Mental disorders among alcoholics. Relationship to age of onset and cerebrospinal fluid neuropeptides

Influence of alcoholism and cholesterol on TSPO binding in brain: PET [11C]PBR28 studies in humans and rodents

Neuroinflammation appears to contribute to neurotoxicity observed with heavy alcohol consumption. To assess whether chronic alcohol results in neuroinflammation we used PET and [¹¹C]PBR28, a ligand that binds to the 18-kDa translocator protein (TSPO), to compare participants with an alcohol use disorder (AUD: n = 19) with healthy controls (HC: n = 17), and alcohol-dependent (n = 9) with -nondependent rats (n = 10). Because TSPO is implicated in cholesterol's transport for steroidogenesis, we investigated whether plasma cholesterol levels influenced [¹¹C]PBR28 binding. [¹¹C]PBR28 binding did not differ between AUD and HC. However, when separating by TSPO genotype rs6971, we showed that medium-affinity binders AUD participants showed lower [¹¹C]PBR28 binding than HC in regions of interest (whole brain, gray and white matter, hippocampus, and thalamus), but no group differences were observed in high-affinity binders. Cholesterol levels inversely correlated with brain [¹¹C]PBR28 binding in combined groups, due to a correlation in AUD participants. In rodents, we observed no differences in brain [¹¹C]PBR28 uptake between alcohol-dependent and -nondependent rats. These findings, which are consistent with two previous [¹¹C]PBR28 PET studies, may indicate lower activation of microglia in AUD, whereas failure to observe alcohol effects in the rodent model indicate that species differences do not explain the discrepancy with prior rodent autoradiographic studies reporting increases in TSPO binding with chronic alcohol. However, reduced binding in AUD participants could also reflect competition from endogenous TSPO ligands such as cholesterol; and since the rs6971 polymorphism affects the cholesterol-binding domain of TSPO this could explain why differences were observed only in medium-affinity binders.

Alcohol, nicotine, caffeine, and mental disorders

Alcohol, nicotine, and caffeine are the most widely consumed psychotropic drugs worldwide. They are largely consumed by normal individuals, but their use is even more frequent in psychiatric patients, Thus, patients with schizophrenia tend to abuse all three substances. The interrelationships between depression and alcohol are complex. These drugs can all create dependence, as understood in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Alcohol abuse is clearly deleterious to the brain, provoking acute and chronic mental disorders, ranging from intoxication with impairment of cognition, to delirium tremens, halluosis, and dementia. In contrast, the main health consequences of nicotine, notably cancer and cardiovascular disases, lie outside the realm of psychiatry However, the mes of nicotine dependence and motivation to smoke or quit are of concern to psychiatrists.

Positron emission tomography study of regional brain metabolic responses to a serotonergic challenge in major depressive disorder with and without comorbid lifetime alcohol dependence

This is the first study contrasting regional glucose metabolic rate (rCMRglu) responses to a serotonergic challenge in major depressive disorder (MDD) with and without comorbid alcohol dependence. In a university hospital, patients with MDD without a history of alcohol dependence (MDD only) and patients with MDD and comorbid alcohol dependence (MDD/ALC) were enrolled in this study. Subjects with comorbid borderline personality disorder were excluded. A bolus injection of approximately 5 mCi of (18)fluorodeoxyglucose was administered 3 h after the administration of placebo or fenfluramine. We found an anterior medial prefrontal cortical area where MDD/ALC subjects had more severe hypofrontality than MDD only patients. This area encompassed the left medial frontal and left and right anterior cingulate gyri. This group difference disappeared after fenfluramine administration. The fact that the observed group difference disappeared after the fenfluramine challenge suggests that serotonergic mechanisms play a role in the observed differences between the groups.

The epidemiology of dual diagnosis

The English language literature on the epidemiology of dual diagnosis is reviewed. The literature shows mental disorders to be significantly related to alcohol and drug use disorders. The strongest associations involve externalizing mental disorders and alcohol-drug dependence. Mental disorders are associated with alcohol-drug use, problems among users, dependence among problem users, and persistence among people with lifetime dependence. These dual diagnoses are associated with severity and persistence of both mental and alcohol-drug disorders. A wider range of mental disorders is associated with nicotine dependence. Most people with dual diagnosis report their first mental disorder occurred at an earlier age than their first substance disorder. Prospective studies confirm this temporal order, although significant predictive associations are reciprocal. Analyses comparing active and remitted mental disorders suggest that some primary mental disorders are markers and others are causal risk factors for secondary substance disorders. The article closes with a discussion of ways epidemiologic research can be used to help target and evaluate interventions aimed at preventing secondary substance use disorders by treating early-onset primary mental disorders.

