Alterations in amygdala-prefrontal circuits in infants exposed to prenatal maternal depression

Prenatal exposure to maternal depression is common and puts offspring at risk for developing a range of neuropsychiatric disorders. Despite its prevalence and adverse associations, neurobiological processes by which prenatal maternal depression (PMD) confers risk remain poorly understood. Maternal mood and fetal behavior were assessed between 34 and 37 gestational weeks. Using resting-state functional magnetic resonance imaging (fMRI) and diffusion MRI, we examined functional and structural connectivity within amygdala-prefrontal circuits in 64 infants (mean age=5.8±1.7 weeks) with (n=20) and without (n=44) in utero exposure to PMD. Resting fMRI and diffusion MRI both indicated atypical amygdala-prefrontal connectivity in PMD-exposed infants: Resting fMRI indicated increased inverse, or negative, functional connectivity between the amygdala and the dorsal prefrontal cortex (PFC), bilaterally, and diffusion MRI indicated decreased structural connectivity between the right amygdala and the right ventral PFC. Spectral dynamic causal modeling supported these findings suggesting altered amygdala-PFC effective (or directed) connectivity in PMD-exposed infants. Last, path analyses supported a mechanistic account relating PMD to a third-trimester fetal behavior: PMD alters amygdala-PFC connectivity, which in turn, is associated with an increase in fetal heart rate reactivity to in utero perturbation. These data suggest that the maturation and coordination of central and peripheral physiology are altered by prenatal exposure to maternal depression. To the best of our knowledge, this is the first study to directly associate infant MRI measures with a behavior-fetal heart rate response, and supports hypotheses that PMD-associated variations in the development of amygdala-PFC circuits are relevant for future neurobehavioral maturation.

Selectively reduced posterior corpus callosum size in a population-based sample of young adults born with low birth weight

BACKGROUND AND PURPOSE

Several studies suggest that VLBW is associated with a reduced CC size later in life. We aimed to clarify this in a prospective, controlled study of 19-year-olds, hypothesizing that those with LBWs had smaller subregions of CC than the age-matched controls, even after correcting for brain volume.

MATERIALS AND METHODS

One hundred thirteen survivors of LBW (BW <2000 grams) without major handicaps and 100 controls underwent a 3T MR examination of the brain. The cross-sectional area of the CC (total callosal area, and the callosal subregions of the genu, truncus, and posterior third) was measured. Callosal areas were adjusted for head size.

RESULTS

The posterior third subregion of the CC was significantly smaller in individuals born with a LBW compared with controls, even after adjusting for size of the forebrain. Individuals who were born with a LBW had a smaller CC (mean area, 553.4 mm(2)) than the controls (mean area, 584.1 mm(2)). Differences in total area, however, did not remain statistically significant after adjusting for FBV.

CONCLUSIONS

The uncorrected callosal size in 19-years-olds born with LBW was smaller than that of normal controls. However, after adjusting for FBV, the group difference was restricted to the posterior third. The clinical impact of a smaller posterior part needs further investigation.

Basal ganglia surface morphology and the effects of stimulant medications in youth with attention deficit hyperactivity disorder

OBJECTIVE

Disturbances in the basal ganglia portions of cortico-striato-thalamo-cortical circuits likely contribute to the symptoms of attention deficit hyperactivity disorder (ADHD). The authors examined the morphologic features of the basal ganglia nuclei (caudate, putamen, and globus pallidus) in children with ADHD.

METHOD

A total of 104 individuals (combined-type ADHD patients: N=47; healthy comparison subjects: N=57), aged 7 to 18 years, were examined in a cross-sectional case-control study using anatomical magnetic resonance imaging. Conventional volumes and the surface morphology for the basal ganglia were measured.

RESULTS

Overall volumes were significantly smaller only in the putamen. Analysis of the morphological surfaces revealed significant inward deformations in each of the three nuclei, localized primarily in portions of these nuclei that are components of limbic, associative, and sensorimotor pathways in the cortico-striato-thalamo-cortical circuits in which these nuclei reside. The more prominent these inward deformations were in the patient group, the more severe the ADHD symptoms. Surface analyses also demonstrated significant outward deformations of all basal ganglia nuclei in the ADHD children treated with stimulants compared with those ADHD youth who were untreated. These stimulant-associated enlargements were in locations similar to the reduced volumes detected in the ADHD group relative to the comparison group. The outward deformations associated with stimulant medications attenuated the statistical effects of the primary group comparisons.

CONCLUSIONS

These findings potentially represent evidence of anatomical dysregulation in the circuitry of the basal ganglia in children with ADHD and suggest that stimulants may normalize morphological features of the basal ganglia in children with the disorder.

Challenges of using MR spectroscopy to detect neural progenitor cells in vivo

A recent report of detection of neural progenitor cells (NPCs) in living human brain by using in vivo proton MR spectroscopy ((1)H-MR spectroscopy) has sparked great excitement in the field of biomedicine because of its potential influence and utility in clinical neuroscience research. On the other hand, the method used and the findings described in the report also caused heated debate and controversy. In this article, we will briefly detail the reasons for the debate and controversy from the point of view of the in vivo (1)H-MR spectroscopy methodology and will propose some technical strategies in both data acquisition and data processing to improve the feasibility of detecting NPCs in future studies by using in vivo (1)H-MR spectroscopy.

