Neuropsychological task performance in bipolar spectrum illness: genetics, alcohol abuse, medication and childhood trauma

Introduction:  Impaired executive and memory function is a putative genetic trait marker of bipolar I disorder (BPD I). Although executive/memory function has been posited to be an endophenotype of BPD I, it is unclear whether this extends to bipolar spectrum illness. It is also unclear to what extent non-genetic factors such as childhood abuse, alcoholism and medication influence neurocognitive function. We assessed the neuropsychological performance of a large cohort of bipolar disorder probands and their affectively ill and healthy family members, while controlling for self-reported childhood sexual and emotional abuse, emotional neglect, alcohol abuse and medication.
Methods:  A total of 230 largely euthymic participants from 47 families, comprising 49 subjects with BPD I, 19 with bipolar II disorder (BPD II), 44 with recurrent major depression (MDE-R), 33 with a single lifetime episode of depression (MDE-S), 20 with other DSM-IV diagnoses and 65 unaffected relatives, were assessed with a battery of neuropsychological tasks.
Results:  Sexual abuse, emotional abuse and emotional neglect scores were associated with poorer cognitive performance. After controlling for childhood trauma, the BPD I group performed worse than unaffected relatives on tests of visual recall memory as well as verbal recall and recognition memory. In contrast, individuals with BPD II and bipolar spectrum illness did not differ significantly from unaffected relatives. Treatment with lithium and antipsychotic medication was associated with reduced executive and verbal recognition memory function. After controlling for medication and other covariates, only verbal recall memory was significantly impaired in the BPD I cohort.
Conclusions:  Verbal recall deficits may be one manifestation of a genetically driven dysfunction of frontal-striatal cortical networks in BPD I.     

Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders

OBJECTIVE: To evaluate childhood experiences (neglect and abuse), temperament and childhood and adolescent psychopathology as risk factors for avoidant and borderline personality disorders in depressed outpatients. METHOD: One hundred and eighty depressed outpatients were evaluated for personality disorders. Risk factors of childhood abuse, parental care, temperament, conduct disorder symptoms, childhood and adolescent anxiety disorders, depressive episodes, hypomania and alcohol and drug dependence were obtained by questionnaires and interviews. RESULTS: Avoidant personality disorder can be conceptualized as arising from a combination of high harm avoidance (shy, anxious), childhood and adolescent anxiety disorders and parental neglect. Borderline personality disorder can be formulated as arising from a combination of childhood abuse and/or neglect, a borderline temperament (high novelty seeking and high harm avoidance), and childhood and adolescent depression, hypomania, conduct disorder and alcohol and drug dependence. CONCLUSIONS: Combinations of risk factors from the three domains of temperament, childhood experiences and childhood and adolescent psychopathology make major contributions to the development of avoidant and borderline personality disorders.     

Health service utilization in patients with major depression and co-morbid pain

Aims:  Patients with depression often have co-morbid pain symptoms. However, rates of service utilization by psychiatric in-patients with co-morbid pain symptoms are unknown. The purpose of this study is to estimate whether patients with major depression and co-morbid pain access medical treatment for their pain as much as their counterparts with psychiatric diagnoses other than major depression.
Methods:  A total of 103 patients (62 female; 41 male) were assessed for a diagnosis of major depression applying a psychiatric clinical interview followed by a self-report pain questionnaire, which assessed physical pain in psychiatric patients.
Results:  Patients with major depression reported higher rates of pain symptoms in the past 6 and 12 months than their counterparts with a psychiatric diagnosis other than major depression. Analysis of variance showed that patients with depression were less likely to attend medical and specialist services for their pain symptoms than their counterparts. On the contrary, depressed patients with pain attended more frequently general in-patient services than non-depressed patients with pain.
Conclusions:  Patients with depression suffer high rates of pain symptoms, but are at higher risk of not accessing appropriate services suggesting inadequate service utilization. The results have implications for screening and health care delivery for psychiatric patients with pain.     

Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality

OBJECTIVE: To investigate the magnitude and independence of the effects of childhood neglect, physical abuse, and sexual abuse on adolescent and adult depression and suicidal behavior. METHOD: A cohort of 776 randomly selected children was studied from a mean age of 5 years to adulthood in 1975, 1983, 1986, and 1992 during a 17-year period. Assessments included a range of child, family, and environmental risks and psychiatric disorders. A history of abuse was determined by official abuse records and by retrospective self-report in early adulthood on 639 youths. Attrition rate since 1983 has been less than 5%. RESULTS: Adolescents and young adults with a history of childhood maltreatment were 3 times more likely to become depressed or suicidal compared with individuals without such a history (p < .01). Adverse contextual factors, including family environment, parent and child characteristics, accounted for much of the increased risk for depressive disorders and suicide attempts in adolescence but not in adulthood (p < .01). The effects of childhood sexual abuse were largest and most independent of associated factors. Risk of repeated suicide attempts was 8 times greater for youths with a sexual abuse history (odds ratio = 8.40, p < .01). CONCLUSIONS: Individuals with a history of sexual abuse are at greater risk of becoming depressed or suicidal during adolescence and young adulthood. Adolescence is the most vulnerable period for those youths who may attempt suicide repeatedly. Many of the apparent effects of neglect, in contrast, may be attributable to a range of contextual factors, suggesting broader focus for intervention in these cases.     

Childhood maltreatment as a risk factor for adult cardiovascular disease and depression

BACKGROUND: Traumatic experiences in childhood are linked to adult depression and cardiovascular disease. Depression is twice as common in women than men, and depression after cardiovascular events is more common in women than men. However, sex differences in these relationships have not been comprehensively investigated using a nationally representative sample in which demographic factors related to these illnesses can be controlled. METHOD: Data come from the Part 2 sample of the U.S. National Comorbidity Survey, a nationally representative sample containing over 5000 adults. Relationships between childhood maltreatment (sexual abuse, physical abuse, neglect), adult depression (DSM-III-R), and cardiovascular disease were examined using multiple logistic regression models with a specific emphasis on the evaluation of sex differences. RESULTS: Childhood maltreatment was associated with a significant increase in cardiovascular disease for women only and with a significant increase in lifetime depression for both genders. A history of childhood maltreatment removed the natural protection against cardiovascular disease for women and depression for men. Although depression and cardiovascular disease were correlated, depression did not contribute to the prediction of cardiovascular disease in women when controlling for history of childhood maltreatment. CONCLUSIONS: Gender is important in evaluating potential psychiatric and physical correlates of childhood maltreatment. Maltreatment is a potent risk factor for cardiovascular disease in women and for depression in both women and men. Effective clinical assessment should recognize the role of childhood abuse or neglect in adult health and disease. Research on the consequences of childhood maltreatment should focus on both psychiatric and physical outcomes.     

Inhalant use, abuse, and dependence among adolescent patients: commonly comorbid problems

OBJECTIVE: Little is known about adolescents with DSM-IV-defined inhalant abuse and dependence. The aim of this study was to compare comorbidity among (1) adolescents with inhalant use disorders, (2) adolescents who reported using inhalants without inhalant use disorder, and (3) other adolescent patients drawn from an adolescent drug and alcohol treatment program. METHOD: The authors examined 847 admissions of patients who had completed structured diagnostic assessments. The three groups were compared for noninhalant substance use disorders, posttraumatic stress disorder, conduct disorder, major depression, previous suicide attempts, and physical/sexual abuse and neglect. RESULTS: Adolescents with inhalant abuse or dependence (group 1; n = 28) were significantly more likely to meet lifetime criteria for abuse or dependence on alcohol, hallucinogens, nicotine, cocaine, and amphetamines, to have had major depression, and to have attempted suicide compared with other adolescent patients who reported never using inhalants (group 3); adolescents with inhalant use disorders also reported significantly more abuse and neglect. Adolescents with inhalant abuse or dependence (group 1) did not differ significantly on any measure compared with adolescents who reported using inhalants without an inhalant use disorder (group 2). CONCLUSIONS: Adolescent patients with a history of inhalant use, abuse, or dependence entering treatment should be carefully screened for noninhalant substance use disorders, major depression, suicidality, and abuse and neglect.     

