support the hypothesis that, in functional psychoses, the noradrenergic dysfunction is in fact associated with the arousal symptoms described above. The anti‐noradrenergic action of anxiolytics and antipsychotics can explain their sedative effects on the hyperarousal symptoms of these disorders. The results of animal experiments suggest that excessive stress can be a cause of long‐term noradrenergic dysfunction.     

Psychiatric syndromes from a clinical and a biostatistical point of view

Syndromes are typical combinations of symptoms. They may be conceived at different levels of complexity, intuitively from a clinical point of view and objectively by means of factor- or cluster-analyses. Primary factors of symptom scores obtained with the aid of psychiatric rating scales represent syndromes of low complexity, secondary factors represent syndromes of higher complexity. The highest level is achieved by rotating only the first factors extracted from the matrix of intercorrelations among primary factors of psychopathology. Principal component analysis of 12 Inpatient Multidimensional Psychiatric Scale factors that reflect the psychopathological states at admission of 1,080 psychotic inpatients yielded the highly complex endogenomorphic syndromes of schizophrenic and manic-depressive symptomatology, respectively, in a two-factor solution. These syndromes were cut down to lower order syndromes in the four-factor solution resulting from rotation according to the conventional Kaiser criterion. They represent a syndrome of psychotic excitement, a paranoid-hallucinatory syndrome, a syndrome of endogenomorphic (retarded) depression and a syndrome of organic symptomatology. The different factor solutions may be useful for describing psychopathological phenoma objectively at different levels of complexity.     

Psychiatric aspects of mild cognitive impairment

Mild cognitive impairment in the elderly may represent a transitional phase between normal aging and early Alzheimer’s disease (AD). It recently has been recognized as a distinct clinical entity with potentially different cognitive subtypes and etiologies. Like AD, studies have shown that psychiatric symptoms are more common than in the cognitively normal geriatric population. Understanding these symptoms has been recognized as important not only because they may impair patient function and caregiver burden, but also these symptoms may be relevant to understanding the development of AD in general. This article presents current information on psychiatric symptoms in mild cognitive impairment, their suggested role in the pathophysiology of AD and future research considerations on the subject.     

Psychiatric practice and the exigencies of the state: an ethnomedical view

The purpose of this paper is to illustrate the powerful role that the state has in the practice of psychiatry in contemporary American society. An ethnomedical frame of reference is adopted, which is to say that psychiatric practice is looked at culturally and comparatively. In any society social and cultural characteristics condition and structure medical practice. In this sense, psychiatric practice provides an example to be analyzed in relation to other systems of medical practice. The ways in which the modern state, an omnipresent and compelling social structure, can intrude into the dynamics of psychiatric practice is illustrated by means of two case analyses. These draw attention to unique ethnomedical properties of psychiatric practice and to the potentially tragic effect that the state can have on its conduct. Analysis of the material presented is conducted against the background of information from the anthropological and social historical study of medicine and from medical practice in the Soviet Union.     

The cognitive point of view in psychodynamic psychotherapy: mentalization-based treatment

Mentalization, the capacity to understand the mental state of oneself and others which underlies overt behaviour, is a developmental achievement through the context of attachment relationship during infancy and childhood. Mentalization based treatment (MBT) is a psychotherapy that promote the further development of mentalizing. MBT for borderline personality disorder (BPD), developed and manualised by Peter Fonagy and Anthony Bateman, is well-known. According to them, vulnerability to a loss in mentalizing particularly in interpersonal or stressful circumstances is a core feature of BPD. For these patients, traditional psychotherapy would produce iatrogenic harms rather than some improvements. To avoid those iatrogenic effects, MBT therapist takes the stance of "not-knowing". Therapist stimulates the patient's mentalizing, and makes the patient have some inquisitiveness about the mental states of oneself and others. For this purpose, the triad of "event-belief-affect" is explored. At first, the problematic act of the patient is detected. Secondly, rewinding to the time when that problematic act has arisen, the therapist collaborate with the patient to identify the event that provokes the failure of mentalization, and to clarify the affect of patient at the moment. Thirdly, to gain alternative perspectives, that situation is explored through the emotional context. Finally, the specific maladaptive belief which causes a disruption of mentalizing is identified. When the same pattern of mentalizing failure is occurred in the process of the therapy, it was brought up in the "here and now" relationship between the patient and therapist. As seen above, MBT, which explores the relationship between affect and belief, has some technical features similar to cognitive behaviour therapy, which explores the relationship between maladaptive schema and dysfunctional cognition or problematic feeling. However, to the extent of focusing on the "here and now" relationship between patient and therapist, and of placing an emphasis on the context of transference, MBT is still psychodynamic psychotherapy.     