Using perturbation theory to compute the morphological similarity of diffusion tensors

Computing the morphological similarity of diffusion tensors (DTs) at neighboring voxels within a DT image, or at corresponding locations across different DT images, is a fundamental and ubiquitous operation in the postprocessing of DT images. The morphological similarity of DTs typically has been computed using either the principal directions (PDs) of DTs (i.e., the direction along which water molecules diffuse preferentially) or their tensor elements. Although comparing PDs allows the similarity of one morphological feature of DTs to be visualized directly in eigenspace, this method takes into account only a single eigenvector, and it is therefore sensitive to the presence of noise in the images that can introduce error intothe estimation of that vector. Although comparing tensor elements, rather than PDs, is comparatively more robust to the effects of noise, the individual elements of a given tensor do not directly reflect the diffusion properties of water molecules. We propose a measure for computing the morphological similarity of DTs that uses both their eigenvalues and eigenvectors, and that also accounts for the noise levels present in DT images. Our measure presupposes that DTs in a homogeneous region within or across DT images are random perturbations of one another in the presence of noise. The similarity values that are computed using our method are smooth (in the sense that small changes in eigenvalues and eigenvectors cause only small changes in similarity), and they are symmetric when differences in eigenvalues and eigenvectors are also symmetric. In addition, our method does not presuppose that the corresponding eigenvectors across two DTs have been identified accurately, an assumption that is problematic in the presence of noise. Because we compute the similarity between DTs using their eigenspace components, our similarity measure relates directly to both the magnitude and the direction of the diffusion of water molecules. The favorable performance characteristics of our measure offer the prospect of substantially improving additional postprocessing operations that are commonly performed on DTI datasets, such as image segmentation, fiber tracking, noise filtering, and spatial normalization.

Constrained least absolute deviation neural networks

It is well known that least absolute deviation (LAD) criterion or L(1)-norm used for estimation of parameters is characterized by robustness, i.e., the estimated parameters are totally resistant (insensitive) to large changes in the sampled data. This is an extremely useful feature, especially, when the sampled data are known to be contaminated by occasionally occurring outliers or by spiky noise. In our previous works, we have proposed the least absolute deviation neural network (LADNN) to solve unconstrained LAD problems. The theoretical proofs and numerical simulations have shown that the LADNN is Lyapunov-stable and it can globally converge to the exact solution to a given unconstrained LAD problem. We have also demonstrated its excellent application value in time-delay estimation. More generally, a practical LAD application problem may contain some linear constraints, such as a set of equalities and/or inequalities, which is called constrained LAD problem, whereas the unconstrained LAD can be considered as a special form of the constrained LAD. In this paper, we present a new neural network called constrained least absolute deviation neural network (CLADNN) to solve general constrained LAD problems. Theoretical proofs and numerical simulations demonstrate that the proposed CLADNN is Lyapunov stable and globally converges to the exact solution to a given constrained LAD problem, independent of initial values. The numerical simulations have also illustrated that the proposed CLADNN can be used to robustly estimate parameters for nonlinear curve fitting, which is extensively used in signal and image processing.

A placebo-controlled trial of risperidone in Tourette syndrome

OBJECTIVE

To evaluate the efficacy and safety of risperidone in children and adults with Tourette syndrome.

METHODS

This was an 8-week, randomized, double-blind, placebo-controlled trial. The primary outcome measure was the Total Tic score of the Yale Global Tic Severity Scale (YGTSS).

RESULTS

Thirty-four medication-free subjects (26 children and 8 adults) ranging in age from 6 to 62 years (mean = 19.7 +/- 17.0 years) participated. YGTSS Total Tic scores were similar at baseline (26.0 +/- 5.1 for risperidone vs 27.4 +/- 8.5 for placebo). After 8 weeks of treatment (mean daily dose of 2.5 +/- 0.85), the 16 subjects on risperidone showed a 32% reduction in tic severity from baseline, compared to a 7% reduction for placebo patients (n = 18) (F[2,64] = 6.07; p = 0.004). The 12 children randomized to risperidone showed a 36% reduction in tic symptoms compared to an 11% decrease in the 14 children on placebo (F[2,48] = 6.38; p = 0.004). Two children on risperidone showed acute social phobia, which resolved with dose reduction in one subject but resulted in medication discontinuation in the other. A mean increase in body weight of 2.8 kg was observed in the risperidone group compared to no change in placebo (F[2,64] = 10.68; p = 0.0001). No extrapyramidal symptoms and no clinically significant alterations in cardiac conduction times or laboratory measures were observed.

CONCLUSION

Risperidone appears to be safe and effective for short-term treatment of tics in children or adults with Tourette syndrome. Longer-term studies are needed to evaluate the durability of efficacy and safety over time.

Antibodies against neural, nuclear, cytoskeletal, and streptococcal epitopes in children and adults with Tourette's syndrome, Sydenham's chorea, and autoimmune disorders

BACKGROUND

Some cases of Tourette's syndrome (TS) are hypothesized to be caused by autoantibodies that develop in response to a preceding group A beta hemolytic streptococcal infection.

METHODS

To test this hypothesis, we looked for the presence ot total and IgG antibodies against neural, nuclear, cytoskeletal and streptococcal epitopes using indirect immunofluorescent assays and Western blot techniques in three patient groups: TS (n = 81), SC (n = 27), and a group of autoimmune disorders (n = 52) and in normal controls (n = 67). Subjects were ranked after titrations of autoantibodies from 0 to 227 according to their level of immunoreactivity.

RESULTS

TS patients had a significantly higher mean rank for total antineural and antinuclear antibodies, as well as antistreptolysin O titers. However, among children and adolescents, only the total antinuclear antibodies were increased in TS patients compared to age matched controls. Compared to SC patients, TS patients had a significantly lower mean rank for total and IgG class antineural antibodies, significantly lower IgG class anticytoskeletal antibodies, and a significantly higher rank for total antinuclear antibodies. Compared to a mixed group of autoimmune disorders, the TS patients had a significantly lower mean rank for total and IgG class antineural antibodies, total and IgG class antinuclear antibodies, IgG class anticytoskeletal antibodies, and a significantly higher rank for antistreptococcal antibodies.

CONCLUSIONS

TS patients had significantly higher levels of total antineural and antinuclear antibodies than did controls. Their relation to IgG class antineural and antinuclear antibodies, markers for prior streptococcal infection, and other clinical characteristics, especially chronological age, was equivocal.

Effects of image orientation on the comparability of pediatric brain volumes using three-dimensional MR data

PURPOSE

The purpose of this study was to examine the comparability of morphometric measurements made on pediatric data sets collected at five scanner locations, each using variations on a 3D spoiled gradient-recalled echo (SPGR) pulse sequence.

METHOD

Archived MR data from 60 typically developing children were collected and separated into seven groups based on the pulse sequence used. A highly automated image-processing procedure was used to segment the brain data into white tissue, gray tissue, and CSF compartments and into various neuroanatomic regions of interest.