Lower CSF homovanillic acid levels in depressed patients with a history of alcoholism

Major depression and alcoholism are often comorbid, resulting in more impairment and more suicidal behavior compared with either diagnosis alone. This study compared clinical features and cerebrospinal fluid (CSF) monoamine metabolites in depressed subjects with and without a history of alcoholism and healthy volunteers. We hypothesized that depressed subjects with a history of alcoholism would be more aggressive, impulsive, and suicidal than depressed subjects without a history of alcoholism, and would have lower CSF monoamine metabolite levels. We compared 63 subjects with a current major depressive episode (MDE) and a history of alcoholism, 72 subjects with a current MDE but without a history of alcoholism, and 22 healthy volunteers. Participants with a history of alcoholism were in remission for at least 6 months. All subjects were free from prescribed medications known to affect brain serotonin, dopamine, or norepinephrine systems for a minimum of 14 days. Depressive symptoms, lifetime aggression, impulsivity, Axis II disorders, and suicidal behavior were assessed. CSF was sampled and homovanillic acid (HVA), 5-hydroxyindolacetic acid (5-HIAA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) were assayed by high-performance lipid chromatography with electrochemical detection. Depressed subjects with a history of alcoholism did not differ from depressed subjects without a history of alcoholism in current severity of depressive symptoms, or in past suicidal behavior. Depressed subjects with a history of alcoholism had lower CSF HVA levels, and higher lifetime aggression and current suicide ideation scale scores and were more likely to be tobacco smokers compared with depressed subjects without a history of alcoholism. Low HVA was present after adjustment for sex, aggression and depression scores, cigarette smoking, antisocial and borderline personality disorders, psychomotor retardation, and delusions. Controls had CSF HVA levels intermediate between the two depressed groups. We found no group difference in CSF 5-HIAA and MHPG levels. In individuals with current MDE, those with a history of comorbid alcoholism had lower CSF HVA levels compared with those without a history of alcoholism. Low CSF HVA suggests that impaired dopaminergic activity is associated with a history of alcoholism in persons with current MDE.

Cognitive psychosocial performance and recovery in female alcoholics

Female alcoholics experience greater affective symptomatology and are more frequently labeled with comorbid psychiatric diagnoses than male alcoholics. Subgroups of male and female alcoholics with antisocial symptomatology are strikingly similar across behavioral, psychosocial, and alcohol and drug use variables. Relative to controls, female alcoholics manifest deficits in standard neuropsychological testing as well as efficiency of information processing, interpersonal problem solving, neurophysiological measures, and neurophysiological assessment. The deficits are quite similar to those of male alcoholics. However, females may manifest a differential susceptibility to alcohol given the females' comparatively shorter drinking careers. There are no overall sex differences in relapse rates following treatment, although various personal and environmental factors play gender-specific roles in outcome. Patterns of recovery function with abstinence are similar for male and female alcoholics.

[Functional involvement of cerebral diazepam binding inhibitor (DBI) in the establishment of drug dependence]

Mechanisms for formation of drug dependence and emergence of withdrawal syndrome are not yet fully understood despite of a huge accumulation of experimental and clinical data. Several clinical features of withdrawal syndrome are considered to be common (i.e., anxiety) among patients with drug dependence induced by different drugs of abuse. In this review, we have discussed the possibility of the functional involvement of diazepam binding inhibitor (DBI), an endogenous neuropeptide for benzodiazepine receptors with endogenously anxiogenic potential, in the development of drug dependence and emergence of its withdrawal symptom. The levels of DBI protein and its mRNA significantly increased in the brain derived from mice dependent on alcohol (ethanol), nicotine and morphine, and abrupt cessation of these drugs facilitated further increase in DBI expression. In the cases of nicotine- and morphine-dependent mice, concomitant administration of antagonists for nicotinic acetylcholine and opioid receptors, respectively, abolished the increase in DBI expression. Therefore, these alterations in DBI expression have a close relationship with formation of drug dependence and/or emergence of withdrawal syndrome and are considered to be a common biochemical process in drug dependence induced by different drugs of abuse.

Childhood trauma and depression in alcoholics: relationship to hostility

OBJECTIVE

To examine for a relationship between childhood trauma and depression in alcoholics.

