Effects of acute prednisone administration on memory, attention and emotion in healthy human adults

Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad?

It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.

Glucocorticoids and cognitive function: a walkthrough in endogenous and exogenous alterations

PURPOSE

The hypothalamic-pituitary-adrenal (HPA) axis exerts many actions on the central nervous system (CNS) aside from stress regulation. Glucocorticoids (GCs) play an important role in affecting several cognitive functions through the effects on both glucocorticoid (GR) and mineralocorticoid receptors (MR). In this review, we aim to unravel the spectrum of cognitive dysfunction secondary to derangement of circulating levels of endogenous and exogenous glucocorticoids.

METHODS

All relevant human prospective and retrospective studies published up to 2022 in PubMed reporting information on HPA disorders, GCs, and cognition were included.

RESULTS

Cognitive impairment is commonly found in GC-related disorders. The main brain areas affected are the hippocampus and pre-frontal cortex, with memory being the most affected domain. Disease duration, circadian rhythm disruption, circulating GCs levels, and unbalanced MR/GR activation are all risk factors for cognitive decline in these patients, albeit with conflicting data among different conditions. Lack of normalization of cognitive dysfunction after treatment is potentially attributable to GC-dependent structural brain alterations, which can persist even after long-term remission.

CONCLUSION

The recognition of cognitive deficits in patients with GC-related disorders is challenging, often delayed, or mistaken. Prompt recognition and treatment of underlying disease may be important to avoid a long-lasting impact on GC-sensitive areas of the brain. However, the resolution of hormonal imbalance is not always followed by complete recovery, suggesting irreversible adverse effects on the CNS, for which there are no specific treatments. Further studies are needed to find the mechanisms involved, which may eventually be targeted for treatment strategies.

Sleep, Cognition and Cortisol in Addison's Disease: A Mechanistic Relationship

Sleep is a critical biological process, essential for cognitive well-being. Neuroscientific literature suggests there are mechanistic relations between sleep disruption and memory deficits, and that varying concentrations of cortisol may play an important role in mediating those relations. Patients with Addison's disease (AD) experience consistent and predictable periods of sub- and supra-physiological cortisol concentrations due to lifelong glucocorticoid replacement therapy, and they frequently report disrupted sleep and impaired memory. These disruptions and impairments may be related to the failure of replacement regimens to restore a normal circadian rhythm of cortisol secretion. Available data provides support for existing theoretical frameworks which postulate that in AD and other neuroendocrine, neurological, or psychiatric disorders, disrupted sleep is an important biological mechanism that underlies, at least partially, the memory impairments that patients frequently report experiencing. Given the literature linking sleep disruption and cognitive impairment in AD, future initiatives should aim to improve patients' cognitive performance (and, indeed, their overall quality of life) by prioritizing and optimizing sleep. This review summarizes the literature on sleep and cognition in AD, and the role that cortisol concentrations play in the relationship between the two.

Cognitive performance in patients with Myasthenia Gravis: an association with glucocorticosteroid use and depression

ABSTRACT. We investigated the cognitive performance of patients with Myasthenia Gravis (MG) through a cross-sectional study. A battery of cognitive assessments and self-report questionnaires regarding quality of life (QoL), sleep, and depression were applied. The sample consisted of 39 patients diagnosed with MG. The scores showed a predominance of cognitive impairment in the Montreal Cognitive Assessment screening test (MoCA) (66.7%) and in the immediate (59.0%) and recent memory (56.4%) tests. However, after the Poisson regression analysis with robust variance, it was found that patients diagnosed with depression had a prevalence ratio (PR) of 1,887 (CI 1,166‒3,054) for lower MoCA scores, PR=9,533 (CI 1,600‒56,788) for poorer phonemic verbal fluency scores, and PR=12,426 (CI 2,177‒70,931) for the Semantic Verbal Fluency test. Moreover, concerning a decline in short-term memory retention, patients using glucocorticosteroids (GC) and with Beck Depression Inventory scores indicating depression showed PR=11,227 (CI 1,736‒72,604) and PR=0.35 (CI 0.13‒0.904), respectively. No correlation was found between the QoL questionnaire and performance in cognitive tests. We found worse performance in tasks of memory and executive functions in MG patients. These are not associated with the length and severity of the disease. However, a significant prevalence ratio was found for poorer memory performance in patients diagnosed with depression and in those using GC.

A Review of Psychiatric Comorbidity in Myasthenia Gravis

This study aimed to review studies focused on the affective comorbidities associated with myasthenia gravis and to determine the extent to which neuromuscular treatment modalities address non-somatic aspects of autoimmune myasthenia gravis. Depression, anxiety, and emotional hyperactivity can aggravate myasthenia gravis, hinder accurate diagnoses, and presumably influence overall health-related quality of life.

Studies were identified using PubMed Medline and Web of Science to assess the effects of psychological factors on myasthenia gravis, encompassing 49 years of research worldwide. After analysis, approximately 6,060 patients from 32 studies worldwide between 1971 and 2020 were included. Standard-of-care approaches to diagnosis and treatment continue to under-appreciate the prevalence or impact of mood disorders in myasthenia gravis.

The majority of studies evaluated demonstrated an association between myasthenia gravis and mood disorders. However, the initiative to detect and treat affective comorbidities probably remains suboptimal. Although treatments for the somatic effects of myasthenia gravis have evolved over the past century, the paradigm of clinical practice has yet to adequately address the management of psychological impacts on the disease. This review is hoped to raise the necessary awareness in this regard.

Risk of Depressive Disorders Following Myasthenia Gravis: A Nationwide Population-Based Retrospective Cohort Study

The chronic autoimmune disease myasthenia gravis (MG) is characterized by fluctuating muscle weakness, which can lead to a large amount of stress in the patient. The current investigation plans to assess the risk of depressive disorders in MG patients. A retrospective cohort study of patients ageing 20 years and older and also newly diagnosed with MG between January 1, 2000, and December 31, 2008, was conducted from the National Health Insurance Research Database (NHIRD) in Taiwan. Observations of all 349 MG patients and 1,396 control individuals were made until a diagnosis of a depressive disorder by a psychiatrist, until death, or until December 31, 2013. A range of comorbidities were found, such as coronary artery disease, hypertension, diabetes mellitus, and dyslipidemia, with cerebrovascular disease being reported more frequently in MG patients in comparison with control subjects. After adjustment of patients' sex, age, urbanization, comorbidities, and monthly income, results indicated that MG individuals are 1.94 times more at risk (95% confidence interval [CI], 1.15-3.27, P = 0.014) of developing depressive disorders than are controls. This showed an increased risk in the development of depressive disorders in people with MG. Thus, depressive symptoms in MG patients should be regularly assessed.

