Mania and attention-deficit/hyperactivity disorder: common symptomatology, common pathophysiology and common treatment?

Thymus transplantation as immunotherapy for the enhancement and/or correction of T cell function

The thymus is where T cells, among the most important immune cells involved in biological defense and homeostasis, are produced and developed. The thymus plays an important role in the defense against infection and cancer as well as the prevention of autoimmune diseases. However, the thymus gland atrophies with age, which might have pathological functions, and in some circumstances, there is a congenital defect in the thymus. These can be the cause of many diseases related to the dysregulation of T cell functions. Thus, the enhancement and/or normalization of thymic function may lead to protection against and treatment of a wide variety of diseases. Therefore, thymus transplantation is considered a strong candidate for permanent treatment. The status and issues related to thymus transplantation for possible immunotherapy are discussed although it is still at an early stage of development.

Sensory white noise in clinical ADHD: Who benefits from noise, and who performs worse?

Background

Experimental research has shown the benefits of auditory white noise on cognitive performance in children with attention problems. However, little is currently known about individual differences in noise response amongst children with a clinical diagnosis of attention deficit hyperactivity disorder (ADHD). In addition, no research has so far tested the effects of visual white noise on children with ADHD.

Objectives

The present work aimed at testing the effect of visual and auditory white noise on cognitive performance in children diagnosed with ADHD.

Method

Forty-three children with ADHD diagnosis performed a visuo-spatial working memory test with experimentally controlled auditory and visual white noise. Symptomatic and demographic data were collected.

Results

Surprisingly, results did not show significant effects of noise across the full sample of ADHD children. However, responses to noise appeared to affect subgroups of ADHD children differently: Those with relatively more inattentive traits responded positively on noise exposure whereas those with relatively more hyperactive/impulsive traits performed worse during noise exposure. Individual differences in noise response in the auditory and visual modalities were strongly correlated.

Conclusions

It is important to consider individual differences in response to noise exposure, and to take into account the specific ADHD symptom profile (inattentive vs. hyperactive/impulsive) in applying noise to support cognitive performance in children with ADHD.

Neurocognitive and cerebellar function in ADHD, autism and spinocerebellar ataxia

The cerebellum plays a major role in balance, motor control and sensorimotor integration, but also in cognition, language, and emotional regulation. Several neuropsychiatric disorders such as attention deficit-hyperactivity disorder (ADHD), autism spectrum disorder (ASD), as well as neurological diseases such as spinocerebellar ataxia type 3 (SCA3) are associated with differences in cerebellar function. Morphological abnormalities in different cerebellar subregions produce distinct behavioral symptoms related to the functional disruption of specific cerebro-cerebellar circuits. The specific contribution of the cerebellum to typical development may therefore involve the optimization of the structure and function of cerebro-cerebellar circuits underlying skill acquisition in multiple domains. Here, we review cerebellar structural and functional differences between healthy and patients with ADHD, ASD, and SCA3, and explore how disruption of cerebellar networks affects the neurocognitive functions in these conditions. We discuss how cerebellar computations contribute to performance on cognitive and motor tasks and how cerebellar signals are interfaced with signals from other brain regions during normal and dysfunctional behavior. We conclude that the cerebellum plays a role in many cognitive functions. Still, more clinical studies with the support of neuroimaging are needed to clarify the cerebellum's role in normal and dysfunctional behavior and cognitive functioning.

Heart and brain traumatic stress biomarker analysis with and without machine learning: A scoping review

The enigma of post-traumatic stress disorder (PTSD) is embedded in a complex array of physiological responses to stressful situations that result in disruptions in arousal and cognitions that characterise the psychological disorder. Deciphering these physiological patterns is complex, which has seen the use of machine learning (ML) grow in popularity. However, it is unclear to what extent ML has been used with physiological data, specifically, the electroencephalogram (EEG) and electrocardiogram (ECG) to further understand the physiological responses associated with PTSD. To better understand the use of EEG and ECG biomarkers, with and without ML, a scoping review was undertaken. A total of 124 papers based on adult samples were identified comprising 19 ML studies involving EEG and ECG. A further 21 studies using EEG data, and 84 studies employing ECG meeting all other criteria but not employing ML were included for comparison. Identified studies indicate classical ML methodologies currently dominate EEG and ECG biomarkers research, with derived biomarkers holding clinically relevant diagnostic implications for PTSD. Discussion of the emerging trends, algorithms used and their success is provided, along with areas for future research.

Clinical correlates of comorbid attention deficit hyperactivity disorder in adults suffering from bipolar disorder: A meta-analysis

OBJECTIVE

Attention deficit hyperactivity disorder is a frequent comorbid condition in adults with bipolar disorder. We performed a meta-analysis aimed at assessing sociodemographic and clinical correlates of attention deficit hyperactivity disorder in bipolar disorder.

METHOD

We searched main electronic databases up to June 2021. Random-effects meta-analyses, with relevant meta-regression and quality-based sensitivity analyses, were carried out to estimate the association between attention deficit hyperactivity disorder and putative correlates, grading the quality of evidence.

RESULTS

We included 43 studies, based on 38 independent samples. Attention deficit hyperactivity disorder participants were more likely to be males (odds ratio = 1.46; p < 0.001) and unemployed (odds ratio = 1.45; p = 0.045), and less likely to be married (odds ratio = 0.62; p = 0.014). They had an earlier onset of bipolar disorder (standardized mean difference = -0.36; p < 0.001); more mood episodes (standardized mean difference = 0.35; p = 0.007), particularly depressive (standardized mean difference = 0.30; p = 0.011) and mixed (standardized mean difference = 0.30; p = 0.031) ones; higher odds of using antidepressants (odds ratio = 1.80; p = 0.024) and attempted suicides (odds ratio = 1.83; p < 0.001) and lower odds of psychotic features (odds ratio = 0.63; p = 0.010). Moreover, they were more likely to have generalized anxiety disorder (odds ratio = 1.50; p = 0.019), panic disorder (odds ratio = 1.89; p < 0.001), social phobia (odds ratio = 1.61; p = 0.017), eating disorders (odds ratio = 1.91; p = 0.007), antisocial personality disorder (odds ratio = 3.59; p = 0.004) and substance (odds ratio = 2.29; p < 0.001) or alcohol (odds ratio = 2.28; p < 0.001) use disorders. Quality of the evidence was generally low or very low for the majority of correlates, except for bipolar disorder onset and alcohol/substance use disorders (high), and suicide attempts (moderate).

CONCLUSION

Comorbid bipolar disorder/attention deficit hyperactivity disorder may have some distinctive clinical features including an earlier onset of bipolar disorder and higher comorbid alcohol/substance use disorder rates. Further research is needed to identify additional clinical characteristics of this comorbidity.

Attention-Deficit Hyperactivity Disorder and Comorbid Mental Health Conditions Associated with Increased Risk of Injury

Background

To describe the influence of attention-deficit hyperactivity disorder (ADHD) and comorbid mental health conditions on the risk of selected injuries.

Methods

A retrospective cohort study design was employed using medical claim data from the Deseret Mutual Benefit Administrators (DMBA). Mental health conditions, injury, medication, and demographic data were extracted from claim files for ages 4-64, years 2016-2020.

Results

Approximately 51.8% of individuals with ADHD had one or more comorbid mental health conditions (anxiety [37.0%], depression [29.9%], autism spectrum disorder (ASD) [3.6%], bipolar disorder [4.7%], obsessive compulsive disorder (OCD) [2.4%], schizophrenia [0.9%], and manic disorder [0.2%]). The rate of injury was 1.33 (95% CI 1.27–1.39) for ADHD only versus no ADHD and 1.62 (95% CI 1.56–1.68) for ADHD and comorbid mental health conditions versus no ADHD, after adjusting for age, sex, salary, and year. Cases with ADHD but no comorbid mental health conditions versus no ADHD were at increased risk of each of 12 types of injury. The increased risk was noticeably more pronounced for ADHD cases with one or more comorbid mental health conditions versus no ADHD. The greatest increased risk of injury was among ADHD cases with comorbid schizophrenia, followed by bipolar disorder and OCD. Comorbid autism disorder does not increase the risk of injury, but lowers it. Finally, the number of comorbid mental health conditions among ADHD cases was positively associated with increased injury rates (6% for one, 30% for two, 65% for three, and 129% for four).