METHODS

Euthymic depressed alcoholics (N = 23) were compared with never depressed alcoholics (N = 20) for their scores on the Childhood Trauma Questionnaire (CTQ). Subjects also completed the Hostility and Direction of Hostility Questionnaire (HDHQ).

RESULTS

Euthymic depressed alcoholics had significantly higher scores on the CTQ for childhood emotional abuse, physical abuse, sexual abuse, and emotional neglect. They also had significantly higher hostility scores on the HDHQ. There were significant correlations between adult hostility scores and CTQ scores for childhood emotional neglect, physical neglect, sexual abuse and total childhood trauma.

CONCLUSION

A history of childhood trauma was correlated with adult depression in male alcoholics: a hostile personality dimension might be a mediating variable.

LIMITATION

Subjects were queried on their memories of childhood traumas. Prospective studies are needed.

Ritanserin in relapse prevention in abstinent alcoholics: results from a placebo-controlled double-blind international multicenter trial. Ritanserin in Alcoholism Work Group

Ritanserin, a long-acting specific 5-HT2 receptor antagonist, revealed promising effects on alcohol intake behavior in both animal and preliminary human studies. To test its effectiveness in alcohol dependence this phase III clinical trial was initiated. In a placebo-controlled, randomized, double-blind international multicenter study 493 patients with moderate or severe alcohol dependence (DSM-III-R) were treated with three doses of ritanserin 2.5 mg/day (n = 122), 5 mg/day (n = 123), 10 mg/day (n = 126), or placebo (n = 122) over a period of 6 months. Ritanserin was well tolerated. The most frequent adverse experiences were headache and insomnia. A small increase in weight in the ritanserin-treated patients was observed. There were no significant differences between any dose of ritanserin and placebo in the relapse-rate, the time to relapse, craving for alcohol, or quantity and frequency of drinking after relapse. So far, neither ritanserin nor any other serotonergic medication has shown its specific effectiveness in relapse prevention in alcohol dependence.

Neuroticism and depression in alcoholics

BACKGROUND

To examine neuroticism as a possible determinant of depression in alcoholics.

METHOD

24 euthymic depressed alcoholics and 18 never-depressed alcoholic controls completed the Eysenck Personality Questionnaire.

RESULT

Euthymic depressed alcoholics had significantly higher neuroticism scores than alcoholic controls.

LIMITATION

No women alcoholics were studied.

CONCLUSION

Neuroticism may be a risk factor for depression in alcoholics.

Hostility is associated with a heightened prolactin response to meta-chlorophenylpiperazine in abstinent cocaine addicts

The prolactin (PRL) response to the administration of serotonin (5HT) agonists is an index of central nervous system 5HT activity. This index is blunted in association with hostile aggression in personality and depressive disorder patients without substance abuse. We tested whether the PRL response to the oral administration of the partial 5HT agonist meta-chlorophenylpiperazine (MCPP), 0.35 mg/kg, was associated with a measure of trait hostility, the Buss Durkee Hostility Inventory (BDHI), in cocaine addicts who were completing a 3-week detoxification and rehabilitation program. We also tested whether the cocaine addicts differed from healthy volunteers on their PRL, cortisol (CORT) or temperature responses to MCPP. The PRL response to MCPP was positively associated with the total score on the BDHI. There were, however, no differences in the neuroendocrine or temperature responses to MCPP between the cocaine-dependent group and the healthy volunteers once age effects were controlled for.

The 2-year course following detoxification treatment of substance abuse: the possible influence of psychiatric comorbidity

The influence of psychiatric comorbidity on the course and outcome in a nationwide representative sample (n = 351) of treatment-seeking substance users over a 28-month period was studied prospectively. The patients were administered the Diagnostic Interview Schedule and a questionnaire on drinking history. At 16 and 28 months after admission the patients returned a questionnaire on drinking history and mental health. In cases of those lacking information on either follow-up (45%), details on drinking status was obtained from informants. Completely abstinent were 16%. Generalized anxiety disorder and/or social phobia at the index admission predicted abstinence during the follow-up [odds ratio (OR) = 0.25], whereas onset of alcoholism among these patients after age 25 years predicted a worse prognosis (OR = 13.5). Also increasing number of social consequences related to abuse (OR = 1.3) and drinking more than the median (OR = 2.1) predicted a poor outcome. The abstinent group had significantly better mental health at follow-up. The patients with comorbid psychiatric disorders at admission were worse at follow-up. Although substance use disorders and comorbid psychiatric disorders have to a certain degree separate courses, there is nevertheless significant interaction between them. Early treatment and recognition of comorbid psychiatric disorders among substance abusers is necessary.

