Autistic traits distribution in different psychiatric conditions: A cluster analysis on the basis of the Adult Autism Subthreshold Spectrum (AdAS Spectrum) questionnaire

Increasing interest is being paid on full-threshold and sub-threshold autism spectrum conditions among adults. Sub-threshold autistic traits (AT) seem to be distributed in a continuum from the clinical to the general population, being particularly higher among subjects with other psychiatric disorders. The aim of the present study was to evaluate the distribution of AT in a sample of subjects with different psychiatric conditions by means of a cluster analysis on the basis of the score reported to the AdAS Spectrum instrument. A total of 738 subjects recruited by seven Italian Universities were divided in 5 groups depending on the clinical diagnosis: Autism spectrum disorder (ASD), subthreshold ASD symptoms (partial ASD), Bipolar disorder (BD), Feeding and eating disorders (FED), and controls (CTLs). All subjects were assessed with the AdAS Spectrum. The cluster analysis identified 3 clusters: the high, medium and low autism clusters. The Restricted interests and rumination domain reported the highest influence in forming the clusters. The high, medium and low autism clusters were respectively more represented in the ASD, partial ASD and CTL groups. The clusters were represented intermediately in the FED and BD groups, confirming the presence of intermediate levels of AT in these clinical populations.

Convergence between clinician-rated and patient-reported PTSD symptoms in a specialized outpatient service: The moderator role of gender

PURPOSE

Posttraumatic stress disorder (PTSD) includes different symptoms: re-experiencing, avoidance of reminders and numbing, and hyperarousal. Although questionnaires are widely used, clinician-administered interviews provide a more comprehensive exploration of symptoms. Few studies examined the convergence between clinician-rated and patient-reported general severity and symptoms, with mixed findings. We explored the association between clinician-rated and patient-reported general severity and symptoms and the moderator role of gender in PTSD patients referred to a specialized outpatient service.

DESIGN AND METHODS

The Clinician-Administered PTSD Scale and Davidson Trauma Scale were administered to 56 patients.

FINDINGS

Patients classified by clinicians as with higher avoidance/numbing symptoms and women classified with higher hyperarousal symptoms reported higher general severity.

PRACTICE IMPLICATIONS

The assessment of the patients reporting high severity should focus on hyperarousal, particularly for women.

Influence of birth cohort on age of onset cluster analysis in bipolar I disorder

Purpose:

Two common approaches to identify subgroups of patients with bipolar disorder are clustering methodology (mixture analysis) based on the age of onset, and a birth cohort analysis. This study investigates if a birth cohort effect will influence the results of clustering on the age of onset, using a large, international database.

Methods:

The database includes 4037 patients with a diagnosis of bipolar I disorder, previously collected at 36 collection sites in 23 countries. Generalized estimating equations (GEE) were used to adjust the data for country median age, and in some models, birth cohort. Model-based clustering (mixture analysis) was then performed on the age of onset data using the residuals. Clinical variables in subgroups were compared.

Results:

There was a strong birth cohort effect. Without adjusting for the birth cohort, three subgroups were found by clustering. After adjusting for the birth cohort or when considering only those born after 1959, two subgroups were found. With results of either two or three subgroups, the youngest subgroup was more likely to have a family history of mood disorders and a first episode with depressed polarity. However, without adjusting for birth cohort (three subgroups), family history and polarity of the first episode could not be distinguished between the middle and oldest subgroups.

Conclusion:

These results using international data confirm prior findings using single country data, that there are subgroups of bipolar I disorder based on the age of onset, and that there is a birth cohort effect. Including the birth cohort adjustment altered the number and characteristics of subgroups detected when clustering by age of onset. Further investigation is needed to determine if combining both approaches will identify subgroups that are more useful for research.

Post-traumatic stress disorder in Italy: a comprehensive evaluation of all the ICD comorbidities and gender-related differences

Objectives

The association between post-traumatic stress disorder (PTSD) and medical comorbidities is controversial since most studies focused on specific comorbidity and victim types. In Italy, data on this issue are scarce. A comprehensive evaluation of all the ICD medical categories co-occurring in PTSD may orient assessment and treatment during clinical and forensic practice. This is the first study evaluating all the ICD physical comorbidities and gender-related differences in Italian PTSD patients. Eighty-four PTSD patients (36 females, 48 males) were included. The Clinician-Administered PTSD Scale, Mini International Neuropsychiatric Interview and Davidson Trauma Scale were administered.

Results

Most patients had a PTSD consequent to an accident and half of them presented extreme symptom severity. No gender differences emerged on symptom severity/duration and age at the event. Metabolic (39.29%), circulatory (20.24%) and musculoskeletal systems/connective tissue diseases (17.86%) were the most frequent comorbidities. Metabolic/circulatory diseases were more frequent among males (p = 0.019 and p = 0.027, respectively) while females more frequently showed neoplasms (p = 0.039). Physical comorbidities represent a serious complication in PTSD patients and are more prevalent than in the Italian population. While gender is not associated with symptom presentation, it seems to play a key role in specific comorbidities including metabolic, circulatory and neoplastic diseases.