Frontal EEG asymmetry in extremely low birth weight adult survivors: Links to antenatal corticosteroid exposure and psychopathology

OBJECTIVE

Extremely low birth weight (ELBW; <1000 g) survivors are exposed to significant perinatal adversity. In many cases, mothers of these infants receive antenatal corticosteroids (ACS), which reduce offspring neonatal mortality but may have lasting neuropsychiatric effects. However, the long-term neurophysiological effects of being born at ELBW and exposed to ACS are unknown.

METHODS

We compared resting frontal electroencephalogram (EEG) alpha asymmetry in ELBW survivors (n = 51), some of whom were exposed to antenatal corticosteroids (ELBW-S; n = 23) versus non-exposed (ELBW-NS; n = 28), and normal birth weight controls (NBW; n = 66) in adulthood (m_age = 32.3 years).

RESULTS

ELBW survivors exhibited greater relative right frontal EEG alpha (11.5 to 13.5 Hz) asymmetry at rest relative to NBW controls. A linear relation was observed between increased exposure to perinatal adversity (NBW vs. ELBW-NS vs. ELBW-S) and greater relative right frontal asymmetry. Relative right frontal asymmetry was also linked to contemporaneous psychopathology in all individuals.

CONCLUSION

In the fourth decade of life, exposure to perinatal adversity was associated with patterns of frontal brain activity that reflect risk for psychopathology. Exposure to additional physiological stresses such as antenatal corticosteroids may amplify these effects.

SIGNIFICANCE

The mental health of ELBW survivors, particularly those exposed to antenatal corticosteroids, should be monitored into adulthood.

Prednisolone increases neural reactivity to negative socio-emotional stimuli in healthy young men

Exogenous glucocorticoids are known to trigger affective changes, but these are highly variable across individuals. A better understanding of how synthetic glucocorticoids impact the processing of negative emotions in the human brain might help to predict such changes. In the present functional magnetic resonance imaging (fMRI) study, we sought to uncover the slow effects of a synthetic glucocorticoid infusion on the neural response to socio-emotional scenes using a within-participant, double-blind, placebo-controlled design. In two separate sessions, 20 young males were given either an intravenous prednisolone dose (250mg) or placebo in a cross-over, randomized order. Four hours later, they were scanned while viewing drawings of persons in a neutral or negative emotional situation. On the next morning participants provided a blood sample for serum cortisol measurement, which served as a manipulation check. Prednisolone strongly suppressed morning cortisol, and heightened brain reactivity to emotional stimuli in left amygdala, left caudate head, right inferior frontal gyrus, bilateral supplementary motor area, and right somatosensory cortex. Amygdala reactivity was related to lower self-reported fatigue and higher irritability in the prednisolone condition. Moreover, prednisolone blunted inferior frontal and amygdala connectivity with other regions of the emotion-processing neural circuitry. Our results suggest specific brain pathways through which exogenous glucocorticoids may labilize affect.

Relative hypo- and hypercortisolism are both associated with depression and lower quality of life in bipolar disorder: a cross-sectional study

BACKGROUND

Depression in unipolar and bipolar disorders is associated with hypothalamic-pituitary-adrenal-axis (HPA-axis) hyperactivity. Also, unipolar disorder has recently been shown to exhibit HPA-axis hypoactivity. We studied for the first time how HPA-axis hypo- and hyperactivity relate to depression and disease burden in bipolar disorder. We were interested in studying hypocortisolism; characterized by increased HPA-axis negative feedback sensitivity and lower basal cortisol levels together with the opposite HPA-axis regulatory pattern of hypercortisolism.

METHODS

This cross-sectional study includes 145 type 1 and 2 bipolar outpatients and 145 matched controls. A dexamethasone-suppression-test (DST) measures the negative feedback sensitivity and a weight-adjusted very-low-dose DST was employed, which is sensitive in identifying hypocortisolism and hypercortisolism. The 25th and 75th percentiles of control post-DST values were used as cut-offs identifying patients exhibiting relative hypo-, and hypercortisolism. Self-report questionnaires were employed: Beck-Depression-Inventory (BDI), Montgomery-Åsberg-Depression-Rating-Scale (MADRS-S), World-Health-Organization-Quality-of-Life-Assessment-100 and Global-Assessment-of-Functioning.

RESULTS

Patients exhibiting relative hypocortisolism expectedly exhibited lowered basal cortisol levels (p = 0.046). Patients exhibiting relative hypercortisolism expectedly exhibited elevated basal levels (p<0.001). Patients exhibiting relative hypocortisolism showed 1.9-2.0 (BDI, p = 0.017, MADRS-S, p = 0.37) and 6.0 (p<0.001) times increased frequencies of depression and low overall life quality compared with patients exhibiting mid post-DST values (eucortisolism). Adjusted Odds Ratios (OR:s) for depression ranged from 3.8-4.1 (BDI, p = 0.006, MADRS-S, p = 0.011) and was 23.4 (p<0.001) for life quality. Patients exhibiting relative hypercortisolism showed 1.9-2.4 (BDI, p = 0.017, MADRS-S, p = 0.003) and 4.7 (p<0.001) times higher frequencies of depression and low overall life quality compared with patients exhibiting eucortisolism. Adjusted OR:s for depression ranged from 2.2-2.7 (BDI, p = 0.068, MADRS-S, p = 0.045) and was 6.3 (p = 0.008) for life quality.

LIMITATIONS

The cross-sectional design and lack of pre-established reference values of the DST employed.

CONCLUSIONS

Relative hypocortisolism and relative hypercortisolism were associated with depression and lower life quality, providing novel insights into the detrimental role of stress in bipolar disorder.