RESULTS

Volumetric comparisons between groups revealed differences in areas of the temporal and occipital lobes. These differences were observed when comparing data sets with different image orientations and appeared to be due to partial volume averaging (PVA) and susceptibility-induced geometric distortions.

CONCLUSION

Our results indicate that slice selection and image resolution should be controlled in volumetric studies using aggregated data from multiple centers to minimize the effects of PVA and susceptibility-induced geometric distortions.

Prospective, longitudinal study of tic, obsessive-compulsive, and attention-deficit/hyperactivity disorders in an epidemiological sample

OBJECTIVE

Understanding the interrelatedness of tics, obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD) has been complicated by studying only cross-sectional samples of clinically referred subjects. The authors report the cross-sectional and longitudinal associations of these disorders in an epidemiological sample of children followed prospectively into early adulthood.

METHOD

Structured diagnostic interview information was acquired on 976 children, aged 1 to 10 years, who were randomly selected from families living in upstate New York in 1975. Reassessments were acquired in 776 of these subjects 8, 10, and 15 years later. Diagnostic prevalences were estimated at each time point. The associations among tics, OCD, and ADHD were assessed within and across time points, as were their associations with comorbid illnesses and demographic risk factors.

RESULTS

In temporal cross-section, tics and ADHD symptoms were associated with OCD symptoms in late adolescence and early adulthood after demographic features and comorbid psychiatric symptoms were controlled. In prospective analyses, tics in childhood and early adolescence predicted an increase in OCD symptoms in late adolescence and early adulthood. ADHD symptoms in adolescence predicted more OCD symptoms in early adulthood, and OCD in adolescence predicted more ADHD symptoms in adulthood. The associations of tics with ADHD were unimpressive in temporal cross-section and were not significant in prospective analyses. Tics, OCD, and ADHD shared numerous complex associations with demographic and psychopathological risk factors. ADHD was associated with lower IQ and lower social status, whereas OCD was associated with higher IQ.

CONCLUSIONS

Tics and OCD were significantly associated in this sample, as were OCD and ADHD. These findings are in general consistent with those from family studies, and they help to define the natural history, comorbid illnesses, and interrelatedness of these conditions.

The question of PANDAS in adults

BACKGROUND

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are a well-defined cause of obsessive-compulsive disorder in children. However, they have not been described or fully investigated in adults newly diagnosed with obsessive-compulsive disorder.

METHODS

We describe an adult with onset of obsessive-compulsive disorder at 25 years of age after a severe antibiotic-responsive pharyngitis. He was evaluated with multiple psychiatric rating scales for obsessive-compulsive disorder and Tourette's syndrome, as well as with serologic assays and radiologic studies.

RESULTS

In all respects except age our patient fulfilled established criteria for PANDAS. Assays for antibodies to group A beta-hematolytic streptococci, serum D8,17 lymphocytes, antistriatal (neuronal) antibodies, and anticytoskeletal antibodies all supported the hypothesis that a poststreptococcal process was active. Magnetic resonance imaging was abnormal and is described.

CONCLUSIONS

The findings suggest that this patient's illness is similar to PANDAS in presentation and that poststreptococcal disease may result in adult-onset obsessive-compulsive disorder.

Mutual information analysis of the EEG in patients with Alzheimer's disease

OBJECTIVE

Mutual information provides a measure of both the linear and nonlinear statistical dependencies between two time series. Cross-mutual information (CMI) is used to quantify the information transmitted from one time series to another, while auto mutual information (AMI) in a time series estimates how much on average the value of the time series can be predicted from values of the time series at preceding points. The aim of this study is to assess information transmission between different cortical areas in Alzheimer's disease (AD) patients by estimating the average CMI between EEG electrodes.

METHODS

We recorded the EEG from 16 scale electrodes in 15 AD patients and 15 age-matched normal controls, and estimated the local, distant, and interhemispheric CMIs of the EEG in both groups. The rate of decrease (with increasing delay) of the AMI of the EEG was also measured to evaluate the complexity of the EEG in AD patients.

RESULTS

The local CMI in AD subjects was lower than that in normal controls, especially over frontal and antero-temporal regions. A prominent decrease in information transmission between distant electrodes in the right hemisphere and between corresponding interhemispheric electrodes was detected in the AD patients. In addition, the AMIs throughout the cerebrums of the AD patients decreased significantly more slowly with delay than did the AMIs of normal controls.

CONCLUSIONS

These results are consistent with previous findings that suggest the association of EEG abnormalities in AD patients with functional impairment of information transmission in long cortico-cortical connections.

Regional brain and ventricular volumes in Tourette syndrome

BACKGROUND

The pathophysiology of Tourette syndrome (TS) is thought to involve disturbances in cortico-striato-thalamo-cortical circuitry. The morphological characteristics of the cortical and associated white matter portions of these circuits have not been previously examined in TS subjects.

METHODS

High-resolution anatomical magnetic resonance images were acquired in 155 TS and 131 healthy children and adults. The cerebrums and ventricles were isolated and then parcellated into subregions using standard anatomical landmarks.

RESULTS

For analyses that included both children and adults, TS subjects were found to have larger volumes in dorsal prefrontal regions, larger volumes in parieto-occipital regions, and smaller inferior occipital volumes. Significant inverse associations of cerebral volumes with age were seen in TS subjects that were not seen in healthy controls. Sex differences in the parieto-occipital regions of healthy subjects were diminished in the TS group. The age-related findings were most prominent in TS children, whereas the diminished sex differences were most prominent in TS adults. Group differences in regional ventricular volumes were less prominent than in the cerebrum. Regional cerebral volumes were significantly associated with the severity of tic symptoms in orbitofrontal, midtemporal, and parieto-occipital regions.

CONCLUSIONS

Broadly distributed cortical systems are involved in the pathophysiology of TS. Developmental processes, sexual dimorphisms, and compensatory responses in these cortical regions may help to modulate the course and severity of tic symptoms.