Conclusions

ADHD is positively associated with an increased risk of injury. Comorbid mental health conditions further increase the risk of injury among those with ADHD.

Comorbidity of adult ADHD and substance use disorder in a sample of inpatients bipolar disorder in Iran

BACKGROUNDS

The study of the relationship between adult Attention deficit hyperactivity disorder (ADHD) and bipolar disorder has received more attention in recent years and there is limited information in this area. On the other hand, there is a significant comorbidity between ADHD and bipolar disorder with substance use disorder. In this study, we investigated the prevalence of comorbidity of adult ADHD and substance use disorder among a group of bipolar patients admitted to a psychiatric hospital.

METHODS

One hundred fifty patients from a total of 200 consecutive patients who were referred to the emergency department of Roozbeh Psychiatric Hospital in Tehran, diagnosed with bipolar disorder based on the initial psychiatric interview and needed hospitalization, were evaluated again by an experienced faculty member psychiatrist by using a subsequent interview based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition(DSM-5). They were evaluated using the Structured Clinical Interview for DSM-5 (SCID-5) questionnaire to confirm the diagnosis of bipolar disorder and the comorbidity of adult ADHD and substance use disorder.

RESULTS

From 150 patients diagnosed with bipolar disorder, 106 patients (70.7%) had adult ADHD. 89 patients (59.3%) had substance use disorder and 58 patients (38.7%) had both of these comorbidities with bipolar disorder. Comorbidity of adult ADHD was associated with the earlier onset of the first mood episode in bipolar disorder (p value = 0.025). There was no statistically significant relationship between substance use disorder and age of onset of the first episode. (P value = 0.57).

CONCLUSIONS

Due to the limitations of studies on adult ADHD comorbidity with bipolar disorder, especially in hospital settings, as well as the increased risk of association with substance use disorder, further multicenter studies in this area with larger sample sizes can increase awareness in this regard.

Muskelin regulates actin-dependent synaptic changes and intrinsic brain activity relevant to behavioral and cognitive processes

Muskelin (Mkln1) is implicated in neuronal function, regulating plasma membrane receptor trafficking. However, its influence on intrinsic brain activity and corresponding behavioral processes remains unclear. Here we show that murine Mkln1 knockout causes non-habituating locomotor activity, increased exploratory drive, and decreased locomotor response to amphetamine. Muskelin deficiency impairs social novelty detection while promoting the retention of spatial reference memory and fear extinction recall. This is strongly mirrored in either weaker or stronger resting-state functional connectivity between critical circuits mediating locomotor exploration and cognition. We show that Mkln1 deletion alters dendrite branching and spine structure, coinciding with enhanced AMPAR-mediated synaptic transmission but selective impairment in synaptic potentiation maintenance. We identify muskelin at excitatory synapses and highlight its role in regulating dendritic spine actin stability. Our findings point to aberrant spine actin modulation and changes in glutamatergic synaptic function as critical mechanisms that contribute to the neurobehavioral phenotype arising from Mkln1 ablation.

A murine muskelin knockout induces increased exploratory drive and alters cognition and functional connectivity. These effects correlate with actin-dependent changes in dendritic branching, spine structure, and AMPAR-mediated synaptic transmission.

Disentangling the Association between ADHD and Alcohol Use Disorder in Individuals Suffering from Bipolar Disorder: A Systematic Review and Meta-Analysis

Attention Deficit-Hyperactivity disorder (ADHD) may influence rates of Alcohol Use Disorder (AUD) among individuals suffering from Bipolar Disorder (BD). The aim of this systematic review and meta-analysis was to estimate the strength and consistency of the potential association between ADHD and AUD in BD. We searched main electronic databases for studies indexed up to November 2020. We included observational studies investigating the association between ADHD and AUD among individuals with BD. The association between ADHD and AUD was estimated using odds ratios (ORs) with 95% Confidence Intervals (CIs). Eleven studies, involving 2734 individuals with BD (516 with ADHD), were included in the meta-analysis. Individuals with both BD and ADHD had higher rates of AUD as compared with subjects with BD only (34.0% vs. 18.3%). The estimated OR of AUD for ADHD was 2.50 (95% CI: 1.91 to 3.27; I2 = 13.0%). Study-level characteristics did not influence the effect size. No risk of publication bias was estimated. Despite some limitations, this meta-analysis estimated an association between ADHD and AUD among individuals suffering from BD. At least a portion of the high rates of AUD in BD may, thereby, be related to comorbid ADHD. Longitudinal studies are needed to clarify the nature of this relationship.

Mixed Amphetamine Salts Without a Mood Stabilizer for Treating Comorbid Attention-Deficit Hyperactivity Disorder and Bipolar Disorder: Two Case Reports

Attention-deficit hyperactivity disorder (ADHD) and bipolar disorder (BD) are often comorbid in patients and can have significant overlap in symptoms. Because of this common comorbidity and often overlapping symptoms, accurate diagnoses can be difficult. The standard treatment for these comorbid disorders is a mood stabilizer with the possibility of adding a psychostimulant. However, research suggesting treatment for comorbid disorders with a psychostimulant without a mood stabilizer is lacking. Here, we present two cases where mixed amphetamine salts, which are traditionally avoided in those with BD, were effectively used without a mood stabilizer to treat comorbid BD and ADHD in both patients. The outcome of this case series serves to motivate future investigations which are needed to validate treatment with a psychostimulant without a mood stabilizer for the treatment of comorbid BD and ADHD.

Linking RDoC and HiTOP: A new interface for advancing psychiatric nosology and neuroscience

The Research Domain Criteria (RDoC) and the Hierarchical Taxonomy of Psychopathology (HiTOP) represent major dimensional frameworks proposing two alternative approaches to accelerate progress in the way psychopathology is studied, classified, and treated. RDoC is a research framework rooted in neuroscience aiming to further the understanding of transdiagnostic biobehavioral systems underlying psychopathology and ultimately inform future classifications. HiTOP is a dimensional classification system, derived from the observed covariation among symptoms of psychopathology and maladaptive traits, which seeks to provide more informative research and treatment targets (i.e., dimensional constructs and clinical assessments) than traditional diagnostic categories. This article argues that the complementary strengths of RDoC and HiTOP can be leveraged in order to achieve their respective goals. RDoC's biobehavioral framework may help elucidate the underpinnings of the clinical dimensions included in HiTOP, whereas HiTOP may provide psychometrically robust clinical targets for RDoC-informed research. We present a comprehensive mapping between dimensions included in RDoC (constructs and subconstructs) and HiTOP (spectra and subfactors) based on narrative review of the empirical literature. The resulting RDoC-HiTOP interface sheds light on the biobehavioral correlates of clinical dimensions and provides a broad set of dimensional clinical targets for etiological and neuroscientific research. We conclude with future directions and practical recommendations for using this interface to advance clinical neuroscience and psychiatric nosology. Ultimately, we envision that this RDoC-HiTOP interface has the potential to inform the development of a unified, dimensional, and biobehaviorally-grounded psychiatric nosology.