Functional involvement of benzodiazepine receptors in ethanol-induced increases of diazepam binding inhibitor (DBI) and its mRNA in the mouse brain

We have attempted to clarify the mechanisms for alcohol (EtOH)-induced elevation of diazepam binding inhibitor (DBI) mRNA and to investigate whether the increase in DBI mRNA is paralleled with that in DBI using EtOH-treated mice and primary cultured neurons. Both the DBI content and the expression of DBI mRNA were elevated in the cerebral cortex of EtOH-inhaled and -withdrawn mice. Simultaneous administration of flunitrazepam (FLN) and Ro15-1788 with EtOH vapor completely abolished the EtOH-induced elevation of DBI mRNA. In addition, the exposure of the neurons for 3 days significantly elevated the expression of DBI mRNA, which was completely inhibited by concomitant exposure of FLN, Ro15-4513 and Ro-15-1788 with EtOH, while muscimol and bicuculline showed no effects on the EtOH-induced increase of DBI mRNA expression. These results indicate that functional interaction between EtOH and benzodiazepine (BDZ) receptors is a critical role in the increased expression of DBI mRNA.

Cerebrospinal fluid neuroendocrinology of alcohol misusers

Cerebrospinal fluid (CSF) neurohumors reflect central nervous system physiology in a way that peripheral indices can not. We reviewed clinical studies of CSF biogenic amines and neurohormones in alcohol misusers during various stages of withdrawal or abstinence and found them difficult to compare because of highly variable experimental methods, reliance on single time collections (lumbar punctures) that fail to control for potential stress-induced effects of the procedure, lack of control for tobacco use, and a paucity of non-alcoholmisusing controls. However, taken together, the data thus far show that a variety of neuroactive substances are reduced in concentration in the CSF of some alcohol misusers. Low CSF levels of corticotropinreleasing hormone, beta-endorphin, norepinephrine, diazepam-binding inhibitor, 5-hydroxyindoleacetic acid and somatostatin have all been reported. Whether the decreased CSF levels of these neurohormones and neurotransmitters are a cause or consequence of alcoholism has not been determined. In fact, further studies using serial or continuous CSF sampling techniques with homogeneous, better-characterized patients and normal volunteers are still needed to establish the precise CSF neurochemical abnormalities in alcohol misusers.

Age effects on the clinical presentation of alcoholics at a psychiatric hospital

Little is known about the effects of age on the clinical presentation of alcoholism in various treatment settings, despite the clinical importance of this factor. This study evaluates the effects of age on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. Young alcoholics displayed the most prominent substance use, antisocial behavior, depressive symptoms (including suicidality), and impulsivity. Early middle-aged alcoholics displayed the highest levels of drinking. Elderly alcoholics displayed the highest levels of cognitive dysfunction, although some level of cognitive dysfunction was present among even the youngest alcoholics. These findings confirm and clarify the effects of age on the clinical profile of alcoholics presenting for initial evaluation at a psychiatric hospital.

Serotonin in early-onset alcoholism

This chapter examines current, common schemes to subgroup alcoholics to arrive at relatively homogeneous groups of patients to facilitate psychobiological and molecular genetic studies. Early-onset, male-limited alcoholism is commonly associated with antisocial personality disorder or antisocial behavioral traits. It is often preceded by early-onset aggressiveness, which is followed by conduct disorder. Early-onset alcoholism among men is associated with low central serotonin turnover rate. The data concerning platelet MAO activity and serotonin uptake to platelets among early-onset alcoholics are conflicting. Recent molecular genetic and brain imaging studies on early-onset alcoholics are preliminary but appear very promising.

Aetiology of secondary depression in male alcoholics

BACKGROUND

Secondary depression is common among primary alcoholics. However, its aetiology is poorly understood.

METHOD

Forty men with primary alcoholism, abstinent for two weeks or more, with a secondary major depressive episode were compared with forty matched never-depressed primary alcoholic controls for risk factors for depression and recent life events.

RESULTS

In the six months before the onset of depression depressed alcoholics had experienced significantly more life events, more life events with negative impact, more dependent events caused by alcohol, and more independent events. Significantly more depressed alcoholics than controls had a family history of depression, a family history of suicidal behaviour and had themselves attempted suicide.

CONCLUSION

Having recent life events, particularly events with negative impact, and a family history of depression are risk factors for secondary depression in alcoholics.