The Effects of Terrorist Attacks on Symptom Clusters of PTSD: a Comparison with Victims of Other Traumatic Events

In the Post-Traumatic Stress Disorder (PTSD) literature, no study assessed differences in symptom clusters among victims of terrorist attacks (TA) as compared with victims of other traumatic events. Due to the intentional nature of the harm infliction, TA may be expected to produce more severe symptoms, particularly avoidance, since this cluster was found to be a severity marker and a maintenance factor of the disorder. As several patients delay treatment-seeking, duration of untreated illness (DUI) is another problem potentially influencing PTSD severity. The current study explored differences in PTSD symptom clusters as a function of the traumatic event type (TA compared with other events), DUI, and sex. One hundred-eight patients with primary PTSD were administered The Clinician Administered PTSD Scale. Mean DUI was approximately 12 years, irrespective of the event type. Patients who had experienced TA had significantly more severe Avoidance/Numbing symptoms and general PTSD severity than those who had experienced other events. No significant effects emerged for DUI and sex on all clusters. Timely recognition and intervention on PTSD may include community psychoeducation programs about its symptoms. Tailored intervention on TA-related PTSD may focus on Avoidance/Numbing by including medication and psychotherapeutic approaches for this symptom cluster.

Psychological and Brain Connectivity Changes Following Trauma-Focused CBT and EMDR Treatment in Single-Episode PTSD Patients

Among the different therapeutic alternatives for post-traumatic stress disorder (PTSD), Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR) Therapy have shown promising results in helping patients cope with PTSD symptoms. However, given the different theoretical and methodological substrate of TF-CBT and EMDR, a potentially different impact on the brain for the two interventions could be hypothesized, as well as an interaction between trauma-specific PTSD symptomatology and response to a given psychotherapy. In this study, we monitored psychological and spontaneous functional connectivity fMRI patterns in two groups of PTSD patients who suffered by the same traumatic event (i.e., natural disaster), before and after a cycle of psychotherapy sessions based on TF-CBT and EMDR. Thirty-seven (37) PTSD patients were enrolled from a larger sample of people exposed to a single, acute psychological stress (i.e., 2002 earthquake in San Giuliano di Puglia, Italy). Patients were randomly assigned to TF-CBT (n = 14) or EMDR (n = 17) psychotherapy. Clinical assessment was performed using the Clinician-Administered PTSD Scale (CAPS), the Davidson Trauma Scale (DTS) and the Work and Social Adjustment Scale (WSAS), both at baseline and after treatment. All patients underwent a fMRI data acquisition session before and after treatment, aimed at characterizing their functional connectivity (FC) profile at rest, as well as potential connectivity changes associated with the clinical impact of psychotherapy. Both EMDR and TF-CBT induced statistically significant changes in clinical scores, with no difference in the clinical impact of the two treatments. Specific changes in FC correlated with the improvement at the different clinical scores, and differently for EMDR and TF-CBT. However, a similarity in the connectivity changes associated with changes in CAPS in both groups was also observed. Specifically, changes at CAPS in the entire sample correlated with an (i) increase in connectivity between the bilateral superior medial frontal gyrus and right temporal pole, and a (ii) decrease in connectivity between left cuneus and left temporal pole. Results point to a similar, beneficial psychological impact of EMDR and TF-CBT for treatment of natural-disaster PTSD patients. Neuroimaging data suggest a similar neurophysiological substrate for clinical improvement following EMDR and TF-CBT, involving changes affecting bilateral temporal pole connectivity.

A comparison of physical comorbidities in patients with posttraumatic stress disorder developed after a terrorist attack or other traumatic event

No study investigated whether the presence of specific medical comorbidities is associated with the type of traumatic event, in particular with terrorist attack (TA). In a group of subjects with posttraumatic stress disorder (PTSD), the current study investigated the association between the types of traumatic event (TA vs. other traumatic event [OTE]) and medical comorbidities, controlling for sex and PTSD duration. The Mini International Neuropsychiatric Interview, the Clinician-Administered PTSD Scale, and the Davidson Trauma Scale were administered to 84 subjects diagnosed with PTSD. Thirty-nine were victims of TA and 45 victims of OTE. TA was associated with higher prevalence of neoplasms (β = 2.60, p = 0.02). Females were more protected than males from circulatory system comorbidities (β = 1.47, p = 0.04), while PTSD duration was associated with higher prevalence of such comorbidities (β = 0.005, p = 0.01). Females showed a higher prevalence of neoplasms than males (β = 2.50, p = 0.02). Female sex was protective against metabolic syndrome (β = -1.79, p = 0.02). Patients with PTSD due to TA and female patients should be considered for their higher prevalence of neoplasms, while male patients and those with higher symptom duration should be monitored for circulatory disease and metabolic syndrome. Symptom duration might be associated with circulatory and metabolic disease. Implications for tailored and timely psychopharmacological and psychotherapeutic intervention for PTSD are discussed focusing on these specific medical comorbidities.