Differentiation of ADHD and Depression Based on Cognitive Performance

Objective: The aim of this study was to assess whether self-report scales and neuropsychological tests used for adult patients with ADHD can help to distinguish between ADHD-specific and depressive symptoms. Method: In a cross-sectional design, differences in self-report questionnaires and neuropsychological tests among clinical subgroups and healthy controls (HC) were evaluated. Patients in clinical groups were diagnosed with major depressive disorder (MDD) or ADHD with or without depressive symptoms according to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) guidelines. Results: The Hyperactivity subscales of the Conners' Adult ADHD Rating Scale (CAARS) differed between MDD and ADHD, whereas self-concept and inattention scales even distinguished comorbidity subgroups within the ADHD population. A reduced alertness and higher variations in reaction times measured by performance tests indicated problems in sustained attention in ADHD patients compared with HC. Conclusion: The diagnostic process of ADHD, and thereby the distinction from other symptom-overlapping, comorbid mental disorders, might be improved by utilizing ADHD-specific self-report questionnaires and neuropsychological tests, which are short, cost-effective, and standardized screening methods.

The Association between Low Blood Pressure and Attention-Deficit Hyperactivity Disorder (ADHD) Observed in Children/Adolescents Does Not Persist into Young Adulthood. A Population-Based Ten-Year Follow-Up Study

Background: Attention-deficit hyperactivity disorder (ADHD) is one of the most common behavioral disorders in childhood and adolescence associated with relevant psychosocial impairments. The basic pathophysiology of ADHD may be related, at least partly, to a deficit in autonomic arousal processes, which not only influence core symptoms of the disorder, but may also lead to blood pressure (BP) deviations due to altered arousal regulation. Objectives: This study examined long-term changes in BP in children and adolescents with ADHD up to young adulthood. Methods: In children and adolescents aged between 7 and 17 years at baseline, we compared BP recordings in subjects with (n = 1219, 11.1%) and without (n = 9741, 88.9%) ADHD over a 10-year follow-up using data from the nationwide German Health Survey for Children and Adolescents (KiGGS). Propensity score matching was used to improve the comparability between children in the ADHD and control groups with now n = 1.190 in each group. Results: The results of these matched samples revealed that study participants with ADHD showed significantly lower systolic BP (107.6 ± 10.7 mmHg vs. 109.5 ± 10.9 mmHg, p < 0.001, Cohen’s d = 0.17) and diastolic BP (64.6 ± 7.5 mmHg vs. 65.8 ± 7.4 mmHg, p < 0.001, Cohen’s d = 0.16) at baseline. In a sensitivity analysis with a smaller (n = 272) and more stringently diagnosed ADHD group, the significant differences remained stable with somewhat higher Cohen’s d; i.e., 0.25 and 0.27, respectively. However, these differences did not persist after 10-year follow-up in a smaller matched longitudinal sub-group (ADHD n = 273; control n = 323), as subjects with and without ADHD had similar levels of systolic (123.4 ± 10.65 vs. 123.78 ± 11.1 mmHg, p = 0.675, Cohen’s d = 0.15) and diastolic BP (71.86 ± 6.84 vs. 71.85 ± 7.06 mmHg, p = 0.992, Cohen’s d = 0.16). Conclusions: At baseline, children and adolescents with ADHD had significantly lower BP (of small effect sizes) compared to the non-ADHD group, whereas this difference was no longer detectable at follow-up ten years later. These developmental alterations in BP from adolescence to early adulthood may reflect changes in the state of autonomic arousal, probably modulating the pathophysiology of ADHD.

Is brain arousal regulation a predictor of response to psychostimulant therapy in adult ADHD patients?

We investigated whether baseline brain arousal instability during resting state EEG, using the Vigilance Algorithm Leipzig (VIGALL 2.1), can predict response to methylphenidate therapy in adult ADHD patients. An arousal stability score of the EEGs of 28 adult ADHD patients was calculated quantifying the extent of arousal decline. In logistic regression analysis, arousal stability score predicted response to MPH [odds ratio 1.28 (95% CI 1.0-1.65); p = 0.027]. In this pilot study, we demonstrated that arousal stability at baseline predicted methylphenidate treatment response, indicating that less stable arousal regulation during a 15-min EEG at rest increases the chance of treatment response.

Vulnerability to bipolar disorder is linked to sleep and sleepiness

Sleep impairments are a hallmark of acute bipolar disorder (BD) episodes and are present even in the euthymic state. Studying healthy subjects who are vulnerable to BD can improve our understanding of whether sleep impairment is a predisposing factor. Therefore, we investigated whether vulnerability to BD, dimensionally assessed by the hypomanic personality scale (HPS), is associated with sleep disturbances in healthy subjects. We analyzed participants from a population-based cohort who had completed the HPS and had either a 7-day actigraphy recording or a Pittsburgh sleep quality index (PSQI) assessment. In addition, subjects had to be free of confounding diseases or medications. This resulted in 771 subjects for actigraphy and 1766 for PSQI analyses. We found strong evidence that higher HPS scores are associated with greater intraindividual sleep variability, more disturbed sleep and more daytime sleepiness. In addition, factor analyses revealed that core hypomanic features were especially associated with self-reported sleep impairments. Results support the assumption of disturbed sleep as a possibly predisposing factor for BD and suggest sleep improvement as a potential early prevention target.

Combined cognitive, psychomotor and electrophysiological biomarkers in major depressive disorder

The diagnosis of major depressive disorder (MDD) should be based on multimodal evidence, because MDD not only affects mood, but also psychomotor and cognitive functions. Clinical markers such as executive dysfunctions and a reduction in daily motor activity have been observed in MDD. Neurophysiological biomarkers have also been described. In this study, we investigate the utility of combining biomarkers related to executive dysfunctions, motor activity, neurophysiological patterns (i.e. alpha power asymmetry and EEG-vigilance as indicators of brain arousal), and the interaction of these parameters in the diagnosis of MDD. Twenty (female: 11) patients with MDD (age: 51.05 ± 10.50) and 20 (female: 13) healthy controls (HC; age: 47.15 ± 12.57) underwent a 10-min resting EEG. Executive dysfunctions were assessed using the Trail Making Test B (TMT B). Motor activity was analysed by actigraphy measurements. MDD patients displayed significant impairments in executive functions and reduced daily motor activity. In the EEG, MDD patients showed more right than left frontal activity and lower brain arousal relative to HC. TMT B and asymmetrical frontal alpha power alone discriminated between MDD patients and HC with an accuracy of 78%. The interaction of motor activity and the EEG-vigilance stage alongside TMT B increased the accuracy of the discrimination test to 81%. This improved accuracy suggests that the combination of these biomarkers in a discriminant analysis resulted in a more reliable identification of MDD patients.

Brain arousal regulation and depressive symptomatology in adults with attention-deficit/hyperactivity disorder (ADHD)

BACKGROUND

The aim of the present study was to evaluate the stability of brain arousal in adult attention-deficit/hyperactivity disorder (ADHD) outpatients with and without depressive symptomatology, and its association with depressive symptom severity and absolute electroencephalogram (EEG) power in different frequency bands.

METHODS

We included 31 outpatient adults (45.16% females), who were diagnosed according to DSM-IV and received no medication. Their arousal stability score (index of the steepness of arousal decline during a 15-min EEG under resting conditions), the absolute EEG power and self-reports, including depressive and ADHD-related symptoms, were analyzed. Participants were split into an unstable and stable arousal group based on the median (= 6) of the arousal stability score.

RESULTS

ADHD patients in the stable group reported more severe depressive symptoms (p = 0.018) and showed reduced absolute EEG power in the delta (0.002 ≤ p ≤ 0.025) and theta (0.011 ≤ p ≤ 0.034) bands compared to those in the unstable group. There was no correlation between the arousal stability score and self-report-scales concerning ADHD-related symptoms (0.214 ≤ p ≤ 0.989), but a positive association with self-reported depressive severity (p = 0.018) and negative association with powers in the EEG delta and theta bands (0.001 ≤ p ≤ 0.033).