Are individual differences in appetitive and defensive motivation related? A psychophysiological examination in two samples

Appetitive and defensive motivation account for a good deal of variance in personality and mental health, but whether individual differences in these systems are correlated or orthogonal has not been conclusively established. Previous investigations have generally relied on self-report and have yielded conflicting results. We therefore assessed the relation between psychophysiological indices of appetitive and defensive motivation during elicitation of these motivational states: specifically, frontal electroencephalogram asymmetry during reward anticipation and startle response during anticipation of predictable or unpredictable threat of shock. Results in a sample of psychopathology-free community members (n=63), an independent sample of undergraduates with a range of internalising symptoms (n=64), and the combination of these samples (n=127) revealed that differences in responding to the two tasks were not significantly correlated. Average coefficients approached zero in all three samples (community: .04, undergraduate: -.01, combined: .06). Implications of these findings for research on normal and abnormal personality are discussed.

Hydrocortisone infusion exerts dose- and sex-dependent effects on attention to emotional stimuli

Glucocorticoid administration has been shown to exert complex effects on cognitive and emotional processing. In the current study we investigated the effects of glucocorticoid administration on attention towards emotional words, using an Affective Go/No-go task on which healthy humans have shown an attentional bias towards positive as compared to negative words. Healthy volunteers received placebo and either low-dose (0.15mg/kg) or high-dose (0.45mg/kg) hydrocortisone intravenously during two separate visits in a double-blind, randomized design. Seventy-five minutes post-infusion, the subjects performed tests of attention (Rapid Visual Information Processing [RVIP]), spatial working memory (Spatial Span) and emotional processing (Affective Go/No-go task [AGNG]). On the attention task, performance was impaired under both hydrocortisone doses relative to placebo, though the effect on error rate was not significant after controlling for age; Spatial Span performance was unaffected by hydrocortisone administration. On the AGNG task, relative to the placebo condition the low-dose hydrocortisone infusion decreased response time to emotional words while high-dose hydrocortisone increased response time. In the females specifically, both high and low dose hydrocortisone administration attenuated the normal attentional bias toward positively valenced words. These data suggest that, in healthy women, the modulation of attention by the emotional salience of stimuli is influenced by glucocorticoid hormone concentrations.

Psychological distress and salivary cortisol covary within persons during pregnancy

The mechanisms whereby maternal stress during pregnancy exerts organizational effects on fetal development require elaboration. The aim of this study was to assess the plausibility of cortisol as a biological link between maternal psychological distress during pregnancy and fetal development. Previous research has resulted in equivocal findings for between-persons differences in stress and cortisol. Ecological momentary assessment was used to simultaneously assess mood and cortisol 5 times daily for 3 days in 83 women (gestational ages 6-37 weeks). Results from multilevel analysis indicated a robust within-person association between negative mood and cortisol. For each 1.0% increase in negative mood there was a corresponding 1.9% increase in cortisol. This association was unaffected by advancing gestational age. The results suggest that cortisol is a plausible biological mechanism for transducing the effects of maternal psychological distress during pregnancy to fetal development.

Cortisol acutely reduces selective attention for erotic words in healthy young men

Psychological stress prompts activity of the hypothalamic-pituitary-adrenal (HPA) axis resulting in increased release of cortisol. Long-term HPA aberrations have been observed for stress-related affective disorders but research into acute effects of cortisol on affect-regulation has only recently begun. Previous studies reported that exogenous cortisol acutely attenuated automatic attentional processing of task-irrelevant threatening information. This has been taken to suggest that cortisol may have acute anxiolytic properties, possibly through facilitating inhibition of threatening information. However, the role of cortisol in attentional inhibition of non-threatening arousing stimuli remained unclear. Therefore acute effects of 40 mg cortisol on performance of a masked and unmasked emotional Stroop task (EST) were assessed. Results for only the unmasked task demonstrated EST interference (interpreted as increased automatic attention) for erotic stimuli which was abolished by cortisol administration. This implies that effects of cortisol may not be restricted to attenuation of specifically anxiogenic information processing, as previously suggested.

The use of the EEG in measuring therapeutic drug action: focus on depression and antidepressants

A major issue in proof of concept studies and early clinical trials of novel therapeutic agents is that the active drugs can often have a relatively small additional effect compared with placebo. This is especially the case in psychiatry when we usually have no direct method of measuring the pathology underlying the disorder being studied but, rather, have to rely on the subjective assessment of psychiatric symptoms. The use of the electroencephalogram (EEG) offers two potential major means of addressing this problem. First it is able to provide direct data relating to neural activity that may be abnormal in certain disorders. As such there are opportunities for utilizing the EEG in a variety of ways as an objective outcome measure. Second there is growing evidence that in certain circumstances the EEG can be used to predict which patients are likely to respond to treatment, thus potentially increasing the power of studies by decreasing non-response rates and increasing mean changes in outcome measure. Both of these uses of the EEG are illustrated in reference to the study of mood disorders and in particular depression and its treatment with antidepressants.

Acute hydrocortisone treatment increases anxiety but not fear in healthy volunteers: a fear-potentiated startle study

BACKGROUND

The debilitating effects of chronic glucocorticoids excess are well-known, but comparatively little is understood about the role of acute cortisol. Indirect evidence in rodents suggests that acute cortisone could selectively increase some forms of long-duration aversive states, such as "anxiety," but not relatively similar, briefer aversive states, such as "fear." However, no prior experimental studies in humans consider the unique effects of cortisol on anxiety and fear, using well-validated methods for eliciting these two similar but dissociable aversive states. The current study examines these effects, as instantiated with short- and long-duration threats.

METHODS

Healthy volunteers (n = 18) received placebo or a low (20 mg) or a high (60 mg) dose of hydrocortisone in a double-blind crossover design. Subjects were exposed repeatedly to three 150-sec duration conditions: no shock; predictable shocks, in which shocks were signaled by a short-duration threat cue; and unpredictable shocks. Aversive states were indexed by acoustic startle. Fear was operationally defined as the increase in startle reactivity during the threat cue in the predictable condition (fear-potentiated startle). Anxiety was operationally defined as the increase in baseline startle from the no shock to the two threat conditions (anxiety-potentiated startle).