Automated measurement of latent morphological features in the human corpus callosum

Our objective was to develop a novel factor-based analysis of the morphology of the corpus callosum and assess its applicability to the study of normal development, intelligence, and other subject characteristics. The contour of the corpus callosum was defined in the midsagittal planes of the MRI scans of 325 subjects, 6 to 88 years of age. The contours were coregistered, rescaled, and resampled to 50 points that were then entered into a principal components analysis with varimax rotation. The analysis yielded 8 factors for the contours of 138 healthy subjects. A second analysis of contours from 187 subjects in a patient group extracted 8 similar factors. Correlations of factor scores with conventional measures of callosum shape supported the construct validity of the assignment of morphological features to each of the factors. Correlations of factor scores with age, sex, handedness, ventricular volume, and IQ demonstrated the predictive validity of the factor structure and helped to define the neural correlates of these subject characteristics. We conclude that factor-based measures capture latent morphological features of the corpus callosum that are reliable and valid. Future studies will determine whether these novel measures are more closely related to neurobiologically important features of the corpus than are conventional measures of callosum size and shape.

Sex steroids and human behavior: implications for developmental psychopathology

In a variety of mammalian species, prenatal androgens organize brain structures and functions that are later activated by steroid hormones in postnatal life. In humans, studies of individuals with typical and atypical development suggest that sex differences in reproductive and nonreproductive behavior derive in part from similar prenatal and postnatal steroid effects on brain development. This paper provides a summary of research investigating hormonal influences on human behavior and describes how sex differences in the prevalences and natural histories of developmental psychopathologies may be consistent with these steroid effects. An association between patterns of sexual differentiation and specific forms of psychopathology suggests novel avenues for assessing the effects of sex steroids on brain structure and function, which may in turn improve our understanding of typical and atypical development in women and men.

Neonatal auditory activation detected by functional magnetic resonance imaging

The objective of this study was to detect auditory cortical activation in non-sedated neonates employing functional magnetic resonance imaging (fMRI). Using echo-planar functional brain imaging, subjects were presented with a frequency-modulated pure tone; the BOLD signal response was mapped in 5 mm-thick slices running parallel to the superior temporal gyrus. Twenty healthy neonates (13 term, 7 preterm) at term and 4 adult control subjects. Blood oxygen level-dependent (BOLD) signal in response to auditory stimulus was detected in all 4 adults and in 14 of the 20 neonates. FMRI studies of adult subjects demonstrated increased signal in the superior temporal regions during auditory stimulation. In contrast, signal decreases were detected during auditory stimulation in 9 of 14 newborns with BOLD response. fMRI can be used to detect brain activation with auditory stimulation in human infants.

Regional brain volume abnormalities and long-term cognitive outcome in preterm infants

CONTEXT

Preterm infants have a high prevalence of long-term cognitive and behavioral disturbances. However, it is not known whether the stresses associated with premature birth disrupt regionally specific brain maturation or whether abnormalities in brain structure contribute to cognitive deficits.

OBJECTIVE

To determine whether regional brain volumes differ between term and preterm children and to examine the association of regional brain volumes in prematurely born children with long-term cognitive outcomes.

DESIGN AND SETTING

Case-control study conducted in 1998 and 1999 at 2 US university medical schools.

PARTICIPANTS

A consecutive sample of 25 eight-year-old preterm children recruited from a longitudinal follow-up study of preterm infants and 39 term control children who were recruited from the community and who were comparable with the preterm children in age, sex, maternal education, and minority status.

MAIN OUTCOME MEASURES

Volumes of cortical subdivisions, ventricular system, cerebellum, basal ganglia, corpus callosum, amygdala, and hippocampus, derived from structural magnetic resonance imaging scans and compared between preterm and term children; correlations of regional brain volumes with cognitive measures (at age 8 years) and perinatal variables among preterm children.

RESULTS

Regional cortical volumes were significantly smaller in the preterm children, most prominently in sensorimotor regions (difference: left, 14.6%; right, 14.3% [P<.001 for both]) but also in premotor (left, 11.2%; right, 12.6% [P<.001 for both]), midtemporal (left, 7.4% [P =.01]; right, 10.2% [P<.001]), parieto-occipital (left, 7.9% [P =.01]; right, 7.4% [P =.005]), and subgenual (left, 8.9% [P =.03]; right, 11.7% [P =.01]) cortices. Preterm children's brain volumes were significantly larger (by 105. 7%-271.6%) in the occipital and temporal horns of the ventricles (P<. 001 for all) and smaller in the cerebellum (6.7%; P =.02), basal ganglia (11.4%-13.8%; P</=.005), amygdala (left, 20.2% [P =.001]; right, 30.0% [P<.001]), hippocampus (left, 16.0% [P =.001]; right, 12.0% [P =.007]), and corpus callosum (13.1%-35.2%; P</=.01 for all). Volumes of sensorimotor and midtemporal cortices were associated positively with full-scale, verbal, and performance IQ scores (P<.01 for all).

CONCLUSIONS

Our data indicate that preterm birth is associated with regionally specific, long-term reductions in brain volume and that morphological abnormalities are, in turn, associated with poorer cognitive outcome. JAMA. 2000;284:1939-1947.

An event-related functional MRI study of the stroop color word interference task

In this study we have attempted to define the neural circuits differentially activated by cognitive interference. We used event-related functional magnetic resonance imaging (fMRI) to identify areas of the brain that are activated by the Stroop word-color task in two experiments. In the first experiment, we used infrequent, incongruent colored word stimuli to elicit strong Stroop interference (the 'conventional Stroop' paradigm). In the second experiment, we used infrequent, congruent colored words (the 'inverse Stroop' paradigm) to confirm that the regions identified in the first experiment were in fact specifically related to the Stroop effect and not to nonspecific oddball effects associated with the use of infrequent stimuli. Performance of the conventional Stroop specifically activated the anterior cingulate, insula, premotor and inferior frontal regions. These activated regions in the current experiment are consistent with those activated in fMRI experiments that use a more traditional block design. Finally, analysis of the time course of fMRI signal changes demonstrated differential onset and offset of signal changes in these activated regions. The time course results suggest that the action of various brain areas can be temporally dissociated.