Psychiatric syndromes comorbid with mental retardation: differences in cognitive and adaptive skills

The study concerns the specific cognitive and adaptive skills of persons dually diagnosed with mental retardation (MR) and comorbid pathologies, as schizophrenia, personality and mood disorders, pervasive developmental disorders, epilepsy and ADHD. The sample was composed of 182 subjects, diagnosed as mild or moderate MR level, age range from 6 years 8 months to 50 years 2 months, mean age 17.1 (standard deviation 7.9). All the subjects were inpatients in a specialized structure for the diagnosis and the treatment of MR. The instruments of the study were Wechsler Intelligence Scale (WAIS-R or WISC-R according to the chronological age of subjects) and Vineland Adaptive Behavior Scale (VABS). Results confirm that comorbidity is a factor differentiating among mentally retarded subjects. Both verbal processes requiring memory retrieval and visuo-spatial processes are involved as differentiating features. ADHD strongly increases the impairment of cognitive skills, while behavioral disorders are less damaging in MR performance. In adult samples, the differentiating role of comorbid syndromes in MR individuals is reduced for cognitive skills, and limited to some basic verbal abilities, more impaired in mood disorder, less in schizophrenic disorder. The areas of adaptation and socialization, motor and daily living skills, are impaired more in generalized development disturbances than in comorbid schizophrenic and personality and mood disorders. An accurate psychological assessment of dual diagnoses is useful in detecting the specific underlying processes differentiating the comorbid syndromes, and in planning an appropriate rehabilitative treatment.     

The Emperor's new clothes: Eclecticism in autism treatment

Increasingly, Applied Behaviour Analysis (ABA) is internationally recognised as the scientific basis for teaching and treatment in Autism Spectrum Disorders. Yet, many governments and professionals across Europe promote an eclectic model as more child-centred and pragmatic. This paper addresses the issues of eclecticism and ABA by exploring how misinformation stands in the way of evidence-based procedures that are truly unified, practical, and child-centred.     

Psychiatric and cognitive phenotype of childhood myotonic dystrophy type 1

Aim To investigate the psychiatric and cognitive phenotype in young individuals with the childhood form of myotonic dystrophy type 1 (DM1). Method Twenty-eight individuals (15 females, 13 males) with childhood DM1 (mean age 17y, SD 4.6, range 7-24y) were assessed using standardized instruments and cognitive testing of general intelligence, visual attention, and visual-spatial construction abilities. Results Nineteen patients had repeated a school grade. The mean (SD) Full-scale IQ was 73.6 (17.5) and mean Verbal IQ was significantly higher than the mean Performance IQ: 80.2 (19.22) versus 72.95 (15.58), p=0.01. Fifteen patients had one or more diagnoses on the DSM-IV axis 1, including internalizing disorders (phobia, n=7; mood disorder, n=6; other anxiety disorders, n=5) and attention-deficit-hyperactivity disorder, inattentive subtype (n=8). Twelve out of 22 patients had alexithymia (inability to express feelings with words and to recognize and share emotional states). Cognitive testing found severe impairments in visual attention and visual-spatial construction abilities in four out of 18, and 14 out of 24 patients respectively. No diagnosis was correlated with the transmitting parent's sex or with cytosine-thymine-guanine (CTG) repeat numbers. Patients with severe visual-spatial construction disabilities had a significantly longer CTG expansion size than those with normal visual-spatial abilities (p=0.04). Interpretation Children and adolescents with childhood DM1 have frequent diagnoses on DSM-IV axis 1, with internalizing disorders being the most common type of disorder. They also have borderline low intelligence and frequent impairments in attention and visual-spatial construction abilities.     

Psychiatric genetics: a methodologic critique

Psychiatric genetics, which is growing in size and influence within psychiatry, employs four major research paradigms: 1) basic genetic epidemiology, 2) advanced genetic epidemiology, 3) gene finding methods, and 4) molecular genetics. Paradigms 1 and 2 study aggregate genetic risk factors inferred from patterns of resemblance in relatives. Paradigms 3 and 4 study individual susceptibility genes localized on the human genome. Paradigms 1, 2, and 3 are statistical in nature, while paradigm 4 is biological. Genetic risk factors reflect the statistical signals from susceptibility genes. Whether it will be possible to identify all the susceptibility genes that underlie genetic risk factors is uncertain. Furthermore, given current research methods, the inability to detect susceptibility genes cannot disconfirm evidence for genetic risk factors. While paradigms 3 and 4 can provide great explanatory power by tracing etiologic pathways back to basic biological mechanisms, genetic epidemiology can also provide important etiologic insights, albeit of a less basic nature. While paradigms 3 and 4 may eventually replace paradigms 1 and 2, this shift is unlikely to occur quickly. Therefore, the field of psychiatric genetics would do best to integrate these four paradigms, stressing their relative strengths and limitations. This integration can be best done within an overall framework of explanatory pluralism that values a range of reductive explanations across varying levels of biological and psychological complexity.     