RESULTS

Hydrocortisone affected neither baseline nor short-duration, fear-potentiated startle but increased long-duration anxiety-potentiated startle.

CONCLUSIONS

These results suggest that hydrocortisone administration in humans selectively increases anxiety but not fear. Possible mechanisms implicated are discussed in light of prior data in rodents. Specifically, hydrocortisone might increase anxiety via sensitization of corticotrophin-releasing hormones in the bed nucleus of the stria terminalis.

Cortisol involvement in mechanisms of behavioral inhibition

We studied whether baseline cortisol is associated with post-error slowing, a measure that depends upon brain areas involved in behavioral inhibition. Moreover, we studied whether this association holds after controlling for positive associations with behavioral inhibition scores and error-related negativity (ERN) amplitudes that cortisol and post-error slowing may share. Healthy female volunteers performed a flanker task. Cortisol was independently positively associated with post-error slowing and the ERN, supporting hypotheses that cortisol is involved in behavioral inhibition. Additionally, cortisol mediated an association between ERN and more post-error slowing, which suppressed a direct association between ERN and less post-error slowing. The results are relevant, not only for researchers of behavioral inhibition, but also for researchers of the basic mechanisms of the ERN and post-error slowing, and may bring those literatures together.

Glucocorticoids. Mood, memory, and mechanisms

Elevated circulating levels of glucocorticoids are associated with psychiatric symptoms across several different conditions. It remains unknown if this hormonal abnormality is a cause or an effect of the psychiatric conditions. For example, the hypercortisolemia observed in a subset of patients with depression may have a direct impact on the symptoms of depression, but it is also possible that the hypercortisolemia merely reflects the stress associated with depression. Further, rather than causing depression, hypercortisolemia could represent a homeostatic attempt to overcome glucocorticoid resistance. Each of these possibilities will be considered, and correlational and causal evidence will be reviewed. This article will focus on the relationships between glucocorticoids and psychiatric symptoms in Cushing's syndrome, major depression, and steroid psychosis/steroid dementia, as well as the effects of exogenously administered glucocorticoids in normal volunteers. Similarities and differences in the relationship of glucocorticoid hormones to psychiatric symptoms in these conditions will be reviewed. Possible mediators of glucocorticoid effects on the brain and behavior, as well as possible "pro-aging" effects of glucocorticoids in certain cells of the body, will be reviewed. The article concludes with a conceptual model of glucocorticoid actions in the brain that may lead to novel therapeutic opportunities.

Central nervous system effects of natural and synthetic glucocorticoids

Natural glucocorticoids (NGC) physiologically modulate body homeostasis and coordinate adaptive responses to stress, involving almost all organs and tissues, including brain. Since their therapeutic availability, synthetic GC (SGC) have been successfully prescribed for a variety of diseases. Mounting evidence, however, demonstrated pleiotropic adverse effects (AE), including central nervous system (CNS) disturbances, which are often misdiagnosed or underestimated. The aim of the present study was therefore to review and discuss the CNS effects of both NGC and SGC. A detailed search was carried out of the available literature using the PubMed (US National Library of Medicine) database. Cortisolemia plays a crucial role in control of behavior, cognition, mood, and early life programming of stress reactivity. Hypercortisolemia or SGC treatments may induce behavioral, psychic and cognitive disturbances, due to functional and, over time, structural alterations in specific brain target areas. These AE are generally dose and time dependent (infrequent at prednisone-equivalent doses <20 mg/day) and usually reversible. Pediatric patients are particularly susceptible. Behavioral changes, including feeding and sleeping modifications, are common. Psychic AE are unpredictable and heterogeneous, usually mild/moderate, severe in 5-10% of cases. Manic symptoms have been mostly associated with short SGC courses, and depressive disorder with long-term treatments. Suicidality has been reported. Cognitive AE peculiarly affect declarative memory performance. Physiologic levels of NGC are essential for efficient brain functions. Otherwise, hypercortisolemia and SGC treatments may cause dose-/time-dependent neuropsychic AE and, over time, structural alterations in brain target areas. Clinicians should carefully monitor patients, especially children and/or when administering high doses SGC.

Immunity and acquired alterations in cognition and emotion: lessons from SLE

Classic immunologic teaching describes the brain as an immunologically privileged site. Studies of neuroimmunology have focused for many years almost exclusively on multiple sclerosis, a disease in which inflammatory cells actually infiltrate brain tissue, and the rodent model of this disease, experimental allergic encephalitis. Over the past decade, however, increasingly, brain-reactive antibodies have been demonstrated in the serum of patients with numerous neurological diseases. The contribution these antibodies make to neuronal dysfunction has, in general, not been determined. Here, we describe recent studies showing that serum antibodies to the N-methyl-D-aspartate receptor occur frequently in patients with systemic lupus erythematosus and can cause alterations in cognition and behavior following a breach in the blood-brain barrier.

Neural activity and diurnal variation of cortisol: evidence from brain electrical tomography analysis and relevance to anhedonia

The medial prefrontal cortex (mPFC), hippocampus, and amygdala are implicated in the regulation of affect and physiological processes, including hypothalamic-pituitary-adrenal (HPA) axis function. Anhedonia is likely associated with dysregulation of these processes. Dense-array resting electroencephalographic and cortisol were obtained from healthy and anhedonic groups. Low-resolution electromagnetic tomography was used to compute intracerebral current density. For the control group, voxelwise analyses found a relationship between current density in beta and gamma bands and steeper cortisol slope (indicative of more adaptive HPA axis functioning) in regions of the hippocampus, parahippocampal gyrus, and mPFC. For the anhedonic group, the mPFC finding was absent. Anhedonia may be characterized by disruptions of mPFC-mediated neuroendocrine regulation, which could constitute a vulnerability to the development of stress-related disorders.