Preliminary findings of antistreptococcal antibody titers and basal ganglia volumes in tic, obsessive-compulsive, and attention deficit/hyperactivity disorders

BACKGROUND

Previous studies have provided preliminary serological evidence supporting the theory that symptoms of tic disorders or obsessive-compulsive disorder (OCD) may be sequelae of prior streptococcal infection. It is unclear, however, whether previously reported associations with streptococcal infection were obscured by the presence of diagnostic comorbidities. It is also unknown whether streptococcal infection is associated in vivo with anatomical alterations of the brain structures that have been implicated in the pathophysiology of these disorders.

METHODS

Antistreptococcal antibody titers were measured in 105 people diagnosed as having CTD, OCD, or attention-deficit/hyperactivity disorder (ADHD) and in 37 community controls without a disorder. Subjects were unselected with regard to their history of streptococcal exposure. Basal ganglia volumes were measured in 113 of these subjects (79 patients and 34 controls).

RESULTS

A DSM-IV diagnosis of ADHD was associated significantly with titers of 2 distinct antistreptococcal antibodies, antistreptolysin O and anti-deoxyribonuclease B. These associations remained significant after controlling for the effects of CTD and OCD comorbidity. No significant association was seen between antibody titers and a diagnosis of either CTD or OCD. When basal ganglia volumes were included in these analyses, the relationships between antibody titers and basal ganglia volumes were significantly different in OCD and ADHD subjects compared with other diagnostic groups. Higher antibody titers in these subjects were associated with larger volumes of the putamen and globus pallidus nuclei.

CONCLUSIONS

These findings suggest that the prior reports of an association between antistreptococcal antibodies and either CTD or OCD may have been confounded by the presence of ADHD. They also support the hypothesis that in susceptible persons who have ADHD or OCD, chronic or recurrent streptococcal infections are associated with structural alterations in basal ganglia nuclei.

An fMRI study of Stroop word-color interference: evidence for cingulate subregions subserving multiple distributed attentional systems

BACKGROUND

The goal of this study was to model the functional connectivity of the neural systems that subserve attention and impulse control. Proper performance of the Stroop Word-Color Interference Task requires both attention and impulse control.

METHODS

Word-color interference was studied in 34 normal adult subjects using functional magnetic resonance imaging.

RESULTS

Interregional correlation analyses suggested that the anterior cingulate is coupled functionally with multiple regions throughout the cerebrum. A factor analysis of the significant regional activations further emphasized this functional coupling. The cingulate or related mesial frontal cortices loaded on each of the seven factors identified in the factor analysis. Other regions that loaded significantly on these factors have been described previously as belonging to anatomically connected circuits believed to subserve sensory tuning, receptive language, vigilance, working memory, response selection, motor planning, and motor response functions. These seven factors appeared to be oriented topographically within the anterior cingulate, with sensory, working memory, and vigilance functions positioned more rostrally, and response selection, motor planning, and motor response positioned progressively more caudally.

CONCLUSIONS

These findings support a parallel distributed processing model for word-color interference in which portions of the anterior cingulate cortex modify the strengths of multiple neural pathways used to read and name colors. Allocation of attentional resources is thought to modify pathway strengths by reducing cross-talk between information processing modules that subserve the competing demands of reading and color naming. The functional topography of these neural systems observed within the cingulate argues for the presence of multiple attentional subsystems, each contributing to improved task performance. The topography also suggests a role for the cingulate in coordinating and integrating the activity of these multiple attentional subsystems.

The temporal dynamics of tics in Gilles de la Tourette syndrome

BACKGROUND

Statistical characterization of tic behavior in Gilles de la Tourette syndrome (GTS) may provide insight into the dynamic functioning of the human central nervous system, as well as improve the quantitative assessment of tic symptom severity.

METHODS

Twenty-two medication-free GTS subjects underwent videotaping of their tics. The intervals between temporally adjacent tics were measured, and the statistical properties of these intervals were assessed through graphical representation of frequency distributions, autoregressive integrated moving average (ARIMA) modeling, spectral analysis, and construction of first return maps.

RESULTS

The frequency distribution of tic interval durations followed an inverse power law of temporal scaling. Spectral analyses similarly demonstrated that the spectral power density of tic interval duration scales inversely with frequency. ARIMA modeling suggested that the time series for tics are nonstationary as well as moving average processes. The first return maps demonstrated "burstlike" behavior and short-term periodicity in tics, and proved that successive tic intervals are not statistically independent. Graphic display of the time series confirmed shortterm periodicity, and in addition suggested the presence of period doubling.

CONCLUSIONS

These findings are suggestive though not conclusive evidence for the presence of a fractal, deterministic, and possibly chaotic process in the tic time series. These analytic methods provide insight into the temporal features of tics that commonly are described clinically (such as short-term bouts or bursting, and longer term waxing and waning), and they reveal certain important temporal features of tics that have not been clinically described. The methods may also prove useful in the improved characterization of tic symptom severity.

A double-blind, placebo-controlled, crossover trial of an antiandrogen in the treatment of Tourette's syndrome

The objective of this study was to document the effects of androgen receptor blockade on tic and obsessive-compulsive symptoms in Tourette's syndrome (TS) patients. Thirteen adult TS subjects, 10 men and 3 women, completed 3 weeks of each phase of a double-blind, placebo-controlled, crossover trial of flutamide, a selective androgen receptor antagonist. Symptom severity ratings and hormone levels were obtained at each of the trial's six clinic visits. Flutamide was well-tolerated and produced a significant reduction in motor but not phonic tic symptom severity. It modestly improved symptoms of obsessive-compulsive disorder in the men who had this disorder. Changes in hormone levels during flutamide administration provided evidence for the existence of physiologic mechanisms that compensate for the blocking of the androgen receptor. The therapeutic effects of flutamide are modest in magnitude and they seem to be short-lived, possibly because of physiologic compensation for androgen receptor blockade. Given the potentially serious side effects of flutamide, the use of this agent in the treatment of tics should be reserved for patients who have relatively debilitating symptoms. The therapeutic and endocrine findings may have implications for understanding the sex differences in TS prevalence and the sex-specific variability in the phenotypic expression of the putative TS vulnerability genes.