Hostility is associated with a low prolactin response to meta-chlorophenylpiperazine in abstinent alcoholics

The prolactin response to the administration of serotonin agonists is an index of central nervous system serotonin (5HT) activity. This index is blunted in association with hostile aggression in personality-disordered individuals without substance abuse. We tested whether prolactin response to the partial 5HT agonist meta-chlorophenylpiperazine (MCPP) (0.35 mg/kg po) was associated with measures of trait hostility in alcoholics who were completing a 3-week rehabilitation program after medical detoxification. We also tested whether the same 5HT index differed in the group of alcoholics compared with the healthy volunteers. The prolactin response to MCPP was inversely associated with the main index of trait hostility and was similarly inversely associated with an index of depression. There was, however, no difference in neuroendocrine or temperature responses to MCPP between the alcohol-dependent group and the healthy volunteers.

Mental disease in a forensic autopsy population of alcoholics

A retrospective examination of fatalities was carried out during a five-year period among alcoholics in Copenhagen who had undergone forensic examination. The frequency of mental disease was compared with that among a non-alcoholic control group. In an examination of 2298 deaths, it was found that alcoholics had a higher frequency of unipolar affective disorder and of general "nervousness'. Previous suicide attempts were more frequent in alcoholics, and both alcoholics and controls had a higher frequency of previous suicide attempts among the depressed and those who later committed suicide than among those who did not.

Comorbidity between DSM-IV alcohol use disorders and major depression: results of a national survey

The purpose of this study was to describe detailed patterns of comorbidity between Diagnostic and Statistical Manual of Mental Disorders--Fourth Edition (DSM-IV) alcohol use disorders and major depression using a representative sample of the United States. Comorbidity rates and associations between DSM-IV alcohol use disorders and major depression were expressed as odds ratios with confidence intervals adjusted for the complex design characteristics of the NLAES. Comorbidity analyses were presented by sex, ethnicity and age for past year, prior to past year and lifetime diagnoses. Virtually all odds ratios were significantly greater than 1.0, demonstrating that comorbidity of alcohol use disorders and major depression is pervasive in the general population. The magnitude of the association remained stable across the three time frames but diagnostic and subgroup variations in comorbidity were noted. The association between alcohol dependence and major depression was greater than the association between abuse and major depression and the association between alcohol abuse and major depression was consistently greater for females and blacks, compared to their male and non-black counterparts. Implications of the results are discussed in terms of professional help seeking, the self-medication hypothesis, and differential social control theory.

Involvement of endogenous benzodiazepine receptor ligands in brain disorders: therapeutic potential for benzodiazepine antagonists?

Many therapeutic effects of benzodiazepines are mediated by neuronal high-affinity binding sites, i.e. benzodiazepine receptors (BR), located on GABAA receptors. Recently, endogenous BR ligands have partially been identified which, as agonists, either increase or, as inverse agonists, decrease GABAergic inhibition in the brain. BR antagonists, previously described as intrinsically inactive, induce effects in animals and humans under particular circumstances emphasizing a functional relevance of endogenous BR ligands. Several brain disorders, e.g. anxiety, insomnia, epilepsy, spasticity, alcoholism, coma, dementia, may be associated with a disequilibrium of opposing endogenous BR ligands changing the excitability of neurons implicated in aforementioned diseases. It is proposed that, depending on the relative role endogenous BR ligands play in the pathophysiology of these disorders, BR antagonists might demonstrate a variable efficacy in improving their symptomatology. In fact, such therapy would restore the homeostatic balance among various endogenous BR ligands being disturbed during an illness.

Antisocial tendencies and cortical sensory-evoked responses in alcoholism

Alcohol-dependent patients with antisocial, aggressive, and impulsive behaviors form a subgroup, in which a dysfunction of the brain serotonin system is discussed as a pathogenetic factor. Early onset and a transmission from fathers to sons (type II alcoholism; Cloninger, 1987) are supposedly further characteristics of this subgroup. The response pattern of primary auditory cortices to auditory stimuli with different intensities is discussed as a noninvasive indicator of the level of central serotonergic neurotransmission. A strong intensity dependence of these responses is supposed to indicate low serotonergic neurotransmission and vice versa. A strong intensity dependence is therefore expected to characterize patients with antisocial tendencies. Auditory-evoked potentials (N1/P2 component) to stimuli in five different intensities were recorded in 53 hospitalized patients after 1 week of withdrawal. Dipole source analysis was performed to separate responses of primary and secondary auditory cortices. Patients with antisocial tendencies showed a significantly stronger intensity dependence of their evoked responses of primary auditory cortices (tangential dipoles). Age at onset and family history were not related to the intensity dependence of the evoked responses. The results support the notion that alcohol-dependent patients with strong intensity dependence and antisocial tendencies form a subgroup with a serotonergic hypofunction. These patients may respond favorably to a relapse prevention with serotonergic drugs.