Effects of cortisol on the laterality of the neural correlates of episodic memory

Alterations in the laterality of cortical activity have been shown in depressive illnesses. One possible pathophysiological mechanism for this is an effect of corticosteroids. We have previously demonstrated that endogenous cortisol concentrations correlate with the asymmetry of cortical activity related to episodic memory in healthy subjects and depressed patients. To further-examine whether this is due to a causal effect of cortisol on the laterality of episodic memory, we studied the effect of exogenous administration of cortisol in healthy subjects. Twenty-three right-handed healthy male volunteers were tested in a double-blind cross-over study. Event-related potentials (ERPs) were recorded during an episodic memory task following a four-day course of 160mg/day cortisol or placebo. Low-resolution brain electromagnetic tomography (LORETA) was used to identify brain regions involved in the neurocognitive task. Cortisol levels were measured in saliva samples. ERP and LORETA analysis following placebo demonstrated significant left parahippocampal activation associated with successful retrieval. Cortisol led to a decrease in the mean early frontal ERP voltage and an increase in the late right ERP voltage. LORETA suggested this to be due to a significant increased late activation of the right superior frontal gyrus. There was no significant effect of cortisol on episodic memory performance. This study suggests that exogenous cortisol leads to more positive-going waveforms over the right than the left hemisphere, possibly due to increased monitoring of the products of retrieval. The results support the hypothesis of causal effects of cortisol on the laterality of cortical activity occurring during an episodic memory task.

The influence of stress hormones on emotional memory: relevance for psychopathology

Substantial progress within recent years has led to a better understanding of the impact of stress on emotional memory. These effects are of relevance for understanding and treating psychopathology. The present selective review describes how emotional memory is modulated through stress hormones. Acute as well as chronic effects are discussed and information from rodent models is compared to human experimental studies and clinical observations. Finally, the relevance of these findings for emotional memory disturbances in psychiatric disorders is exemplified by discussions on neuroendocrine alterations in depression, post traumatic stress disorder and phobias.

Mood and anxiety disorders in patients with myasthenia gravis: aetiology, diagnosis and treatment

Myasthenia gravis (MG) is a chronic, autoimmune disease involving neuromuscular junctions. It is frequently associated with symptoms such as loss of muscle strength, difficulty in respiration and swallowing, diplopia and ptosis. All chronic diseases, including MG, may have psychiatric consequences in terms of coping and adaptation. Psychiatric morbidity usually appears as anxiety disorders, such as panic disorder and generalised anxiety disorder, and as depressive disorders. However, there are very few data on the prevalence and aetiology of such psychiatric symptoms in patients with MG, and those available in the literature are generally from old studies with poor methodology. The interaction between MG and psychiatric disorders needs to be appreciated, especially in the primary care setting, since the symptoms may overlap. MG may be under-recognised initially because the psychiatric symptoms may coincide with those of the actual disease, such as fatigue, lack of energy and shortness of breath. On the other hand, co-morbid psychiatric symptoms that appear during the course of the illness may be misdiagnosed as true myasthenic symptoms; thus, leading to unnecessary drug treatment. Differentiation of the aetiology of these symptoms might alter the treatment choice and, therefore, affect the treatment success rate and patients' well-being. Psychiatric treatments must be carefully planned because of the risk of aggravating the underlying neurological disease. Even though there appears to be an intricate relationship between MG and psychiatric symptoms, there is very limited information on this subject. As such, prospective, randomised, controlled pharmaco/psychotherapy studies are needed to better direct the management of patients and, thus, improve quality of life during the course of the illness.

The effects of stress and stress hormones on human cognition: Implications for the field of brain and cognition

In this review, we report on studies that have assessed the effects of exogenous and endogenous increases in stress hormones on human cognitive performance. We first describe the history of the studies on the effects of using exogenous stress hormones such as glucocorticoids as anti-inflammatory medications on human cognition and mental health. Here, we summarize the cases that led to the diagnosis of glucocorticoid-induced 'steroid psychosis' in human populations and which demonstrated that these stress hormones could thus cross the blood-brain barrier and access the brain where they could influence cognition and mental health. We then summarize studies that assessed the effects of the exogenous administration of glucocorticoids on cognitive performance supported by the hippocampus, the frontal lobes and amygdala. In the second section of the paper, we summarize the effects of the endogenous release of glucocorticoids induced by exposure to a stressful situation on human cognition and we further dissociate the effects of emotion from those of stress on human learning and memory. Finally, in the last section of the paper, we discuss the potential impact that the environmental context to which we expose participants when assessing their memory could have on their reactivity to stress and subsequent cognitive performance. In order to make our point, we discuss the field of memory and aging and we suggest that some of the 'age-related memory impairments' observed in the literature could be partly due to increased stress reactivity in older adults to the environmental context of testing. We also discuss the inverse negative correlations reported between hippocampal volume and memory for young and older adults and suggest that these inverse correlations could be partly due to the effects of contextual stress in young and older adults, as a function of age-related differences in hippocampal volume.

A study of the neural correlates of episodic memory and HPA axis status in drug-free depressed patients and healthy controls

Altered laterality of cortical activity, neuropsychological impairment and hypercortisolaemia have been shown in depression. The neural correlates of episodic memory in healthy subjects demonstrate hemispheric laterality but it is not known whether this is affected by depression and/or hypercortisolaemia. Twenty-seven drug-free depressed patients and 29 matched healthy controls were studied. Event-related potentials (ERPs) were recorded during an episodic memory test. During the study phase, subjects heard words spoken in either a male or female voice. Old and new words were presented visually during a test phase, when subjects were requested to identify words as old or new and recollect the gender of the voice for old words. Cortisol levels were measured in saliva and plasma samples. The results showed a trend for elevated salivary cortisol concentration in depressed patients. Reaction times were significantly longer in patients; however, there was no difference in memory accuracy performance between the two groups. Recollection performance was found to be negatively correlated with age, with a similar trend for cortisol concentrations. ERP activity not specifically related to episodic memory retrieval recorded 200-500ms post-stimulus from controls showed a marked laterality, with higher voltages over the right hemisphere; however, was not seen in patients. There was significant correlation between cortisol and the laterality of the neural activity specifically related to episodic memory retrieval recorded 500-1400ms post-stimulus in both depressed and healthy groups. These unique findings demonstrate that while the laterality of the neural correlates of episodic memory is sensitive to cortisol, it is not altered by the non-specific laterality effects seen in depression.