Course of tic severity in Tourette syndrome: the first two decades

OBJECTIVE

Prevalence studies indicate a 10-fold higher rate of Tourette syndrome (TS) among children compared with adults. The purpose of this investigation was to examine the course of tic severity during the first 2 decades of life.

METHOD

A birth-year cohort of 42 TS patients followed at the Yale Child Study Center was recontacted an average of 7.3 years after their initial clinical evaluation. Data concerning the onset and course of tic severity until 18 years of age were available on 36 TS patients. A variety of statistical techniques were used to model aspects of the temporal patterning of tic severity.

RESULTS

Mean (SD) tic onset at 5.6 (2. 3) years of age was followed by a progressive pattern of tic worsening. On average, the most severe period of tic severity occurred at 10.0 (2.4) years of age. In eight cases (22%), the frequency and forcefulness of the tics reached a severe level during the worst-ever period such that functioning in school was impossible or in serious jeopardy. In almost every case this period was followed by a steady decline in tic severity. By 18 years of age nearly half of the cohort was virtually tic-free. The onset of puberty was not associated with either the timing or severity of tics.

CONCLUSIONS

A majority of TS patients displayed a consistent time course of tic severity. This consistency can be accurately modeled mathematically and may reflect normal neurobiological processes. Determination of the model parameters that describe each patient's course of tic severity may be of prognostic value and assist in the identification of factors that differentially influence the course of tic severity.

A functional magnetic resonance imaging study of tic suppression in Tourette syndrome

BACKGROUND

The inability to inhibit unwanted behaviors and impulses produces functional debility in a broad range of neuropsychiatric disorders. A potentially important model of impulse control is volitional tic suppression in Tourette syndrome.

METHODS

Tic suppression was studied in 22 adult subjects with Tourette syndrome by using functional magnetic resonance imaging. Images acquired during periods of voluntary tic suppression were compared with images acquired when subjects allowed the spontaneous expression of their tics. The magnitudes of signal change in the images were then correlated with measures of the severity of tic symptoms.

CONCLUSIONS

Significant changes in signal intensity were seen in the basal ganglia and thalamus and in anatomically connected cortical regions believed to subserve attention-demanding tasks. The magnitudes of regional signal change in the basal ganglia and thalamus correlated inversely with the severity of tic symptoms. These findings suggest that the pathogenesis of tics involves an impaired modulation of neuronal activity in subcortical neural circuits.

The treatment of Tourette's syndrome: multimodal, developmental intervention

The increasing clinical recognition of milder phenotypic variants of Tourette's syndrome and the keener appreciation of its phenomenological continuity with other transient and chronic tic syndromes have required a greater comprehensiveness and sophistication in the assessment and management of the disorder. Treatment must be individualized based on considerations of the source and degree of functional impairment associated with tics, the current and future impairment associated with comorbid illnesses, the available internal and external sources of support and capacities for coping, and the challenges that the tics and comorbidities present at varying stages of development. Specific therapeutic interventions must target not only tic symptoms, but also comorbid illnesses and coping strategies that can profoundly influence the unique impact that tic symptoms may have on an individual's well being during childhood and adolescence, and later into adulthood.

Tic disorders

The picture that emerges is one of complex behavioral phenotypes that alter over the course of CNS development. While many cases are mild and may not come to medical attention, others are chronic and disabling. The aim of this article is to provide an overview of recent progress in understanding phenomenology, epidemiology, genetics, neurobiology, and treatment of tic disorders.

Symptoms of obsessive-compulsive disorder

OBJECTIVE

Obsessive-compulsive disorder encompasses a broad range of symptoms that represent multiple psychological domains, including perception, cognition, emotion, social relatedness, and diverse motor behaviors. The purpose of these analyses was to evaluate the correlational relationships of the symptoms of obsessive-compulsive disorder.

METHOD

This study examined the 13 a priori categories used to group types of obsessions and compulsions in the Yale-Brown Obsessive Compulsive Scale symptom checklist in two independent groups of patients with obsessive-compulsive disorder (N = 208 and N = 98). A principal-components factor analysis with varimax rotation was performed, followed by a series of other exploratory analyses.

RESULTS

The two data sets yielded nearly identical results. Four factors--obsessions and checking, symmetry and ordering, cleanliness and washing, and boarding--emerged in each data set, in total accounting for more than 60% of the variance.

CONCLUSIONS

Obsessive-compulsive disorder is a multidimensional and etiologically heterogeneous condition. The four symptom dimensions identified in this study are largely congruent with those identified in earlier reports. These factors may be of value in future genetic, neurobiological, and treatment response studies.

Pathogenesis of Tourette's syndrome

This review presents a models of disease pathogenesis in the context of CNS development. It begins with an exploration of the clinical features and natural history of Tourette's syndrome. This is followed by a consideration of the role of genetic and nongenetic factors. An effort is then made to review the anatomical organization of the basal ganglia and related cortical sites. These circuits are intimately involved in the normal processing of sensorimotor, cognitive, and emotionally laden information. Evidence implicating these circuits in the pathobiology of Tourette's syndrome is then considered. The review closes with the prospects for advances in interdisciplinary research and therapeutics using this model as a guide.

A putative poststreptococcal case of OCD with chronic tic disorder, not otherwise specified

A 12-year-old girl presented with an atypical, recurrent, increasingly treatment-resistant case of obsessive-compulsive disorder and chronic tic disorder associated with profound separation anxiety, learning difficulty, and intermittent upper respiratory symptoms. In addition to detailed reviews of history and findings from many clinical caretakers from the prior 7 years, current pediatric, psychiatric, neuropsychological, neuroimaging, and clinical laboratory data were also available. Treatment options were considered from multiple perspectives: psychoanalytically oriented psychotherapy, conventional pharmacotherapy, family interventions, cognitive-behavioral therapy, and learning-supportive strategies. Psychological, neuropsychiatric, and neuroimmunological formulations of etiology were considered. Subsequent treatments included supportive psychotherapy, neuroleptic augmentation of selective serotonin reuptake inhibitors, prophylactic penicillin, and a course of six sessions of plasmapheresis over a 2-week period. The case raises questions for ongoing consideration that juxtapose dynamic, neuropsychiatric, and neuroimmunological perspectives.