Childhood emotional abuse and dissociation in patients with conversion symptoms

Aim:  The aim of the present study was to evaluate the relationship between reported childhood trauma and dissociation in patients who have a conversion symptom.
Method:  Thirty-two outpatients with a conversion symptom were evaluated using Dissociative Experiences Scale, Somatoform Dissociation Questionnaire, Childhood Trauma Questionnaire, Spielberger Trait Anxiety Inventory, Clinician-Administered Dissociative State Scale, and Dissociative Disorders Interview Schedule.
Results:  A DSM-IV dissociative disorder was diagnosed in 46.9% of the patients. Conversion patients with a dissociative disorder had borderline personality disorder more frequently than those without a dissociative disorder. Among childhood trauma types, emotional abuse was the only significant predictor of dissociation in regression analysis. None of the childhood trauma types predicted borderline personality disorder criteria.
Conclusions:  Borderline personality disorder, dissociation and reports of childhood emotional abuse refer to a subgroup among patients with conversion symptom. Dissociation seems to be a mediator between childhood trauma and borderline phenomena among these patients.     

Impact of psychiatric and medical comorbidity on cognitive function in depression

Aim:  The aim of the present study was to investigate the association between cognitive performance and psychiatric and medical comorbidity in major depression.
Methods:  The present study evaluated the cognitive performance of patients ( n  = 96) diagnosed with a major depressive episode in relation to the presence of medical and/or psychiatric comorbidity. Participants were assessed clinically and cognitively using the Mini International Neuropsychiatric Interview and Repeatable Battery for the Assessment of Neuropsychological Status. Four groups of comorbidity were categorized: (i) no comorbidity, (ii) medical comorbidity; (iii) psychiatric comorbidity; and (iv) both medical and psychiatric comorbidity, and subsequently analyzed for differences across six cognitive domains: immediate memory, visuospatial, language, attention, delayed memory, and total score.
Results:  Only 20.8% of the participants did not have a comorbidity of any kind, while psychiatric comorbidities (67.7%) were more frequent than medical comorbidities (39.6%). Education and severity of depressive symptoms negatively influenced cognitive performance. Psychiatric comorbidity alone significantly decreased cognitive performance in the visuospatial/constructional and the language domains and the total score. In addition, increasing numbers of psychiatric comorbidities were related to worse cognitive performance. In contrast, medical illnesses alone had no negative impact on any of the domains of cognitive performance. Evidence was found for additive effects of medical and psychiatric comorbidities in depression on visuospatial/constructional cognitive abilities.
Conclusion:  The strongest predictor of poor cognitive performance in depression was psychiatric comorbidity. The assessment and treatment of cognitive dysfunction in depression should consider the relative impact of psychiatric comorbidity.     

Assessing the Effects of Maternal Symptoms and Homelessness on the Mental Health Problems in their Children

Objective:  This study examines the longitudinal association between measures of child well being and maternal posttraumatic stress disorder symptoms, homelessness, substance abuse, and other psychiatric conditions.
Method:  A sample of 142 mothers who were veterans of the US armed forces were assessed at program entry and every three months thereafter for one year. A repeated-measures with mixed-effects analytic strategy was used to assess the association of children's mental health, school enrolment and attendance with measures of maternal psychiatric symptoms and homelessness.
Results:  Significant associations between mothers' psychiatric symptoms and child well-being were identified. However, the multivariable mixed-models suggest that increased depression and anxiety symptoms among children were associated primarily with mothers' PTSD, and not depression, symptoms.
Conclusions:  These findings provide evidence of an association between maternal and child mental health and may suggest that treating maternal PTSD symptoms may also benefit children, regardless of whether the child was also exposed to the traumatic experience.     

Chronic pain syndromes and their relation to childhood abuse and stressful life events

OBJECTIVE: Childhood abuse, stressful life events, and depression have been repeatedly reported to correlate with chronic pain, but little is known about the mutual relationships among these variables. METHODS: Forty-three women with chronic pelvic pain (CPP), 40 female patients with chronic low-back pain (CLBP), and a female pain-free control group (n=22) were investigated by means of a semistructured interview assessing childhood sexual and physical abuse as well as stressful life events. Additionally, the Beck Depression Inventory (BDI) was used. For multivariate analyses, structured equation modeling was applied. RESULTS: Childhood physical abuse, stressful life events, and depression had a significant impact on the occurrence of chronic pain in general, whereas childhood sexual abuse was correlated with CPP only. Moreover, childhood sexual abuse was related to depression. Both childhood sexual and physical abuse showed a close relationship to an increased occurrence of stressful life events. CONCLUSION: There are complex mutual interactions among childhood abuse, stressful life events, depression, and the occurrence of chronic pain. Therefore, clinicians should take into consideration these psychosocial factors while treating chronic pain patients.     