The effect of a naturalistic stressor on frontal EEG asymmetry, stress, and health

The aim of the current study was to investigate the effect of a naturalistic stressor, examination stress, on frontal EEG asymmetry, psychological stress, hormonal stress, and negative health. Forty-nine subjects were tested during periods of low and high examination stress. During the high examination stress period, subjects reported higher levels of stress on the Spielberger State Anxiety Inventory and Cohen's Perceived Stress Scale. However, no change in cortisol was detected across the two sessions. Furthermore, a shift from relatively greater left frontal activity during the low examination session to relatively greater right frontal activity during the high examination session was also found. Moreover, the increasing right frontal activity asymmetry associated with the high exam session compared to the low exam session correlated with increasing reports of negative health. No evidence was found for the prediction that cortisol mediated either the relationship between examination stressor and right frontal asymmetry or between right frontal asymmetry and negative health. In conclusion, while the findings from this study are compelling, the mechanism mediating increases in psychological stress, relatively greater right frontal activity, and increases in negative health from naturally occurring stressors is in need of further investigation.

Moods in everyday situations: effects of combinations of different arousal-related factors

OBJECTIVE

This study examined women's mood responsiveness associated with patterns of stress hormone levels in everyday situations.

METHODS

Self-reports of negative, positive, and energy dimensions of mood were obtained from 203 nurses throughout the day on a workday and on an off-work day during the luteal and follicular phases of the menstrual cycle. Individual differences in daytime norepinephrine and cortisol were assessed.

RESULTS

Patterns of norepinephrine and cortisol levels were associated with ratings of the following moods: tired, sad, and happy. Phase of the menstrual cycle and the day factor (workday, off-work day) modified the association of mood ratings and stress hormone patterns.

CONCLUSION

The experience of negative mood is associated with both hypoarousal and hyperarousal conditions. A homeostatic arousal-related concept of mood regulation is discussed.

Effects of stress hormones on the structure and function of the human brain

In response to stress, the hypothalamus-pituitary-adrenal axis is activated and glucocorticoids are secreted. These hormones exert multiple effects in the periphery as well as the brain. Acutely, they enhance memory consolidation, but at the same time the ability to retrieve previously learned information is reduced. In addition, glucocorticoids appear to interfere with working (short-term) memory. Chronically elevated glucocorticoid levels, as a result of endocrine or psychiatric disorders or as part of age-associated changes in the hypothalamus-pituitary-adrenal system, mostly have a negative influence on memory. In parallel, structural alterations are observed in the hippocampus and the prefrontal cortex. However, it seems that plasticity/reversibility is more common than previously thought. Moreover, several pharmacological interventions in animal models or small-scale human studies have revealed promising results. The advanced understanding of the CNS effects of glucocorticoids will ultimately lead to progress in the treatment of psychiatric and systemic diseases characterized by hypothalamus-pituitary-adrenal hyper- or hypo-activity.

A momentary assessment study of the relationship between affective and adrenocortical stress responses in daily life

The tendency to experience negative emotions in the face of stress may lead to repeated overactivation of the hypothalamic-pituitary-adrenal axis. In a sample of 556 women, this study used the Experience Sampling Method to assess different daily stressors, current mood, and salivary cortisol, 10 times daily for 5 days. Multilevel analyses estimated the contributions of stressors and mood states as predictors of salivary cortisol secretion. Results showed that minor stressors were associated with decreased positive affect and increased negative affect, agitation, and cortisol. Of the mood states, only negative affect was independently associated with cortisol. Negative affect also mediated effects of daily stressors on cortisol. Although further research is needed to clarify: (i) the causal pathways between daily stress, mood, and cortisol and (ii) the importance of daily stress reactivity as a prospective risk factor, these findings confirm that minor daily stressors can influence emotional and biological processes involved in subjective well-being.

Cognitive neuropsychology of alexithymia: implications for personality typology

INTRODUCTION

We examine the cognitive neuroscience of the five components of the alexithymia syndrome, and propose a classification of alexithymia types based on psychobiological traits.

METHOD

Literature review.

RESULTS

The following neural structures have been shown to be prominent in emotional function: right and left hemisphere, corpus callosum, anterior commissure, anterior cingulate, prefrontal cortex, amygdala, and insular cortex. The specific relevance of these structures to alexithymia is discussed.

CONCLUSIONS

The following conclusions and/or propositions are presented: The right hemisphere produces a global, nonverbal overview of emotional information; the left hemisphere seems dedicated to analysing emotions and higher explicit emotional cognitions. Both orbitoprefrontal cortices are important in affective aspects of alexithymia, while right temporal cortex is involved in cognitive aspects. Two subparts of anterior cingulate fulfil functions in the affective and cognitive dimensions of alexithymia. The amygdalae are involved in both cognitive and affective aspects. All structures mentioned can modulate one another. The role of interhemispheric information transfer via the corpus callosum and the anterior commissure is also discussed. The evidence that that cognitive processing of emotional information inhibits affective processing of such information is discussed in terms of its implications for a theory of alexithymia subtypes.

Deflazacort induced stronger immunosuppression than expected

Prednisone (PDN) impairs cognitive functioning and brain structures in humans and animals. Deflazacort (DFZ) is a synthetic glucocorticoid claimed to have lesser side effects than prednisone. The objective of this study was to assess whether chronic administration (90 days) of DFZ produces less neuronal degeneration and glial reactivity than PDN. Male Swiss-Wistar rats were studied. Controls received 0.1 ml distilled water orally. The PDN group received prednisone 5 mg per kg per day orally, and the DFZ group received deflazacort 6 mg per kg per day orally. This model had to be assembled in three different occasions due to excess mortality in the DFZ group. A fourth model was assembled using only the DFZ group and slides of water and PDN-exposed rats from a previous study were used as comparators. The index of degenerated neurons and the number and cytoplasmic transformation of astrocytes and microglia cells were evaluated in the prefrontal cortex, CA1, and CA3 hippocampus. The results show that the overall mortality was 49% in the DFZ group, 4.5% in the PDN group, and none of the controls died. Routine necropsy showed infection in multiple organs. The PDN group had two times higher neuronal degeneration in the prefrontal cortex, almost 11 times in CA1, and four times in CA3 hippocampus when compared with controls and DFZ group. Astrocytes reactivity was increased in the PDN- and DFZ-exposed rats compared with controls. The DFZ group showed an average of four times less microgial cells in the three studied regions when compared with controls and the PDN group. In conclusion, it seems that DFZ at the equivalent licensed dose produced a stronger immunosuppressive effect--systemic and in brain tissue--than PDN, but induced less neuronal damage. The immunosuppressant magnitude of DFZ should be further studied in clinical settings.