Three cases of symptom change in Tourette's syndrome and obsessive-compulsive disorder associated with paediatric cerebral malignancies

OBJECTIVE

To correlate behaviour manifestations with tumour location in three children who had Gilles de la Tourette's syndrome (GTS), obsessive-compulsive disorder (OCD), and primary cerebral malignancies.

METHOD

Cases were ascertained from a chart review in a GTS and OCD specialty clinic. For each case the temporal progression of change in neuropsychiatric symptoms was qualitatively correlated with radiographic documentation of tumour progression.

RESULTS

The change in symptom severities during tumour progression and treatment, together with prior neurobiological studies of GTS, suggest that the ventral striatum, corpus callosum, thalamus, and midbrain are potentially important neural substrates in the formation or modulation of tic symptoms. The limbic system, including the hypothalamus and cingulate, and the caudate nucleus, seem to be important in the neurobiology of OCD. All structures are neuroanatomically and functionally related to the corticostriato-thalamocortical circuitry that is thought to subserve symptom generation in both GTS and OCD.

CONCLUSION

Although the malignancies were not likely to have caused the tic and OCD symptoms in these children, the locations of these intracranial lesions provide important clues in identifying brain regions that may contribute to the determination of tic and OCD severities.

Risk factors for presenting problems in child psychiatric emergencies

OBJECTIVE

To determine demographic and school-related risk factors for psychiatric emergencies presented by children in a hospital emergency room serving the majority of an urban community.

METHOD

1,436 consecutive psychiatric emergency room visits for children younger than 16 years of age seen over a 10-year period were broadly classified by presenting problem as exhibiting either suicidal ideation, suicide attempt, oppositional-defiance, or aggression. The strength of association of these classes of presentation with demographic risk factors (age, sex, and minority status) and with the school day (weekday or weekend) and school season (school year or vacation) of presentation were modeled using logistic regression. The capacity of these presenting problems and risk factors to predict whether the child was hospitalized was also assessed.

RESULTS

Risk factors additively associated with suicidality included increasing age, being female, and presenting on weekdays and during the school year. Similar risk factors discriminated suicide attempters from suicidal ideators, and racial minority membership contributed additional risk for presenting with a suicide attempt. Risk factors associated with aggressive and oppositional presentation included younger age and male sex. Aggressive children presented relatively more often on weekends, and oppositional children presented more during school vacations. Independent risk factors for hospitalization included a suicidal or aggressive presentation, increasing age, and presentation during the school year. Hospitalization of children at the time of their initial visit protected against suicidality in subsequent presentations of the subset of children who had repeated emergency room visits.

CONCLUSIONS

These findings are consistent with previously reported risk factors for suicidal behaviors and externalizing disorders. The distinctive profiles of risk discerned for the different groups of emergency room psychiatric subjects also suggest some degree of specificity for the risk factors associated with each class of presenting problem. They also suggest the importance of home and school environments as being variably either risk or protective factors for these presenting problems. The findings also suggest a role for hospitalization in the prevention of future suicidality.

Considerations of natural history and pathophysiology in the psychopharmacology of Tourette's syndrome

BACKGROUND

The increasing recognition of Tourette's syndrome is probably responsible for the broadening range of symptom severities seen in clinic patients. Greater clinical diversity also brings greater treatment challenges, particularly for children in whom the risks and benefits of medication for the developing central nervous system must be weighed against the long-term risks associated with the disorder itself. Knowledge of the natural history and pathophysiology of Tourette's syndrome is vitally important for informed clinical decision making.

METHOD

A MEDLINE literature search was undertaken to identify studies of the natural history and pathophysiology of Tourette's syndrome that would be relevant to clinical psychopharmacology.

RESULTS

Although impossible to predict with certainty for any given patient, the natural history of Tourette's syndrome is typically characterized by an early childhood onset, a prepubertal exacerbation, postpubertal attenuation, and an adult stabilization of symptoms. Symptoms fluctuate in all phases of the illness, often in response to stress. The natural history and clinical phenotype of Tourette's syndrome are thought to have both genetic and nongenetic determinants that are mediated through their effects on basal ganglia nuclei and related neural systems. Medications used in the treatment of Tourette's syndrome are thought to modulate the functioning of these neural systems.

CONCLUSION

Although medication decisions must consider tic symptom severity, expectations of the disorder's natural history, and the child's adaptive capacities-his or her comorbid illnesses, coping mechanisms, interpersonal relatedness, impulse control, affect regulation, and family and social supports-are the most important determinants of well-being and outcome. These therefore are the most important considerations when making treatment decisions, as well.

Neuroimaging in child and adolescent neuropsychiatric disorders

OBJECTIVE

To review the major findings and pathophysiological implications of imaging studies of neuropsychiatric disorders that onset in childhood or adolescence.

METHOD

More than 200 neuroimaging studies were selected for review from Medline searches if the studies concerned developmental neuropsychiatric disorders such as autism, fragile X syndrome, Down syndrome, schizophrenia, obsessive-compulsive disorder, Tourette's syndrome, attention-deficit hyperactivity disorder, and dyslexia.

RESULTS

Disordered central nervous system development may produce evidence of cortical neuronal migration abnormalities in autism, smaller cortical structures in Down syndrome, frontal lobe deficits and larger basal ganglia in schizophrenia, hypoplastic basal ganglia in Tourette's syndrome, aberrancies of the planum temporale in dyslexia, and hypoplastic cerebellar structures in numerous developmental disorders. Normal cerebral asymmetries appear to be disrupted in a number of disorders, including schizophrenia, Tourette's syndrome, attention deficit disorder, and dyslexia.

CONCLUSIONS

Neuroimaging data regarding pathological central nervous system development in childhood are still sparse, and many of the findings in developmental disorders of childhood onset concern the study of adult subjects with those disorders. Nevertheless, imaging modalities previously used only in adults are with increasing frequency being applied to the study of children, which will likely continue to contribute to the understanding of pathological brain structure and function throughout childhood and to the improved treatment of these disorders.

Risperidone treatment of children and adolescents with chronic tic disorders: a preliminary report

OBJECTIVE

The purpose of this trial was to investigate the short-term safety and efficacy of risperidone in the treatment of chronic tic disorders in children and adolescents.