Types of childhood trauma and spirituality in adult patients with depressive disorders

ObjectiveThe aim of this study was to investigate the differences in spirituality among adult patients with depressive disorders, who had suffered various types of abuse or neglect in childhood.MethodsA total of 305 outpatients diagnosed with depressive disorders completed questionnaires on socio-demographic variables, childhood trauma history, and spirituality. We used the Childhood Trauma Questionnaire-Short Form (CTQ-SF) to measure five different types of childhood trauma (emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp-12) to assess spirituality.ResultsDepressive symptoms and total CTQ-SF scores showed a negative correlation with spirituality. In the regression model, being older and belonging to a religion significantly predicted greater spirituality. Depressive symptoms significantly predicted lower spirituality. From among the five types of childhood trauma assessed by the CTQ-SF, only emotional neglect significantly predicted lower spirituality.ConclusionA history of childhood emotional neglect was significantly related to lower spirituality, especially in the case of the Meaning aspect of spirituality. This finding suggests the potential harmful influence of childhood emotional neglect on the development of spirituality in psychiatric patients. Investigating different aspects of childhood trauma might be important in order to develop a more comprehensive psychiatric intervention that aids in the development of spirituality.     

Depression and its association with self-esteem, family, peer and school factors in a population of 9586 adolescents in southern Taiwan

Aims:  The aim of the present study was to gain insight into the prevalence of depression and its association with self-esteem, family, peer and school factors in a large-scale representative Taiwanese adolescent population.
Methods:  A total of 12 210 adolescent students were recruited into the present study. Subjects with a score >28 on the Center for Epidemiological Studies' Depression Scale were defined as having significant depression; the Rosenberg Self-Esteem Scale, Adolescent Family and Social Life Questionnaire and Family C-APGAR Index were applied to assess subjects' self-esteem, family, peer and school factors. The association between depression and correlates were examined on t -test and χ² test. The significant factors were further included in logistic regression analysis.
Results:  Among 9586 participants (response rate: 86.3%), the prevalence of depression was 12.3%. The risk factors associated with depression in univariate analysis included female gender, older age, residency in urban areas, lower self-esteem, disruptive parental marriage, low family income, family conflict, poorer family function, less satisfaction with peer relationships, less connectedness to school, and poor academic performance. After adjusting the effects of sex, age and location, only subjects with lower self-esteem, higher family conflict, poorer family function, lower rank and decreased satisfaction in their peer group, and less connectedness to school were prone to depression on logistic regression.
Conclusion:  The prevalence of depression is high in Taiwanese adolescents, and the multiple factors of family, peer, school and individuals are associated with adolescent depression. The factors identified in the present study may be helpful when designing and implementing preventive intervention programs.     

Dissociative symptomatology and traumatogenic factors in adolescent psychiatric patients

This study describes the relation of different types of childhood trauma to the degree of dissociative experiences. Subjects were 198 consecutively admitted adolescent psychiatric patients, 11 to 19 years old (89 inpatients and 109 outpatients). All patients completed the Adolescent Dissociative Experiences Scale. A Checklist of Traumatic Childhood Events was filled out by clinicians. The results showed an increase in the degree of dissociative experiences in patients with a history of sexual abuse, physical abuse, neglect, and stressful life events. With the exception of life events, a moderate form of traumatic experience had the same effect on dissociative experiences as severe forms. The strongest effect was found for emotional neglect, which seems to be an important pathogenic risk factor. The results suggest that therapists and researchers should be aware that even less severe forms of abuse and neglect may have a significant impact on the development of dissociative psychopathology in adolescents.     