[Medication and memory: interactions among the elderly]

Several different systems govern human memory, and different drugs may act specifically on one or more of them. The central nervous system in the elderly is particularly sensitive to drugs, and an iatrogenic cause must be sought for all recent and/or sudden alterations in memory functions. In the case of recent alterations in memory, all nonessential drugs, especially psychotropic agents; should be withdrawn or reduced. Elderly persons, especially those with dementia, are at risk because of the frequent and substantial effects of drugs on their memory: the benefit-risk ratio must be evaluated regularly and essential treatments maintained.

Acute cortisol administration modulates EEG alpha asymmetry in volunteers: relevance to depression

The acute effects of cortisol (35mg) administration in 11 healthy male volunteers on resting frontal EEG asymmetry measured in the alpha band were investigated, using a within-subjects double-blind design. Results were indicative of a relative increase of right frontal activity with cortisol. This pattern of activity is similar to the deviant pattern that has been reported in patients suffering from depression, a condition often accompanied by elevated plasma cortisol levels. The significant effect on frontal asymmetry provides convergent support for our hypothesis, based upon previous results, that sustained (>30 minutes after stress termination) relative high levels of cortisol inhibit approach motivation.

Transient early postnatal corticosterone treatment of rats leads to accelerated aquisition of a spatial radial maze task and morphological changes in the septohippocampal region

In the present study new-born rats were treated with corticosterone (CORT) between postnatal days 1 and 12. At the age of 16-20 weeks, these animals were tested for spatial learning capacity using an eight-arm radial maze. After behavioral testing, density of cholinergic fibers and sizes of the mossy fiber terminal fields in the hippocampus and number of cholinergic and GABAergic neurons in the septal area were quantified. In the radial arm maze CORT-treated animals initially showed better working memory performance than controls. However, control animals showed a significant improvement of spatial working memory in the last trials and reached similar working memory scores as compared to treated animals. At neither day of training differences in reference memory errors were found between groups. In the diagonal band of Broca, both numbers of cholinergic and GABAergic neurons were increased after corticosterone treatment. The fiber systems in hippocampus showed no significant differences between groups. In conclusion, early postnatal stress induced by CORT administration in neonatal rats results in mild, yet significant morphological and behavioral changes in later life.

Effect of phenytoin on mood and declarative memory during prescription corticosteroid therapy

BACKGROUND

In humans and animals, corticosteroid excess is associated with impairment in declarative memory and changes in hippocampal structure. In animals, phenytoin pretreatment blocks the effects of stress on memory and hippocampal histology, although no studies have examined the use of phenytoin to prevent corticosteroid-associated memory changes in humans. Mood changes are also common with corticosteroids, but few treatment data are available. This report examines whether phenytoin can prevent mood or declarative memory changes secondary to bursts of prescription corticosteroids.

METHODS

Thirty-nine patients with allergies or pulmonary or rheumatologic illnesses and given systemic corticosteroid therapy were randomized to receive either phenytoin (300 mg/day) or placebo concurrently with the corticosteroids. Mood was assessed with the Hamilton Rating Scale for Depression, Young Mania Rating Scale, and Activation (ACT) subscale of the Internal State Scale; declarative memory was assessed with the Rey Auditory Verbal Learning Test (RAVLT) at baseline and after approximately 7 days of corticosteroid plus phenytoin or placebo therapy.

RESULTS

The two groups were similar in age, gender, education, and corticosteroid dose. The phenytoin-treated group showed significantly smaller increases on the ACT, a mania self-report scale, than the placebo-treated group. Groups did not differ significantly on RAVLT change scores.

CONCLUSIONS

This is the first placebo-controlled study to examine whether a medication can prevent mood and memory changes secondary to corticosteroids. Phenytoin blocked the hypomanic effects of prescription corticosteroids; however, phenytoin did not block the declarative memory effects of corticosteroids.

Inverted-U Function Between Salivary Cortisol and Retrieval of Verbal Memory After Hydrocortisone Treatment

The present study investigated the effect of a single oral dose of hydrocortisone (cortisol) on retrieval of verbal and nonverbal declarative memory. Fifty-nine healthy participants were randomly assigned to either receive 25 mg cortisol or a placebo 45 min before retrieval in a standardized memory test procedure. There was no global effect of cortisol on either verbal or nonverbal memory. However, a specific negative effect on free recall of associative verbal material appeared. In addition, high responders (salivary cortisol concentration>68.25 nmol/L) exhibited impaired verbal memory compared with low responders (<68.25 nmol/L). The results suggest specific nonlinear effects of cortisol on declarative memory retrieval, which appear to be more pronounced for verbal material.

Preclinical research on stress, memory, and the brain in the development of pharmacotherapy for depression

We have reviewed two areas of research on stress, memory, and synaptic plasticity which may be relevant toward understanding the neurobiology of major depressive disorder (MDD). First, we have presented the view that the hippocampus (HC) and prefrontal cortex (PFC) function jointly as a memory system which enables multitask processing (working memory) and consolidation of contextual information. The amygdala, by contrast, is necessary for the consolidation of emotional memories. Cognitive and neurophysiological studies have shown that HC-PFC processing is impaired, and amygdaloid processing is enhanced, by stress and in anxiety and mood disorders, including MDD. Second, we have reviewed research on the behavioral and neurophysiological actions of tianeptine, an antidepressant that is known to block the adverse effects of chronic stress on hippocampal morphology. Recent work has shown that acute tianeptine enhances cognitive and electrophysiological measures of HC-PFC functioning without interfering with the emotion-induced enhancement of amygdaloid functioning in rodents. We conclude with a synthesis of the preclinical and clinical literature on stress, memory, and tianeptine with the proposal that tianeptine should enhance HC-PFC memory-related processing in people under stress.