Early treatment of women with alcohol addiction (EWA): a comprehensive evaluation and outcome study. I. Patterns of psychiatric comorbidity at intake

This paper deals with psychiatric comorbidity among 60 women problem drinkers treated in a specialized women-only treatment programme (EWA) at Karolinska Hospital, Stockholm, Sweden. The programme attracts women who have not been previously treated for alcohol problems. The methods used were structured interviews (SCID-I and SCID-II) applied at least 10 days after the start of treatment. All but two of the women had a definite alcohol dependence according to the DSM-III-R, and a majority (60%) also fulfilled the criteria for at least one psychiatric disorder during their lifetime. However, only 23% had a personality disorder (PD), and all subjects with a PD also had at least one Axis I disorder. The most common disorders were mood disorders (48%) and anxiety disorders (38%). However, alcohol dependence developed without definite pre-existing psychiatric disorders among a substantial proportion of the women (40%). It remains to be seen whether and how psychiatric disturbances among female problem drinkers affect treatment compliance and long-term outcome.

Neurochemical correlates of sympathetic activation during severe alcohol withdrawal

Cerebrospinal fluid (CSF) was obtained from 17 patients during acute alcohol withdrawal. Eight of these 17 patients had a second lumbar puncture a mean of 11.9 +/- 8.1 (SD) days later, when the clinical signs of alcohol withdrawal had subsided. CSF 3-methoxy-4-hydroxyphenylglycol concentrations declined significantly (p < 0.05) during the course of alcohol withdrawal from 52.0 +/- 22.1 (SD) to 39.6 +/- 12.6 pM/ml. In early withdrawal, there was a significant positive correlation between CSF norepinephrine (NE) and corticotropin releasing hormone (CRH) concentrations (r = 0.95, p < 0.001). Both NE and CRH concentrations correlated positively with diastolic blood pressure (r = 0.88, p < 0.001 and r = 0.62, p < 0.05, respectively). In all samples, CSF 5-hydroxyindole acetic acid concentrations correlated positively with CSF-homovanillic acid concentrations (r = 0.83, p < 0.001). These findings indicate significant perturbations of the noradrenergic neuronal system and a change in CRH-NE interactions during acute alcohol withdrawal.

Correlates of early- and late-onset alcohol dependence

The present study aimed at finding out demographic, clinical, personality, and behavioural correlates of age at onset of alcohol dependence. Fifty-one male patients of alcohol dependence (DSM-III-R, APA, 1987) attending the drug de-addiction clinic of a general teaching hospital in India comprised the sample. They were administered a composite socio-demographic and alcohol use proforma, modified Sensation-Seeking Scale (SSS), Multiphasic Personality Questionnaire (MPQ), and a checklist of behavioural tendencies when drinking. The early-onset alcoholics (age at onset of alcohol dependence 25 years or less) were younger. They had a larger proportion of first-degree relatives with both lifetime use and abuse/dependence of alcohol but not of other psychoactive substances. They had experienced a greater number of alcohol-related problems in the previous 1 year. They were also higher sensation seekers, higher on the Psychopathic deviate scale of MPQ, and tended to display aggression, violence, and general disinhibition when drinking. The late-onset alcoholics (age at onset of alcohol dependence more than 25 years) were anxiety-prone and guilt-ridden, and had less alcohol-related problems. The two groups were comparable on duration, frequently, and quantity of alcohol consumption. The findings are discussed in relation to some of the recently proposed typologies of alcoholism.

Alpha-1- and 2-adrenoceptor subsensitivity in siblings of opioid addicts with personality disorders and depression

Noradrenergic receptor sensitivity of 16 healthy male siblings of heroin addicts and of 8 age and sex-matched controls was examined by administering a clonidine stimulation test and by measuring the resulting growth hormone (GH) (alpha-2-adrenoceptors) and beta-endorphin (beta-endorphin) (alpha-1-adrenoceptors) responses. Siblings were divided into two groups: A = siblings of heroin addicts with personality disorders and high aggressivity and B = siblings of heroin addicts without mental disorders. The GH and beta-endorphin responses to clonidine were blunted in group A subjects compared with controls and normal in group B.