CONCLUSIONS

In view of high comorbidity of depression and ADHD in adult patients, these findings support the assumption that brain arousal regulation could be considered as a helpful marker for the clinical differentiation between ADHD and depression.

Brain arousal regulation in SSRI-medicated patients with major depression

EEG measures of arousal have been suggested as diagnostic and predictive biomarkers for major depression. The aim of the present study was to examine whether self-rated depression severity in SSRI-medicated patients with major depression (MD) is associated with EEG measures of brain arousal. Based on previous studies, we expected that a higher level of brain arousal and a slower arousal decline during a 15-min EEG recording are associated with higher symptom severity as assessed with the Beck Depression Inventory (BDI) at the time of the EEG recording. EEGs of 78 MD patients and 46 healthy controls were analyzed. Brain arousal was assessed using the Vigilance Algorithm Leipzig (VIGALL 2.1). Based on automatically classified 1-s segments (EEG-vigilance Stages 0, A1, A2, A3, B1, B2/3 or C) we computed indices to assess the level (mean EEG-vigilance) and the decline of arousal (slope index) during the 15-min resting state EEG under eyes-closed condition. We found that a higher arousal level and a slower arousal decline corresponded to higher severity of depressive symptoms (rho = 0.238, p = .018; and rho = 0.236; p = .019). Self-rated non-remitters (BDI>12) had a higher arousal level (mean EEG-vigilance: t₇₆ = -2.19, p = .016) and slower arousal decline (slope index: Z = -2.08, p = .019) during the 15-min recording as compared to remitters. Similar results were obtained between non-remitters and healthy controls (mean EEG-vigilance: t₁₀₂ = -2.75, p = .004; slope index: Z = -1.92, p = .028), but not between remitters and controls (p > .260). The findings support the model that brain arousal regulation plays an important role in the pathophysiology and treatment of MD.

Exposure to attachment narratives dynamically modulates cortical arousal during the resting state in the listener

BACKGROUND

Affective stimulation entails changes in brain network patterns at rest, but it is unknown whether exogenous emotional stimulation has a prolonged effect on the temporal dynamics of endogenous cortical arousal. We therefore investigated differences in cortical arousal in the listener following stimulation with different attachment-related narratives.

METHODS

Resting-state EEG was recorded from sixteen healthy subjects for ten minutes each with eyes closed: first at baseline and then after passively listening to three affective narratives from strangers about their early childhood experiences (prototypical for insecure-dismissing, insecure-preoccupied, and secure attachment). Using the VIGALL 2.1 algorithm, low or high vigilance stages in consecutive EEG segments were classified, and their dynamic profile was analyzed. Questionnaires assessed the listeners' emotional response to the content of the narrative.

RESULTS

As a general effect of preceding affective stimulation, vigilance following the stimulation was significantly elevated compared to baseline rest, and carryover effects in dynamic vigilance profiles were observed. A difference between narrative conditions was revealed for the insecure-dismissing condition, in which the decrease in duration of high vigilance stages was fastest compared to the other two conditions. The behavioral data supported the observation that especially the insecure narratives induced a tendency in the listener to affectively disengage from the narrative content.

DISCUSSION

This study revealed carryover effects in endogenous cortical arousal evoked by preceding affective stimulation and provides evidence for attachment-specific dynamic alterations of brain states and individual differences in emotional reactivity.

Brain arousal regulation in adults with attention-deficit/hyperactivity disorder (ADHD)

The main aim of the current study was to test the hypothesis that adult patients with attention-deficit/hyperactivity disorder (ADHD) have less stable brain arousal regulation than healthy controls. We objectively assessed brain arousal regulation using the Vigilance Algorithm Leipzig (VIGALL 2.1) to analyze 15-min resting EEG data of thirty-three ADHD patients and thirty-five matched controls. Based on automatically classified 1-s segments we computed mean EEG-vigilance (indexing arousal level) and arousal stability score (indexing arousal regulation). Adult ADHD patients showed significantly lower arousal levels and significantly less stable brain arousal regulation than controls. Multiple regression analysis indicated that arousal regulation (i.e., arousal stability score) predicted the retrospectively-assessed severity of childhood ADHD symptoms, supporting the trait aspect of brain arousal regulation. Our findings support the arousal regulation model of ADHD, which interprets hyperactivity and sensation seeking as an autoregulatory reaction to an unstable regulation of brain arousal. EEG-based arousal parameters may be candidate biomarkers for adult ADHD.

Regulation of sustained attention, false alarm responding and implementation of conditional rules by prefrontal GABAA transmission: comparison with NMDA transmission

RATIONALE

Both prefrontal cortex (PFC) GABA_A and NMDA transmission regulate attentional processes, yet how they may differentially regulate signal detection or other aspects of attention is unclear.

OBJECTIVES

We examined PFC GABA_A and NMDA receptor regulation of attention using a sustained attention task (SAT) permitting identification of distinct forms of impairments. As this task requires implementation of conditional rules, we also investigated how reducing PFC GABA transmission affected performance of visual and auditory conditional discriminations.

METHODS

Male rats were well-trained on the SAT that required identifying whether a brief visual stimulus (500-50 ms) was present/absent by pressing one of two levers. They then received intra-PFC infusions of the GABA_A antagonist bicuculline (12.5-50 ng), the NMDA antagonist MK-801 (6 μg), and i.p. injections of MK-801 (0.1-0.3 mg/kg) prior to testing. Separate groups were trained either on a similar task where the visual stimulus was presented for 2.5 s, or a task where presentation of one of two auditory cues required responding on a left or right lever.

RESULTS

Both doses of bicuculline impaired vigilance, selectively increasing errors during nonsignal trials. Intra-PFC MK-801 induced subtle impairments at short signal durations. Systemic MK-801 impaired performance and increased response latencies. Visual and auditory conditional discrimination was impaired by 50 ng, but not 12.5 ng of bicuculline.

CONCLUSIONS

These findings highlight a key role for PFC GABA transmission in reducing sensitivity to distractors during attentional performance. Furthermore, they reveal that disruption of GABA signaling can interfere with the ability to implement conditional rules.

Use of Stimulants in Bipolar Disorder

Several international guidelines indicate stimulants, including methylphenidate (MPH), amphetamines and derivatives, modafinil, and armodafinil among the second-third-line choices for bipolar depression. Efficacy of stimulants has been also reported for the management of residual depressive symptoms such as fatigue and sleepiness and for the management of affective, cognitive, and behavioral symptoms in children and adult bipolar patients with comorbid ADHD. Few case reports show positive results with MPH in the treatment of resistant mania. Finally, MPH might be an option in some bipolar forms observed in psychiatric presentations of frontotemporal dementia and traumatic brain injury. In spite of these preliminary observations, the use of stimulants in bipolar patients is still controversial. Potential of misuse and abuse and mood destabilization with induction of (hypo)manic switches, mixed states, and rapid cycling are the concerns most frequently reported. Our aims are to summarize available literature on this topic and discuss practical management implications.

Assessment of Wakefulness and Brain Arousal Regulation in Psychiatric Research

During the last few decades, much knowledge has been gained about sleep being a heterogeneous condition with several distinct sleep stages that represent fundamentally different physiological states. The same applies for the wake state which also comprises distinct global functional states (called vigilance stages). However, various terms and concepts have been introduced describing different aspects of wakefulness, and accordingly several methods of assessment exist, e.g. sleep laboratory assessments (Multiple Sleep Latency Test, Maintenance of Wakefulness Test), questionnaires (Epworth Sleepiness Scale, Karolinska Sleepiness Scale), behavioural tasks (Psychomotor Vigilance Test) or electroencephalography (EEG)-based assessments (Alpha Attenuation Test, Karolinska Drowsiness Test). Furthermore, several theoretical concepts about the regulation of sleep and wakefulness have been put forward, and physiological correlates have been identified. Most relevant for healthy functioning is the regulation of brain arousal and the adaption of wakefulness to the environmental and situational needs so that the optimal balance between energy conservation and responsiveness can be obtained. Since one approach to the assessment of brain arousal regulation is the classification of EEG vigilance stages, a computer-based algorithm (Vigilance Algorithm Leipzig) has been introduced, allowing classification of EEG vigilance stages in EEG recordings under resting conditions. The time course of EEG vigilance stages in EEGs of 15-20 min duration allows estimation of the individual arousal regulation (hyperstable, adaptive, or unstable vigilance pattern). The vigilance model of affective disorders and attention-deficit/hyperactivity disorder links a disturbed arousal regulation to the pathogenesis of psychiatric disorders and accordingly helps to explain and possibly also predict treatment effects of pharmacological and non-pharmacological interventions for these conditions.