Increased soluble tumor necrosis factor-α receptors in patients with major depressive disorder

Aim:  Several lines of evidence suggest that major depressive disorder is associated with an inflammatory status. Tumor necrosis factor-α has been investigated as a potential molecular target in mood disorders. Tumor necrosis factor-α exerts its activity through binding to specific cell membrane receptors named as TNFR1 and TNFR2. The aim of the present study was to investigate soluble plasma TNFR1 (sTNFR1) and TNFR2 levels (sTNFR2) in major depressive disorder patients.
Methods:  Female outpatients with major depressive disorder ( n  = 30) were compared with a healthy control group ( n  = 19). Severity of depressive symptoms was evaluated on Beck Depression Inventory; post-traumatic stress disorder (PTSD) symptoms were evaluated on PTSD Checklist–Civilian Version; and childhood abuse and neglect on the Childhood Trauma Questionnaire. Plasma tumor necrosis factor-α and its soluble receptors were measured by ELISA.
Results:  Patients had no changes in tumor necrosis factor-α concentrations but did have increased sTNFR1 ( P  < 0.001) and sTNFR2 ( P  < 0.001) levels compared to controls. Plasma level of sTNFR1 was positively predicted by age (B = 0.25, P  = 0.05) and PTSD-like symptoms (B = 0.41, P  = 0.002) and plasma levels of sTNFR2 by depression severity (B = 0.67, P  < 0.001).
Conclusions:  Soluble tumor necrosis factor-α receptors could be reliable markers of inflammatory activity in major depression.     

Psychological features and coping styles in patients with chronic pain

Aims:  It is said that psychological factors play a crucial role in the development, continuation or amplification of chronic pain. The purpose of the present study was to examine psychological features and coping styles related to chronic pain.
Methods:  Sixty-three patients with persistent pain over 3 months (average age of 59.3 years; 22 men and 41 women) were recruited as subjects from December 2005 to March 2007. As for chronic pain, the duration of pain and the intensity of pain, applied using the Visual Analogue Scale, were evaluated in each patient. In addition, their psychological features were examined with the Profile of Mood States (POMS) and their coping styles were examined using the Coping Inventory for Stressful Situations (CISS).
Results:  The duration of pain was not significantly correlated with values of the POMS or CISS. The intensity of pain according to the Visual Analogue Scale was significantly correlated with the tension–anxiety, anger–hostility and fatigue scales of the POMS. Also, the intensity of pain showed negative correlations with the avoidance-oriented coping scale of the CISS.
Conclusions:  Understanding psychological features and coping styles are critical when we determine the proper treatment for chronic pain.     

Til Dansk psykiatrisk Selskabs medlemmer: Med kollegial hilsen

Aims: Knowledge of sleep problems and their relationships among adolescent psychiatric patients is limited. This study investigated whether adolescents in specialty mental health care differ in rate and correlates of sleep problems from adolescents in a community sample; 2465 adolescents from a community sample were compared with a representative clinical sample of 129 adolescent patients. Methods: Comparisons were made on frequent sleep problems according to scores on the Youth Self-Report, the Mood and Feelings Questionnaire, and instruments assessing coping styles, stresses and family functioning. Results: Sleep problems were more frequent in the clinical sample than the community sample (31.3% vs. 5%). Sleeping little and being overtired were the most common sleep problems. Sleep problems were multivariately associated with internalizing problems in both samples. Poor family functioning and distractive coping were multivariately associated with sleep problems among adolescent patients, whereas depressive symptoms were multivariately associated in community adolescents. Conclusions: Prevalences of sleep problems were high among adolescent patients. However, sleep problems may be in danger of being unnoticed in clinical practice. Clinicians should ask about such problems and be aware of possible connections with family functioning, depression and suicidality. Therapeutic interventions directed towards sleep problems should be considered.     