Serotonin and alcohol intake, abuse, and dependence: clinical evidence

A large body of literature has emerged concerning the role of the neurotransmitter serotonin (5-hydroxytryptamine, or 5-HT) in the regulation of alcohol intake and the development of alcoholism. Despite the wealth of information, the functional significance of this neurotransmitter remains to be fully elucidated. This paper, part one of a two-part review, summarizes the available clinical research along two lines: the effects of alcohol on serotonergic functioning and the effects of pharmacological manipulation of serotonergic functioning on alcohol intake in normal (nonalcohol dependent) and alcohol-dependent individuals. It is concluded that considerable evidence exists to support the notion that some alcoholic individuals may have lowered central serotonin neurotransmission.

Prevalence and patterns of "dual diagnosis" among psychiatric inpatients

Studies of patients admitted to public mental hospitals have consistently found high rates of comorbid substance use disorders. We sought a better understanding of this comorbidity among psychiatric inpatients, in particular differentiating two groups of "dual diagnosis" patients, (1) those with independent mental disorders complicated by substance use disorders, and (2) those with psychoactive substance use disorder-induced organic mental disorders (PSUD-induced OMD). The diagnoses of 435 consecutively admitted inpatients from an inner-city catchment area were ascertained with the Structured Clinical Interview for DSM-III-R (1987 Inpatient Version [SCID-P]), modified to describe more accurately the relationships between psychiatric syndromes and substance use. More than half (55.9%) of these psychiatric patients had current substance use disorders. Over half (53.6%) of these "dually diagnosed" patients had no lifetime history of an independent mental disorder, but rather had psychiatric syndromes related to psychoactive substance use. The dual diagnosis subgroups differed on treatment history, principal psychiatric diagnoses, and the types of substances used. The results underscore the heterogeneity of dual diagnosis patients admitted to psychiatric hospitals and the potential importance of differentiating among these subgroups.

Serotonin, violent behavior and alcohol

At the NIAAA intramural research program, in collaboration with investigators at the Department of Psychiatry, University of Helsinki, we have mounted an extensive research program on early onset male alcoholism. A central serotonergic deficit is common among these patients. This finding has led to behavioral, biochemical, physiological and molecular genetic studies on the serotonin system in early onset, antisocial and violent male alcoholics and in appropriate control populations. The results of the studies completed by the fall of 1993 are summarized in this communication.

A systematic assessment of the comorbidity of DSM-III-R personality disorders in alcoholic outpatients

To our knowledge, this is the first study to examine the systematic comorbidity of DSM-III-R personality disorders (PDs) in a sample of alcoholic outpatients. The extent and direction of overlap can provide a measure of heterogeneity and descriptive validity. Fifty sober alcoholic outpatients enrolled in a treatment program were assessed by Structured Clinical Interview for DSM-III (SCID) instruments for the presence of axis I and axis II disorders; 80% had either a coexistent axis I or II disorder, with 66% having an axis I disorder, 64% an axis II disorder, and 50% both axis I and II disorders. There were 84 PD diagnoses among the 32 PD patients (2.6/patient), with multiple diagnoses in 20 (62%). The most prevalent PD diagnoses were paranoid (44%), antisocial (20%), avoidant (20%), passive-aggressive (18%), and borderline (16%). Overlap was extensive and not confined to any one of the three designated axis II clusters. Poorer outcome was associated with the presence of PD. Personality variables may offer a means of further characterizing the heterogeneity observed in axis I disorders. Further refinement of the current system of PD classification and investigation into alternate models is needed.

Primary prevention of secondary disorders: a proposal and agenda

This paper calls for consideration of a new class of preventive interventions designed explicitly to prevent comorbidity of psychiatric disorders. Epidemiologic data show that successful interventions of this type could be extremely valuable, as up to half of lifetime psychiatric disorders and an even larger percent of chronic and seriously impairing disorders occur to people with a prior history of some other disorder. Furthermore, a review of etiologic hypotheses concerning the causes of comorbidity suggests that interventions aimed at primary prevention of secondary disorders might be feasible. However, more basic risk factor research is needed on the causes of comorbidity before we can make a clear assessment of feasibility and discover promising intervention targets. A number of methodological problems arise in carrying out this type of formative research. These problems are reviewed and suggestions are offered for solutions involving innovations in measurement, design, and data analysis.