Comparing Auditory Noise Treatment with Stimulant Medication on Cognitive Task Performance in Children with Attention Deficit Hyperactivity Disorder: Results from a Pilot Study

Background: Recent research has shown that acoustic white noise (80 dB) can improve task performance in people with attention deficits and/or Attention Deficit Hyperactivity Disorder (ADHD). This is attributed to the phenomenon of stochastic resonance in which a certain amount of noise can improve performance in a brain that is not working at its optimum. We compare here the effect of noise exposure with the effect of stimulant medication on cognitive task performance in ADHD. The aim of the present study was to compare the effects of auditory noise exposure with stimulant medication for ADHD children on a cognitive test battery. A group of typically developed children (TDC) took the same tests as a comparison.

Methods: Twenty children with ADHD of combined or inattentive subtypes and twenty TDC matched for age and gender performed three different tests (word recall, spanboard and n-back task) during exposure to white noise (80 dB) and in a silent condition. The ADHD children were tested with and without central stimulant medication.

Results: In the spanboard- and the word recall tasks, but not in the 2-back task, white noise exposure led to significant improvements for both non-medicated and medicated ADHD children. No significant effects of medication were found on any of the three tasks.

Conclusion: This pilot study shows that exposure to white noise resulted in a task improvement that was larger than the one with stimulant medication thus opening up the possibility of using auditory noise as an alternative, non-pharmacological treatment of cognitive ADHD symptoms.

Time to wake up: No impact of COMT Val158Met gene variation on circadian preferences, arousal regulation and sleep

Dopamine has been implicated in the regulation of sleep-wake states and the circadian rhythm. However, there is no consensus on the impact of two established dopaminergic gene variants: the catechol-O-methyltransferase Val158Met (COMT Val158Met; rs4680) and the dopamine D4 receptor Exon III variable-number-of-tandem-repeat polymorphism (DRD4 VNTR). Pursuing a multi-method approach, we examined their potential effects on circadian preferences, arousal regulation and sleep. Subjects underwent a 7-day actigraphy assessment (SenseWear Pro3), a 20-minute resting EEG (analyzed using VIGALL 2.0) and a body mass index (BMI) assessment. Further, they completed the Morningness-Eveningness Questionnaire (MEQ), the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI). The sample comprised 4625 subjects (19-82 years) genotyped for COMT Val158Met, and 689 elderly subjects (64-82 years) genotyped for DRD4 VNTR. The number of subjects varied across phenotypes. Power calculations revealed a minimum required phenotypic variance explained by genotype ranging between 0.5% and 1.5% for COMT Val158Met and between 3.3% and 6.0% for DRD4 VNTR. Analyses did not reveal significant genotype effects on MEQ, ESS, PSQI, BMI, actigraphy and EEG variables. Additionally, we found no compelling evidence in sex- and age-stratified subsamples. Few associations surpassed the threshold of nominal significance (p < .05), providing some indication for a link between DRD4 VNTR and daytime sleepiness. Taken together, in light of the statistical power obtained in the present study, our data particularly suggest no impact of the COMT Val158Met polymorphism on circadian preferences, arousal regulation and sleep. The suggestive link between DRD4 VNTR and daytime sleepiness, on the other hand, might be worth investigation in a sample enriched with younger adults.

[Significance of clinical electroencephalogram in psychiatry]

The generation of an electroencephalogram (EEG) provides a sensitive, non-invasive and inexpensive method for the investigation of brain function. This article critically reviews the significance of EEG examinations in clinical psychiatric practice and describes relevant applications and limitations. A summary of the basic principles of the production and interpretation of an EEG is followed by a survey of typical EEG patterns in healthy subjects and pathological alterations of EEG patterns. The importance of the EEG for the clinical diagnostics of Alzheimer's disease and acute delirium as well as the differentiation between psychiatric syndromes and non-convulsive status epilepticus is reviewed. Moreover, the usefulness of the EEG is highlighted with respect to the diagnostics and monitoring of the course of lithium intoxication. Finally, this article gives a brief insight into promising research approaches that are currently being followed in modern psychiatry using an EEG.

Mice heterozygous for cathepsin D deficiency exhibit mania-related behavior and stress-induced depression

Mutations in cathepsin D (CTSD), an aspartic protease in the endosomal-lysosomal system, underlie congenital neuronal ceroid-lipofuscinosis (cNCL, also known as CLN10), a devastating neurodegenerative disease. CLN10 patients die within the first few days of life, and in the few patients who live into adulthood psychopathological symptoms have not been reported. Extensive neuropathology and altered neurotransmission have been reported in CTSD-deficient mice; however signs of neuropsychiatric behavior in these mice are not well characterized due to the severe movement disorder and premature death of the animal. In the present study, we show that heterozygous CTSD-deficient (CTSD HET) mice display an overall behavioral profile that is similar to human mania, including hyperlocomotion, d-amphetamine-induced hyperactivity, sleep-disturbance, and reduced anxiety-like behavior. However, under stressful conditions CTSD HET mice manifest depressive-like behavior, including anhedonia, behavioral despair, and enhanced learned helplessness. Chronic administration of lithium chloride or valproic acid, two clinically effective mood stabilizers, reverses the majority of these behavioral abnormalities. In addition, CTSD HET mice display stress-induced hypersecretion of corticosterone. These findings suggest an important role for CTSD in the regulation of mood stabilization.

Are uric acid plasma levels different between unipolar depression with and without adult attention deficit hyperactivity disorder?

BACKGROUND

The aim of our study is to compare uric acid plasma levels in patients with unipolar depression between those with Attention deficit hyperactivity disorder (ADHD) comorbidity and those without. Our hypothesis is that uric acid plasma levels may be higher in unipolar depressive patients with adult ADHD than without ADHD.

METHODS

Sixty four patients diagnosed with MDD were investigated, among which 28 patients had been diagnosed with ADHD according to DSM5. 28 patients were ADHD. 36 patients were diagnosed as not having ADHD. One of the criteria was including cases that had not started using medication for the current depressive episode. The control group (HC) consisted of 43 healthy staff members from our hospital who had no prior psychiatric admission or treatment history and matched with the patient group in terms of age and gender. Blood samples were obtained, and plasma uric acid levels were recorded in mg/dl after being rotated for 15min in a centrifuge with 3000 rotations and kept at -80°C.

RESULTS

Uric acid plasma levels 5.1±1.6 in unipolar depression and ADHD group, 4.6±1.8 in unipolar depression group. Uric acid plasma levels were higher in the comorbid unipolar depression and ADHD group than in the unipolar depression and healthy control (HC) groups (F= 4.367, p= 0.037). There was no correlation between ADHD (predominantly inattentive type) and uric acid plasma levels (p>0.05).

LIMITATIONS

The limitation of this study is the small number of sample and one of the criteria was including cases that had not started using medication for the current depressive episode.

CONCLUSION

The identification of a different etiologic process of biological markers may lead to a better understanding of the physiological mechanisms involved in drive and impulsivity and may suggest different potential targets for therapeutic intervention.