METHOD

This was an 11-week open-label trial and included seven subjects (five boys and two girls) with a mean age of 12.9 +/- 1.9 years. The sample included five patients with Tourette's syndrome and two with chronic motor tic disorder. The children were seen at baseline and for two follow-up visits. Three children had a comorbid diagnosis of obsessive-compulsive disorder (OCD).

RESULTS

Clinical response, as measured by the Yale Global Tic Severity Scale and the Children's version of the Yale-Brown Obsessive Compulsive Scale, revealed a statistically significant reduction in tic scores ranging from 26% [corrected] to 66%. One of three children with comorbid OCD showed substantial improvement; the other two subjects showed no change. The most frequent side effect was weight gain, which ranged from 8 to 14 lb.

CONCLUSIONS

Risperidone, a neuroleptic with both serotonin- and dopamine-blocking properties, appears to be effective in reducing tic frequency and intensity in children and adolescents with chronic tic disorders.

Abnormal magnetic resonance imaging T2 relaxation time asymmetries in Tourette's syndrome

Recent imaging studies in Tourette's syndrome (TS) have reported a loss of normal asymmetry in basal ganglia volumes. Our recent report of reduced midline sagittal cross-sectional area in TS suggests that altered lateralization may be widespread throughout the TS cerebrum. We report here our analyses of cerebral asymmetries of T2 (transverse or spin-spin) relaxation times derived from multi-echo/multi-planar/spin-echo magnetic resonance images in 14 adult TS subjects and 14 matched normal control subjects. T2 relaxation times were found to be asymmetric throughout the cerebrum of normal control subjects, with differences seen between T2 times of corresponding regions of both cerebral hemispheres that were small in magnitude (2-5%) but of a high degree of statistical significance in all regions examined. Our hypothesis of altered T2 relaxation time asymmetries in TS was confirmed in a multivariate analysis of variance, with post hoc analyses suggesting that group differences were attributable to specific asymmetry differences in the TS insular cortex and frontal white matter. Exploratory analyses revealed group differences in T2 times of the amygdala and red nucleus, as well as significantly lower ferritin levels in the TS group. These findings are discussed in relation to the previous TS volumetric studies, and the tissue characteristics that might produce normal and abnormal relaxation time asymmetries are considered.

Corpus callosum morphology from magnetic resonance images in Tourette's syndrome

We measured the midline cross-sectional area and other morphologic features of the corpus callosum (CC) from magnetic resonance (MR) images in 14 unmedicated patients with Tourette's syndrome (TS) and 14 normal control subjects matched for age, sex, handedness, and socioeconomic status. Each CC was manually circumscribed on midline images from a T1-weighted sagittal series, and the area of the entire CC and five anatomic subdivisions were measured. CC circumference, regional width, and mean callosal curvature were also measured. CC cross-sectional area correlated positively with brain size and basal ganglia volumes. The magnitude of reduction (17.7%) in total CC area in TS patients compared with control subjects was similar to the reductions seen in all CC subdivision areas. Analyses of covariance with total midsagittal cross-sectional head area as a covariate revealed the reductions to be statistically significant for the overall CC area and all subregion areas. CC width tended to be nonsignificantly thinner in all subdivisions (from 5% to 11%), and the overall length of the center line measured from rostrum to splenium was significantly reduced in the TS group (by 5.3%). Measures of mean callosal curvature suggested that CCs in TS patients are less rounded than those of normal control subjects. Worst-ever motor tic symptoms showed the strongest significant correlation with the length of the CC center line in TS patients (r = 0.88). These findings suggest that structural interhemispheric connectivity may be aberrant in the central nervous systems of TS patients, and they provide indirect supportive evidence for the presence of altered cerebral lateralization in the disorder.

Steroid hormones and Tourette's syndrome: early experience with antiandrogen therapy

We report here the first use in Tourette's syndrome of the nonsteroidal androgen receptor blocking agent flutamide. One man and one woman underwent open trials of the medication, and a second man participated in a placebo-controlled, double-blind crossover trial. Improvement in tic symptoms ranged from 45 to 60%. The improvement was sustained in the woman during daily flutamide use and in one man during its intermittent use. One man's symptoms became refractory to treatment after 5 weeks of flutamide use, whereas the woman became depressed and had protracted diarrhea during her treatment.

Human basal ganglia volume asymmetries on magnetic resonance images

The brains of 19 healthy adults, ages 18-49, were imaged on a GE Signa 1.5 T MR scanner. Basal ganglia were circumscribed on sequential axial proton density-weighted images (TR 1700, TE 20) and submitted for 3-dimensional reconstruction and volumetric analysis at a computer graphics workstation. The 15 right-handed patients (12 men, 3 women) had significantly larger left total basal ganglia volumes, which included larger globus pallidus and lenticular nuclei on the left, but larger caudate nuclei on the right. In contrast, basal ganglia asymmetries were not seen in four left-handers. No sex differences were detected. The basal ganglia appear to belong to an increasing number of CNS structures that display anatomical hemispheric lateralization.

Steroid hormones and CNS sexual dimorphisms modulate symptom expression in Tourette's syndrome

We present our hypothesis that various steroid hormones play an important role in the symptom expression of Gilles de la Tourette's syndrome (TS) and that androgenic hormones, in particular, are likely to exacerbate symptoms of the disorder. We review the clinical evidence supporting our hypothesis. Sex steroids establish brain sexual dimorphisms early in CNS development, and we suggest mechanisms whereby androgenic and other hormonal changes later in human development might act at dimorphic brain regions to influence the natural history of TS. Finally, we discuss the various ways in which neuroendocrine studies might assist in genetic and neurobiologic research programs in TS.

Attempts to suppress experimental allergic encephalomyelitis in rats with alpha fetoprotein

Rats of the Lewis strain were immunized with bovine basic myelin protein to develop experimental allergic encephalomyelitis. Neither human nor rat fetal sources of purified alpha-fetoprotein were able to significantly ameliorate the development of this dyscrasia. The plasma of pregnant rats at term was without effect. Immunization of pregnant rats was also accompanied by the usual course of development of typical encephalomyelitis.