Lifetime stressors and recurrent depression: preliminary findings of the Adult Life Phase Interview (ALPHI)

  Background: The well-established association between stress and depression is explored in a lifespan context in relation to adverse childhood experience. A new retrospective interview instrument, the Adult Life Phase Interview (ALPHI) examined the number of chronic stressors (or `adversities') experienced over the adult life course in relation to chronic or recurrent clinical depression. The role of such lifetime adversity in mediating the relationship between childhood neglect/abuse and adult disorder was examined. Method: The ALPHI uses an investigator-based, contextual approach suited to retrospective and time-linked enquiries. Reliability of the instrument was found to be satisfactory. Its association with both lifetime clinical depression and childhood neglect or abuse was examined in a community series of 198 women, consisting of 99 sister pairs, where one-half of the series was selected for having had adverse childhood experience and the other for comparison. Results: Adult adversity, both at settled/fixed times and at times of major life change, was significantly higher among those with prior childhood neglect or abuse. Both a high adult adversity score and childhood neglect or abuse were related to chronic or recurrent episodes of clinical depression, with logistic regression indicating both indices contributed independently to disorder. The same results held when controls were made for sister status, given possible familial bias in experience, and for age, since women under age 25 had fewer adult phases and less adversity. Conclusions: Characteristics of adult life phases and change-points are described and the relevance of the measure for intensive survey work seeking to investigate relationships between lifespan experience and depression is discussed. Accepted: 28 February 2000     

Traumatic life events in bipolar disorder: impact on BDNF levels and psychopathology

Background:  There is evidence that vulnerability to depression and anxiety disorders is markedly increased by traumatic life events. While childhood abuse has been reported to be associated with poorer outcomes in bipolar disorder, little is known about the neurobiological basis underlying this association. The aim of this study was to ascertain whether bipolar patients who were exposed to a traumatic event or events (TE) have lower brain-derived neurotrophic factor (BDNF) levels and more severe psychopathology as indicated by increased comorbidity and other clinical features when compared to those who were not exposed to TE.
Methods:  One-hundred and sixty-three consecutively recruited bipolar outpatients were assessed by Structured Clinical Interview for DSM-IV (SCID) and standard protocol in order to evaluation psychopathology and clinical features. The reported TE was assessed using DSM-IV stem criteria for trauma (as defined by A1 and A2 criteria for trauma for post-traumatic stress disorder). Subjects were divided into 2 groups according to presence or absence of lifetime TE. The levels of BDNF, comorbidity and other clinical features were compared between groups.
Results:  After adjusting for confounders, results indicated that bipolar patients with a history of TE have alcohol abuse/dependence (p < 0.001), anxiety comorbidity, and lower levels of serum BDNF (p < 0.01) compared to those without a history of TE. There was no difference between the 2 groups in age of onset, presence of psychosis, other substance abuse and dependence, rapid cycling or suicide attempts.
Conclusions:  Our findings suggest that TE are associated with significantly increased prevalence of alcohol and anxiety comorbidity as well as lower BDNF levels in bipolar patients. It is possible that a decrease in BDNF levels may account for increased comorbidity, but further prospective studies are required to confirm this.     

儿童期虐待对新兵社会支持及应对方式的影响

目的研究儿童期虐待对新兵社会支持及应对方式的影响。方法对505名入伍新兵进行儿童受虐问卷（CTQ-SF）、简易应对方式问卷（SCSQ）、青少年社会支持量表评定。结果遭受儿童期虐待的新兵在应付方式选择及社会支持上显著低于无虐待组（P〈0．05）。简单相关分析显示儿童期情感虐待、情感忽视、躯体忽视及总虐待分均与积极应对呈负相关（P〈0．01）;儿童期经历过情感虐待、情感忽视、性虐待、躯体虐待、躯体忽视及虐待总分均与消极应对呈正相关（P〈0．05,P〈0．01）。儿童期情感虐待、躯体虐待、情感忽视、躯体忽视及总虐待分均与社会支持总分、客观支持、支持利用度呈负相关（P〈0．01）;儿童期经历过情感虐待、情感忽视、性虐待、躯体虐待、躯体忽视及虐待总分均与主观支持成负相关（P〈0．05,P〈0．01）。情感忽视、躯体忽视与积极应对方式呈负相关（P=0．000,P=0．003）;虐待总分、情感虐待与消极应对方式呈正相关（P=0．032,P=0．026）,与社会支持总分呈负相关（P=0．000,P=0．011）。结论儿童期遭受虐待的新兵在应对方式上往往采取消极应对,且社会支持不良。