Pre-stress performance in an instrumental training predicts post-stress behavioral alterations in chronically stressed rats

Stress is a major factor in the development of major depressive disorder (MDD), but few studies have assessed individual risk based on pre-stress behavioral and cognitive traits. To address this issue, we employed appetitive instrumental lever pressing with a progressive ratio (PR) schedule to assess these traits in experimentally naïve Sprague-Dawley rats. Based on four distinct traits that were identified by hierarchical cluster analysis, the animals were classified into the corresponding four subgroups (Low Motivation, Quick Learner, Slow Learner, and Hypermotivation), and exposed to chronic unpredictable stress (CUS) before monitoring their post-stress responses for 4 weeks. The four subgroups represented the following distinct behavioral phenotypes after CUS: the Low Motivation subgroup demonstrated weight loss and a late-developing paradoxical enhancement in PR performance that may be related to inappropriate decision-making in human MDD. The Quick Learner subgroup exhibited a transient loss of motivation and the habituation of serum corticosterone (CORT) response to repeated stress. The Slow Learner subgroup displayed resistance to demotivation and a suppressed CORT response to acute stress. Finally, the Hypermotivation subgroup exhibited resistance to weight loss, habituated CORT response to an acute stress, and a long-lasting amotivation. Overall, we identified causal relationships between pre-stress traits in the performance of the instrumental training and post-stress phenotypes in each subgroup. In addition, many of the CUS-induced phenotypes in rats corresponded to or had putative relationships with representative symptoms in human MDD. We concluded that the consequences of stress may be predictable before stress exposure by determining the pre-stress behavioral or cognitive traits of each individual in rats.

Electroencephalography and externalizing behavior: a meta-analysis

Electroencephalography (EEG) has been used to examine the possibility of dysfunctional brain activity in externalizing behavior, but findings across studies have been inconsistent. Furthermore, studies of attention-deficit/hyperactivity disorder (ADHD) versus other externalizing behaviors, such as disruptive behavior disorders or antisocial behavior, have developed parallel literatures. The purpose of the present study was to reconcile these two literatures. A meta-analysis of 62 studies of EEG power at rest in relationship to externalizing behaviors was performed. Results of the meta-analyses showed significantly higher delta (Hedges's g=0.25) and theta power (g=0.40) and lower beta power (g=-0.22) in externalizing participants compared to controls. Alpha (g=-0.26) and gamma power (g=-0.26) were marginally lower in externalizing samples. Results were not moderated by type of externalizing behavior. Overall, the results of the meta-analyses were consistent with the hypoarousal theory of externalizing behavior.

Adult attention-deficit/hyperactivity disorder in major depressed and bipolar subjects: role of personality traits and clinical implications

A significant comorbidity between attention-deficit/hyperactivity disorder (ADHD) and affective disorders has been consistently reported in adults. Less data regarding the role of personality traits and the influence of ADHD co-occurrence on clinical characteristics and outcome of mood disorders are currently available. One hundred and six remitted major depressed, 102 euthymic bipolar subjects, and 120 healthy controls, homogeneous with respect to demographic characteristics, were included in the study. ADHD diagnosis was based on DSM-IV-TR criteria. Childhood and adult ADHD features were measured with the Wender Utah Rating Scale, the Adult ADHD Self-rating Scale, and the Brown Attention-Deficit Disorder Scale. The Revised NEO Personality Inventory was also administered to the clinical groups, in order to investigate personality dimensions. The occurrence of adult ADHD in subjects with bipolar disorders (BD) or major depressive disorder (MDD) was 15.7 and 7.5 %, respectively, compared to 3.3 % in healthy controls (HC). Significant associations (p < .001) between personality traits (neuroticism, conscientiousness, and extraversion) and ADHD features were observed. Logistic regression analysis of all clinical subjects (n = 208) showed that those with lower levels of neuroticism (OR = 1.031; p = .025) had a lower frequency of ADHD comorbidity. The present study emphasizes the close relationship between affective disorders, especially BD, and ADHD in adults. Our findings support the need to assess subjects with mood disorders in the clinical setting for possible coexisting ADHD and to further investigate personality traits to better understand the etiology of affective disorders and ADHD co-occurrence.

Hyperactivity and sensation seeking as autoregulatory attempts to stabilize brain arousal in ADHD and mania?

Hypoarousal as indicated by skin conductance and electroencephalography (EEG) has been discussed as a pathogenetic factor in attention-deficit/hyperactivity disorder (ADHD). The aim of this paper was to review these arousal-related pathogenetic concepts and to present the more recently proposed vigilance regulation model of affective disorders and ADHD. The latter builds on methodological advances in classifying short EEG segments into vigilance stages (Vigilance Algorithm Leipzig, VIGALL), indicating different states of global brain function ("brain arousal"). VIGALL allows the objective assessment of vigilance regulation under defined conditions, e.g. how fast vigilance declines to lower vigilance stages associated with drowsiness during 15-20-min EEG recordings under resting conditions with eyes closed. According to the vigilance regulation model, the hyperactivity and sensation seeking observed in overtired children, ADHD and mania may be interpreted as an autoregulatory attempt to create a stimulating environment in order to stabilize vigilance. The unstable regulation of vigilance observed in both mania and ADHD may thus explain the attention deficits, which become especially prominent in monotonous sustained attention tasks. Among the arguments supporting the vigilance regulation model are the facts that destabilizing vigilance (e.g., via sleep deprivation) can trigger or exacerbate symptoms of ADHD or mania, whereas stabilizing vigilance (e.g., via psychostimulants, reducing sleep deficits) alleviates these symptoms. The potential antimanic effects of methylphenidate are presently being studied in an international randomized controlled trial. We propose vigilance regulation as a converging biomarker, which could be useful for identifying treatment responders to psychostimulants and forming pathophysiologically more homogeneous ADHD subgroups for research purposes.

Genetic association of objective sleep phenotypes with a functional polymorphism in the neuropeptide S receptor gene

BACKGROUND

The neuropeptide S receptor (NPSR1) and its ligand neuropeptide S (NPS) have received increased attention in the last few years, as both establish a previously unknown system of neuromodulation. Animal research studies have suggested that NPS may be involved in arousal/wakefulness and may also have a crucial role in sleep regulation. The single nucleotide polymorphism (SNP) rs324981 in NPSR1 has begun to shed light on a function of the NPS-system in human sleep regulation. Due to an amino acid exchange, the T-allele leads to an increased sensitivity of the NPSR1. In the only genome-wide association study to date on circadian sleep parameters in humans, an association was found between rs324981 and regular bedtime. However, the sleep parameters in this study were only measured by self-rating. Therefore, our study aimed to replicate these findings using an objective measure of sleep.

METHODS

The study included n = 393 white subjects (62-79 years) who participated in an actigraphic assessment for determining sleep duration, rest duration, sleep onset, rest onset and sleep onset latency. Genotyping of the SNP rs324981 was performed using the TaqMan OpenArray System.

RESULTS

The genotype at rs324981 was not significantly associated with rest onset (bedtime) or sleep onset (p = .146 and p = .199, respectively). However, the SNP showed a significant effect on sleep- and rest duration (p = .007 and p = .003, respectively). Subjects that were homozygous for the minor T-allele had a significantly decreased sleep- and rest duration compared to A-allele carriers.

CONCLUSION

The results of this study indicate that the sleep pattern in humans is influenced by the NPS-system. However, the previously reported association between bedtime and rs324981 could not be confirmed. The current finding of decreased sleep duration in T/T allele carriers is in accordance with studies in rodents reporting similar results after NPS application.

Could comorbid bipolar disorder account for a significant share of executive function deficits in adults with attention-deficit hyperactivity disorder?