Paternal lineage of alcoholism, cohort effects, and alcoholism criteria

Adoption studies have led to the suggestion that there may be two distinct subgroups of alcoholics with differing genetic contributions. Among 249 male alcoholics we used discriminant analysis to relate the features of type 1 and type 2 alcoholism to the presence or absence of a family history of alcoholism in male paternal relatives. We found that guilt and binging, features usually attributed to type 1 (milieu-limited) alcoholism, were in fact more prevalent in the family history positive group. An additional cohort analysis found cohort-related variations in type 1/type 2 characteristics. The possible implications of these findings are discussed.

Substance abuse among subjects screened out from an alcoholism research program

Three hundred and eight subjects were screened over the phone for admission to an inpatient alcohol treatment research unit. Using a structured interview, the prospective patients were asked questions regarding demographics, drinking history, previous treatments, physical health, family history, and a detailed history of past and present substance use. Drug use was studied as regular use versus no use or brief experimental use of five drug categories: cannabinoids, stimulants, sedatives, opiates, and hallucinogens. Fifty-one percent of the men and 48% of the women reported regular use of one or more of the drugs in addition to alcohol. For women, the amount of alcohol intake was positively correlated with use of stimulants (r = .32, p = .001), cannabinoids (r = .24, p = .019), sedatives (r = .30, p = .003), and hallucinogens (r = .30, p = .003). For men, correlations between the amount of alcohol intake and drug use were weaker but significant for stimulants (r = .21, p = .002), opiates (r = .15, p = .028), and hallucinogens (r = .15, p = .029). Women with alcoholic mothers displayed higher alcohol intake than women with nonalcoholic mothers (p = .02) and also showed more frequent use of most drugs. Although men with alcoholic fathers also showed greater alcohol intake compared to men with nonalcoholic fathers, the two groups did not differ in drug use. Younger subjects of both sexes were more likely to use cannabinoids, stimulants, opiates, and hallucinogens. Alcohol and sedative use was relatively constant across all age groups.

Prevalence of alcohol and drug abuse in schizophrenic inpatients

All schizophrenic patients admitted consecutively either to the Psychiatric Hospital of the University of Munich (group 1, N = 183) or the Mental State Hospital Haar/Munich (group 2, N = 447) between 1.8.1989 and 1.2.1990 were examined to assess prevalence estimates for substance abuse in schizophrenic inpatients. Psychiatric diagnosis were made according to ICD-9 criteria. Psychopathology and psychosocial variables were documented by means of the AMDP-protocol on admission and discharge. The diagnostic procedure included a detailed semi-structured interview concerning the individual alcohol and drug history and sociodemographic data, the Munich Alcoholism Screening Test (MALT), a physical examination and the screening of various laboratory parameters such as GGT and MCV, among others. The results show that substance abuse is a very common problem in schizophrenics. Lifetime prevalence rates for substance abuse were estimated at 21.8% in group 1 and 42.9% in group 2, 3-month prevalence rates for substance abuse were estimated at 21.3% resp. 29.0%. Alcohol abuse was by far the most common type of abuse with prevalence estimates being 17.4% resp. 34.6%. Prevalence rates for substance abuse were much higher in the more "chronic"sample of the Mental State Hospital and in male patients. With respect to schizophrenic subtype few differences could be demonstrated with drug dependence being more common in patients with paranoid schizophrenia. The MALT proved to be a valuable screening instrument for alcohol abuse in schizophrenics with both a high specificity and sensitivity. "Dual diagnosis" schizophrenics had a significantly higher rate of suicide attempts and were less likely to be married. Possible clinical implications of these findings are discussed.

Alcohol abuse, substance abuse, and panic disorder

The purpose of this article is to review the literature concerning the interaction of alcohol and/or substance abuse with panic disorder, the comorbidity of these disorders, possible causal relationships, biologic relationships, and the recognition and treatment of dually disordered patients. A number of studies suggest significant comorbidity between panic disorder and alcoholism or abuse of drugs, especially cocaine and sedatives. Panic may lead to drinking or sedative use and also result from prolonged use or withdrawal of alcohol or other drugs. Possible biologic relationships involve the gamma-aminobutyric acid (GABA)-benzodiazepine receptor complex and the central noradrenergic system. Although treatment of panic in substance abusers has not been studied specifically, guidelines for recognition and management of these patients, including use of antipanic medication, are discussed.

Alcohol, the chloride ionophore and endogenous ligands for benzodiazepine receptors

Considerable evidence suggests that at least some of the effects of ethanol are mediated by an action on the GABAA receptor chloride channel complex. More speculative is the suggestion that ethanol might interact with endogenous ligands for the benzodiazepine receptor on the complex. This paper considers the evidence for such interactions.