The cognitive and anatomo-functional basis of reality distortion in schizophrenia: a view from memory event-related potentials

This study investigated the neural and cognitive correlates of reality distortion in schizophrenia by using event-related potentials (ERPs) recorded in a recognition memory task for face. This task has been chosen because previous studies have shown that it provides distinct indices related to specific cognitive processes and to the functioning of specific brain regions. ERPs have been recorded in controls and schizophrenia patients separated into high scorers (RD+) and low-scorers (RD-) according to their Reality Distortion score (hallucination and delusion SAPS subscales). The results indicate that RD+ presents abnormalities on various cognitive processes. First, RD+ are deficient at interference inhibition and knowledge integration (reduced P2a and N400 effect). The similar impairments found in RD- suggest that they represent basic traits of the illness. Second, RD+ showed inappropriate stimulus categorization and contextual integration (larger N300 and fronto-central effect). Third, RD+ showed a late index (P600 effect) not different from controls, but larger than in RD-. This result is consistent with a qualitative, rather than quantitative, impairment of mnemonic binding processes (inappropriate binding) in RD+. Since each of the ERP abnormalities observed represents associated with distinct brain dysfunction, the results are further discussed in regard of the respective contribution of the parietal, frontal and hippocampal structures to reality distortion symptoms.     

Validation of a 6 item cognitive impairment test with a view to primary care usage

OBJECTIVE: To validate the 6 Item Cognitive Impairment Test (6CIT) against the Mini-Mental State Exam (MMSE) with a view to usage as a screening tool.DESIGN: Three groups with varying levels of dementia were tested using the MMSE, 6CIT and Global Deterioration Scale (GDS).SETTING: Testing was carried out within Wiltshire, both in the community and outpatients.SUBJECTS: Patients were selected from a hospital database of dementia patients and were stratified into two groups according to GDS; a control group was also tested.RESULTS: Two hundred and eighty-seven patients were tested: 135 controls (GDS 1-2), 70 with mild dementia (GDS 3-5) and 82 with more severe dementia (GDS 6-7). The 6CIT and MMSE were found to correlate well, r(2)=-0.911 (p<0.01), when all groups were analysed. Correlation falls to r(2)=-0.754 (p<0.01) in the mild dementia group. In the GDS 3-5 group, the MMSE has a sensitivity and specificity of 51.43% and 100% respectively (cutoff 23/24). The 6CIT gives a sensitivity and specificity of 78.57% and 100% (cutoff 7/8).CONCLUSION: The 6CIT is a brief and simple test of cognition, which correlates well with the MMSE but outperforms it in milder dementia. The MMSE is of little value as a screening test for dementia.     

Psychiatric and cognitive phenotype in children and adolescents with myotonic dystrophy

Myotonic dystrophy type 1 (DM1) is the most frequent inherited neuromuscular disorder. The juvenile form has been associated with cognitive and psychiatric dysfunction, but the phenotype remains unclear. We reviewed the literature to examine the psychiatric phenotype of juvenile DM1 and performed an admixture analysis of the IQ distribution of our own patients, as we hypothesised a bimodal distribution. Two-thirds of the patients had at least one DSM-IV diagnosis, mainly attention deficit/hyperactivity disorder and anxiety disorder. Two-thirds had learning disabilities comorbid with mental retardation on one hand, but also attention deficit, low cognitive speed and visual spatial impairment on the other. IQ showed a bi-modal distribution and was associated with parental transmission. The psychiatric phenotype in juvenile DM1 is complex. We distinguished two different phenotypic subtypes: one group characterised by mental retardation, severe developmental delay and maternal transmission; and another group characterised by borderline full scale IQ, subnormal development and paternal transmission.     

Psychiatric morbidity and cognitive representations of illness in chronic daily headache

OBJECTIVES: We studied patients with chronic daily headache (CDH) attending a headache clinic. Our hypothesis was that patients with anxiety or depression would have poorer functional status and differing cognitive representations of illness than would those without psychiatric morbidity. METHODS: The sample consisted of 144 consecutive new patients. Patients underwent a semistructured interview and completed a prospective headache diary, the Hospital Anxiety and Depression Scale (HADS) and other health-related questionnaires. RESULTS: Sixty patients (42%) were probable cases of anxiety or depression on the basis of their HADS score. These HADS-positive cases had longer, more severe headaches, were more worried about them, were more functionally impaired and believed that their illness would last longer. Principal components analysis revealed that the HADS-positive cases believed that psychological factors play a role in their headaches. CONCLUSIONS: Psychological morbidity is high amongst CDH patients who attend specialist clinics. In addition to identifying those with high levels of psychological distress, the HADS can be used to predict those likely to have worse headaches and poorer functional ability.