OBJECTIVE

The frequent comorbidity between attention-deficit hyperactivity disorder (ADHD) and bipolar disorder (BD) represents a challenge for disentangling specific impairments of each disorder in adulthood. Their functional impairments seem to be mediated by executive function deficits. However, little is known about the extent to which each executive function deficit might be disorder specific or explained by the comorbidity. The aim of the present study was to determine if comorbid BD could account for a significant share of executive function deficits when measured by the Wisconsin Card Sorting Test (WCST) in adults with ADHD.

METHODS

Adult patients with ADHD and healthy subjects were evaluated in the ADHD outpatient Program at the Hospital de Clínicas de Porto Alegre. Psychiatric diagnoses were based on DSM-IV criteria. WCST scores were compared by multivariate analysis of covariance among three groups: ADHD with BD (n = 51), ADHD without BD (n = 278), and healthy subjects (n = 91).

RESULTS

When compared to patients without BD and healthy subjects, patients with ADHD and comorbid BD showed lower scores in total correct answers (p = 0.003); higher scores in total errors (p = 0.004) and non-perseverative errors (p = 0.002); and completed fewer categories (p = 0.009). Patients with ADHD without BD did not differ from healthy subjects.

CONCLUSIONS

WCST impairments among patients with ADHD seem to be to a large extent attributable to comorbid BD. Although other executive function deficits (e.g., in the inhibitory control domain) have been demonstrated to accompany ADHD, the present findings suggest that set-shifting deficits are strongly related to comorbid BD.

Personalized Medicine in ADHD and Depression: Use of Pharmaco-EEG

This chapter summarises recent developments on personalised medicine in psychiatry with a focus on ADHD and depression and their associated biomarkers and phenotypes. Several neurophysiological subtypes in ADHD and depression and their relation to treatment outcome are reviewed. The first important subgroup consists of the 'impaired vigilance' subgroup with often-reported excess frontal theta or alpha activity. This EEG subtype explains ADHD symptoms well based on the EEG Vigilance model, and these ADHD patients responds well to stimulant medication. In depression this subtype might be unresponsive to antidepressant treatments, and some studies suggest these depressive patients might respond better to stimulant medication. Further research should investigate whether sleep problems underlie this impaired vigilance subgroup, thereby perhaps providing a route to more specific treatments for this subgroup. Finally, a slow individual alpha peak frequency is an endophenotype associated with treatment resistance in ADHD and depression. Future studies should incorporate this endophenotype in clinical trials to investigate further the efficacy of new treatments in this substantial subgroup of patients.

Impulsivity is associated with uric acid: evidence from humans and mice

BACKGROUND

The ability to control impulses varies greatly, and difficulty with impulse control can have severe consequences; in the extreme, it is the defining feature of many psychiatric disorders. Evidence from disparate lines of research suggests that uric acid is elevated in psychiatric disorders characterized by high impulsivity, such as attention-deficit/hyperactivity disorder and bipolar disorder. The present research tests the hypothesis that impulsivity is associated with higher uric acid in humans and mice.

METHODS

Using two longitudinal, nonclinical community samples (total n = 6883), we tested whether there is an association between uric acid and normal variation in trait impulsivity measured with the Revised NEO Personality Inventory. We also examined the effect of uric acid on behavior by comparing wild-type mice, which naturally have low levels of uric acid, with mice genetically modified to accumulate high levels of uric acid.

RESULTS

In both human samples, the emotional aspects of trait impulsivity, specifically impulsiveness and excitement seeking, were associated with higher levels of uric acid concurrently and when uric acid was measured 3 to 5 years later. Consistent with the human data, the genetically modified mice displayed significantly more exploratory and novelty-seeking behavior than the wild-type mice.

CONCLUSIONS

Higher uric acid was associated with impulsivity in both humans and mice. The identification of biological markers of impulsivity may lead to a better understanding of the physiological mechanisms involved in impulsivity and may suggest potential targets for therapeutic intervention.

Iatrogenic neurology

Iatrogenic disease is one of the most frequent causes of hospital admissions and constitutes a growing public health problem. The most common type of iatrogenic neurologic disease is pharmacologic, and the central and peripheral nervous systems are particularly vulnerable. Despite this, iatrogenic disease is generally overlooked as a differential diagnosis among neurologic patients. The clinical picture of pharmacologically mediated iatrogenic neurologic disease can range from mild to fatal. Common and uncommon forms of drug toxicity are comprehensively addressed in this chapter. While the majority of neurologic adverse effects are listed and referenced in the tables, the most relevant issues are further discussed in the text.

Impact of mood stabilizers and antiepileptic drugs on cytokine production in-vitro

Changes within the immune system have been reported to contribute to the pathophysiology of bipolar disorder and epilepsy. Interestingly, overlapping results regarding the cytokine system have been found for both diseases, namely alterations of interleukins IL-1β, IL-2, IL-4, IL-6, and tumor necrosis factor-α (TNF-α). However, the effect of mood stabilizers and antiepileptic drugs (AEDs) on these cytokines has not been systematically evaluated, and their effect on IL-17 and IL-22, other immunologically important cytokines, has not been reported. Therefore, we systematically measured levels of IL-1β, IL-2, IL-4, IL-6, IL-17, IL-22 and TNF-α in stimulated blood of 14 healthy female subjects in a whole blood assay using the toxic shock syndrome toxin TSST-1 as stimulant. Blood was supplemented with the mood stabilizers or antiepileptic drugs primidone (PRM), carbamazepine (CBZ), levetiracetam (LEV), lamotrigine (LTG), valproic acid (VPA), oxcarbazepine (OXC), topiramate (TPM), phenobarbital (PB), lithium, or no drug. IL-1β production was significantly decreased by PRM, CBZ, LEV, LTG, OXC, PB and lithium. IL-2 significantly decreased by PRM, CBZ, LEV, LTG, VPA, OXC, TPM and PB. IL-22 significantly increased by PRM, CBZ, LEV, OXC, TPM and lithium and decreased by VPA. TNF-α production significantly decreased under all applied drugs. The mechanism of action and side effects of mood stabilizers and AEDs may involve modulation of IL-1β, IL-2, IL-22 and TNF-α signaling pathways. IL-22 may be a research target for specific therapeutic effects of mood stabilizers and AEDs. These drugs might influence cytokine production by modulating ion channels and γ-aminobutyric acid (GABA) receptors of immune cells.

Co-segregation of hyperactivity, active coping styles, and cognitive dysfunction in mice selectively bred for low levels of anxiety

We established mouse models of extremes in trait anxiety, which are based on selective breeding for low vs. normal vs. high open-arm exploration on the elevated plus-maze. Genetically selected low anxiety-related behavior (LAB) coincided with hyperactivity in the home cage. Given the fact that several psychiatric disorders such as schizophrenia, mania, and attention deficit hyperactivity disorder (ADHD) share hyperactivity symptom, we systematically examined LAB mice with respect to unique and overlapping endophenotypes of the three diseases. To this end Venn diagrams were used as an instrument for discrimination of possible models. We arranged the endophenotypes in Venn diagrams and translated them into different behavioral tests. LAB mice showed elevated levels of locomotion in the open field (OF) test with deficits in habituation, compared to mice bred for normal (NAB) and high anxiety-related behavior (HAB). Cross-breeding of hypoactive HAB and hyperactive LAB mice resulted in offspring showing a low level of locomotion comparable to HAB mice, indicating that the HAB alleles are dominant over LAB alleles in determining the level of locomotion. In a holeboard test, LAB mice spent less time in hole exploration, as shown in patients with schizophrenia and ADHD; however, LAB mice displayed no impairments in social interaction and prepulse inhibition (PPI), implying a unlikelihood of LAB as an animal model of schizophrenia. Although LAB mice displayed hyperarousal, active coping styles, and cognitive deficits, symptoms shared by mania and ADHD, they failed to reveal the classic manic endophenotypes, such as increased hedonia and object interaction. The neuroleptic haloperidol reduced locomotor activity in all mouse lines. The mood stabilizer lithium and the psychostimulant amphetamine, in contrast, selectively reduced hyperactivity in LAB mice. Based on the behavioral and pharmacological profiles, LAB mice are suggested as a novel rodent model of ADHD-like symptoms.