Depressive symptoms and inflammatory bowel disease in children and adolescents: a cross-sectional study

OBJECTIVES

This study assessed the rates of depressive symptoms in older children and adolescents with inflammatory bowel disease (IBD) and the associations between depressive symptoms and IBD disease characteristics.

METHODS

One hundred and two youths (aged 11-17 years) with IBD seen consecutively in a gastroenterology clinic were screened for depressive symptoms using the Children's Depression Inventory (CDI). Subjects with CDI scores > or = 12 were evaluated for current psychiatric diagnoses using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Disease characteristics examined included IBD type, duration, current severity, course, age at diagnosis and steroid treatment.

RESULTS

Of the total sample, 25 (24.5%) had a CDI score > or = 12, consistent with clinically significant depressive symptoms. Nineteen of 25 qualified subjects participated in the K-SADS-PL semi-structured interview and 16 of 19 met criteria for major or minor depressive disorder. Mean CDI scores positively correlated with age at IBD diagnosis but not with IBD type, duration or course. Youths with moderate/severe current IBD-related symptoms had significantly higher mean CDI scores than those with inactive disease activity. Anhedonia, fatigue and decreased appetite were selectively correlated with IBD disease severity. Subjects on steroids were more likely to have CDI scores > or = 12, and those with such scores were on higher doses of steroids than subjects without clinically significant depressive symptoms (both P values < 0.05).

CONCLUSIONS

These findings support the recommendation that adolescents with IBD in outpatient medical care settings, particularly older adolescents and those on steroids, should be screened for depression.

Frontal EEG asymmetry as a moderator and mediator of emotion

Frontal EEG asymmetry appears to serve as (1) an individual difference variable related to emotional responding and emotional disorders, and (2) a state-dependent concomitant of emotional responding. Such findings, highlighted in this review, suggest that frontal EEG asymmetry may serve as both a moderator and a mediator of emotion- and motivation-related constructs. Unequivocal evidence supporting frontal EEG asymmetry as a moderator and/or mediator of emotion is lacking, as insufficient attention has been given to analyzing the frontal EEG asymmetries in terms of moderators and mediators. The present report reviews the frontal EEG asymmetry literature from the framework of moderators and mediators, and overviews data analytic strategies that would support claims of moderation and mediation.

The clinical effect of glucocorticoids in patients with rheumatoid arthritis may be masked by decreased use of additional therapies

OBJECTIVE

Our previous analysis of patients with early active rheumatoid arthritis (RA) treated with prednisone or placebo revealed the following discrepancy: although a significant retardation of joint damage was observed in the prednisone group compared with the placebo group, no differences in clinical variables between the 2 groups were observed, due to greater use of additional therapy in the placebo group. We sought to investigate whether this discrepancy would extend to variables of well-being.

METHODS

We conducted a double-blind, randomized, placebo-controlled clinical trial of prednisone (10 mg) in patients with RA; the duration of the study was 2 years. Following the placebo-controlled trial, a 1-year open-label followup study was conducted in 81 patients with early (</=1 year) active, previously untreated RA. Forty-one patients were allocated to receive oral prednisone, 10 mg/day, and 40 patients were assigned to the placebo group. Analgesics, nonsteroidal antiinflammatory drugs (NSAIDs), local injections of a glucocorticoid (only when absolutely necessary), and use of physiotherapy were allowed in both groups. After 6 months, sulfasalazine (2 gm/day) could be prescribed as rescue therapy in both groups. At the beginning of the study and every 6 months thereafter, 2 questionnaires (the VDF [Dutch version of the Health Assessment Questionnaire] and the IRGL [Dutch version of the Arthritis Impact Measurement Scales]) were administered. A visual analog scale (VAS) for morning pain was administered every 3 months. Disease activity and radiologic scores were assessed.

RESULTS

VDF scores in the 2 groups were not statistically significantly different. No statistically significant differences between groups were observed in almost all parameters of the IRGL. In the prednisone group (and only at 6 months), the VAS scores for morning pain and general well-being showed improvement comparable with the transient improvement in some of the disease activity variables. In the prednisone group, use of NSAIDs, analgesics, local injections of glucocorticoids, and physiotherapy sessions was approximately 50% that in the placebo group.

CONCLUSION

Although significant retardation of joint damage in the prednisone group indicates better disease control, no differences between the groups for variables of well-being were found. This discrepancy may be attributed to greater use of additional therapy in the placebo group. In future clinical trials, the use of additional therapies should be taken into account when analyzing the differences in effect between drugs.

Cortisol variation in humans affects memory for emotionally laden and neutral information

In a test of the effects of cortisol on emotional memory, 90 men were orally administered placebo or 20 or 40 mg cortisol and presented with emotionally arousing and neutral stimuli. On memory tests administered within 1 hr of stimulus presentation, cortisol elevations caused a reduction in the number of errors committed on free-recall tasks. Two evenings later, when cortisol levels were no longer manipulated, inverted-U quadratic trends were found for recognition memory tasks, reflecting memory facilitation in the 20-mg group for both negative and neutral information. Results suggest that the effects of cortisol on memory do not differ substantially for emotional and neutral information. The study provides evidence of beneficial effects of acute cortisol elevations on explicit memory in humans.

HPA axis and memory

The hormones of the hypothalamus-pituitary-adrenal (HPA) axis influence memory in situations of acute and chronic stress. The present review tries to summarize the current state of knowledge by describing the enhancing as well as the impairing effects of stress or glucocorticoid (GC) treatment documented in animals and humans. GCs secreted during the acquisition of a stressful task facilitate consolidation. However, acute stress (or GC treatment) unrelated to the task impairs performance. The effects of acute stress are additionally modulated by gender, age and the emotional valence of the learning material. Chronic stress in rodents has mostly impairing effects on memory and hippocampal integrity. However, other regions of the brain, such as the prefrontal cortex, are also sensitive to stress. In humans, similar observations have been reported in several patient populations as well as in older subjects. The potential to reverse these effects using behavioural or pharmacological approaches needs to be explored.