A proposed multisite double-blind randomized clinical trial of neurofeedback for ADHD: need, rationale, and strategy

OBJECTIVE

Additional treatments with persisting benefit are needed for ADHD. Because ADHD often shows excessive theta electroencephalogram (EEG) power, low beta, and excessive theta-beta ratio (TBR), a promising treatment is neurofeedback (NF) downtraining TBR. Although several nonblind randomized clinical trials (RCTs) show a medium-large benefit for NF, a well-blinded, sham-controlled RCT is needed to differentiate specific from nonspecific effects.

METHOD

Experts in NF, ADHD, clinical trials, and statistics collaborated to design a double-blind multisite RCT.

RESULTS/CONCLUSION

At four sites, 180 children aged 7 to 10 years with rigorously diagnosed ADHD and TBR ≥ 5 will be randomized to active TBR-NF versus sham NF of equal duration, intensity, and appearance. Sham, utilizing prerecorded EEGs with participant artifacts superimposed, will keep participants and staff blind. Treatment fidelity will be trained/monitored by acknowledged NF leaders. Multidomain assessments before, during, and after treatment (follow-up to 2 years) will also include tests of blinding and sham inertness.

Evidence-based practice: a model for clinical application

Health care reform authorized by the Affordable Care Act is based on the belief that evidence-based practice (EBP) generates cost savings due to the delivery of more effective care. Published meta-analyses and systematic reviews provide clear, unbiased evidence on the effectiveness of specific interventions. Yet translating the interventions into the practice setting requires additional clinical skills and judgments extending beyond the scientific assessment of the EBP literature. Effective use of EBP interventions requires clinicians effectively answering an additional set of questions specific to the case and clinical context. These questions focus on correctly identifying the problem and increased level of specificity for any given situation. Using a clinical application of the PICO model, the clinician and the patient should be able to achieve a higher level of clinical outcomes.

Methylphenidate in mania project (MEMAP): study protocol of an international randomised double-blind placebo-controlled study on the initial treatment of acute mania with methylphenidate

BACKGROUND

Treatment of patients with acute mania remains a considerable medical challenge since onset of action of antimanic medication is delayed for several days. Psychostimulants could have an earlier onset of action. This assumption is based on the 'vigilance regulation model of mania' which postulates that vigilance is unstable in manic patients. Accordingly, vigilance-stabilising psychostimulants could be more useful than conventional treatment in acute mania. We present here the study protocol of a trial intended to study the efficacy and safety of methylphenidate in the initial treatment of acute mania.

METHODS/DESIGN

A multi-centre, randomised, double-blind, placebo-controlled clinical trial will be conducted in 88 bipolar inpatients with acute mania. Male and female patients older than 18 years will be randomised to treatment with either methylphenidate (20 to 40 mg/day) or placebo for 2.5 days, given once or twice daily. The main outcome measure is the reduction in the Young Mania Rating Scale (YMRS) after 2.5 days of treatment. Other outcome measures include the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) the Clinical Global Impression-Bipolar Scale (CGI-BP), the Screen for Cognitive Impairment in Psychiatry (SCIP), actigraphy and the EEG-'Vigilance Algorithm Leipzig' (VIGALL).

DISCUSSION

A positive study outcome of the proposed study could substantially impact our understanding of the etiopathogenesis of mania and open new treatment perspectives.

The effects of QEEG-informed neurofeedback in ADHD: an open-label pilot study

In ADHD several EEG biomarkers have been described before, with relevance to treatment outcome to stimulant medication. This pilot-study aimed at personalizing neurofeedback treatment to these specific sub-groups to investigate if such an approach leads to improved clinical outcomes. Furthermore, pre- and post-treatment EEG and ERP changes were investigated in a sub-group to study the neurophysiological effects of neurofeedback. Twenty-one patients with ADHD were treated with QEEG-informed neurofeedback and post-treatment effects on inattention (ATT), hyperactivity/impulsivity (HI) and comorbid depressive symptoms were investigated. There was a significant improvement for both ATT, HI and comorbid depressive complaints after QEEG-informed neurofeedback. The effect size for ATT was 1.78 and for HI was 1.22. Furthermore, anterior individual alpha peak frequency (iAPF) demonstrated a strong relation to improvement on comorbid depressive complaints. Pre- and post-treatment effects for the SMR neurofeedback sub-group exhibited increased N200 and P300 amplitudes and decreased SMR EEG power post-treatment. This pilot study is the first study demonstrating that it is possible to select neurofeedback protocols based on individual EEG biomarkers and suggests this results in improved treatment outcome specifically for ATT, however these results should be replicated in further controlled studies. A slow anterior iAPF at baseline predicts poor treatment response on comorbid depressive complaints in line with studies in depression. The effects of SMR neurofeedback resulted in specific ERP and EEG changes.

Sustaining attention to simple tasks: a meta-analytic review of the neural mechanisms of vigilant attention

Maintaining attention for more than a few seconds is essential for mastering everyday life. Yet, our ability to stay focused on a particular task is limited, resulting in well-known performance decrements with increasing time on task. Intriguingly, such decrements are even more likely if the task is cognitively simple and repetitive. The attentional function that enables our prolonged engagement in intellectually unchallenging, uninteresting activities has been termed vigilant attention. Here we synthesized what we have learned from functional neuroimaging about the mechanisms of this essential mental faculty. To this end, a quantitative meta-analysis of pertinent neuroimaging studies was performed, including supplementary analyses of moderating factors. Furthermore, we reviewed the available evidence on neural time-on-task effects, additionally considering information obtained from patients with focal brain damage. Integrating the results of both meta-analysis and review, we identified a set of mainly right-lateralized brain regions that may form the core network subserving vigilant attention in humans, including dorsomedial, mid- and ventrolateral prefrontal cortex, anterior insula, parietal areas (intraparietal sulcus, temporoparietal junction), and subcortical structures (cerebellar vermis, thalamus, putamen, midbrain). We discuss the potential functional roles of different nodes of this network as well as implications of our findings for a theoretical account of vigilant attention. It is conjectured that sustaining attention is a multicomponent, nonunitary mental faculty, involving a mixture of (a) sustained/recurrent processes subserving task-set/arousal maintenance and (b) transient processes subserving the target-driven reorienting of attention. Finally, limitations of previous studies are considered and suggestions for future research are provided.

Neurofeedback in ADHD and insomnia: vigilance stabilization through sleep spindles and circadian networks

In this review article an overview of the history and current status of neurofeedback for the treatment of ADHD and insomnia is provided. Recent insights suggest a central role of circadian phase delay, resulting in sleep onset insomnia (SOI) in a sub-group of ADHD patients. Chronobiological treatments, such as melatonin and early morning bright light, affect the suprachiasmatic nucleus. This nucleus has been shown to project to the noradrenergic locus coeruleus (LC) thereby explaining the vigilance stabilizing effects of such treatments in ADHD. It is hypothesized that both Sensori-Motor Rhythm (SMR) and Slow-Cortical Potential (SCP) neurofeedback impact on the sleep spindle circuitry resulting in increased sleep spindle density, normalization of SOI and thereby affect the noradrenergic LC, resulting in vigilance stabilization. After SOI is normalized, improvements on ADHD symptoms will occur with a delayed onset of effect. Therefore, clinical trials investigating new treatments in ADHD should include assessments at follow-up as their primary endpoint rather than assessments at outtake. Furthermore, an implication requiring further study is that neurofeedback could be stopped when SOI is normalized, which might result in fewer sessions.