Correlates of autistic traits among patients with borderline personality disorder

BACKGROUND

Despite discrete autism-related dimensions, such as deficits in communication, empathy and mentalizing are likely to affect the development of personality and despite they actually frequently occur in borderline patients, no research has so far investigated the relationship between autistic traits and Borderline Personality Disorder (BPD). The objective of this study is to investigate the clinical significance of autistic traits in subjects with BPD.

METHODS

The sample included 50 patients with a clinical diagnosis of BPD and 69 healthy controls. The Structured Clinical Interview for DSM-5 Clinician Version was used to establish the presence of comorbid mental disorders among BPD subjects and to confirm the absence of lifetime mental disorders in the control group. Participants were also asked to fill three self-report instruments: the Adult Autism Subthreshold Spectrum (AdAS Spectrum), the Autism Spectrum Quotient (AQ) and the Mood Spectrum Self-Report (MOODS-SR).

RESULTS

Patients with BPD reported higher autistic traits than healthy individuals. Moreover, autistic traits were shown to exert a significant impact on some clinical features and associated manifestation of BPD, such as suicidality and lifetime exposure to physical and/or sexual abuse.

CONCLUSIONS

Subthreshold autism spectrum may be relevant for subjects suffering from BPD and future research may further address clinical correlates of autistic traits among patients with this disorder.

A study on the association of mood disorders and gluten-related diseases

Our study aimed to evaluate the presence of antibodies related to gluten intolerance in patients with mood disorders. A total of 60 patients with a diagnosis of bipolar disorder or depressive disorder were recruited. Fourty-eight subjects randomly selected among unrelated family members were included as controls. Celiac disease-associated antibodies were assayed both in the patients and controls. Mean values of IgA/IgG anti-gliadin antibodies, IgA/IgG anti-deamidated gliadin peptide antibodies and IgA anti-transglutaminase (tTG) antibodies were not different between patients and controls. However, a significant difference was found for anti-tTG IgG antibodies. Even if both in controls and in patients the mean anti-tTG IgG value was below the cutoff, the estimates produced by the statistical model showed that each unit increase in the anti-tTG IgG antibody value corresponded to an approximately 5% increased chance of having a mood disorder. The patient group showed a more frequent presence of symptoms associated to non-celiac gluten sensitivity. However, as there was neither any correlation between antibody levels and gastrointestinal symptoms, nor with the intensity of the psychiatric symptoms, it may be conceivable that the increase in anti-tTG IgG antibodies is not disorder-related but possibly an outcome of the psychiatric disorder itself.

Morphovolumetric changes after EMDR treatment in drug-naïve PTSD patients

INTRODUCTION

Few studies have investigated the effects of efficacious psychotherapy on structural alterations of discrete brain regions associated with posttraumatic stress disorder (PTSD). We therefore proposed to evaluate the neurobiological effects of eye movement desensitization and reprocessing (EMDR) on 19 patients with drug-naïve PTSD without comorbidity, matched with 19 untreated healthy controls.

METHODS

We administered the Clinician Administered PTSD Scale (CAPS) and conducted brain MRI measurements (with Optimized Voxel-Based Morphometry). Patients received 12 EMDR sessions over three months. Then patients and controls were reassessed.

RESULTS

At baseline, grey matter volume (GMV) differed significantly between patients and controls (F 1,35 =3.674; p=.008; η 2=.298). Analyses of 3-month scans showed no changes for controls, while significant changes were highlighted for patients post-EMDR, with a significant increase in GMV in left parahippocampal gyrus, and a significant decrease in GMV in the left thalamus region. The diagnosis of PTSD was effectively eliminated in 16 of 19 patients, reflected in a significant improvement on the CAPS (t(35)=2.132, p<.004).

DISCUSSION AND CONCLUSIONS

Results indicated post-EMDR changes for patients in brain morphology. We discuss whether EMDR’s mechanism of action may work at the level of the thalamus, an area implicated in PTSD pathology.

Solar insolation in springtime influences age of onset of bipolar I disorder

OBJECTIVE

To confirm prior findings that the larger the maximum monthly increase in solar insolation in springtime, the younger the age of onset of bipolar disorder.

METHOD

Data were collected from 5536 patients at 50 sites in 32 countries on six continents. Onset occurred at 456 locations in 57 countries. Variables included solar insolation, birth-cohort, family history, polarity of first episode and country physician density.

RESULTS

There was a significant, inverse association between the maximum monthly increase in solar insolation at the onset location, and the age of onset. This effect was reduced in those without a family history of mood disorders and with a first episode of mania rather than depression. The maximum monthly increase occurred in springtime. The youngest birth-cohort had the youngest age of onset. All prior relationships were confirmed using both the entire sample, and only the youngest birth-cohort (all estimated coefficients P < 0.001).

CONCLUSION

A large increase in springtime solar insolation may impact the onset of bipolar disorder, especially with a family history of mood disorders. Recent societal changes that affect light exposure (LED lighting, mobile devices backlit with LEDs) may influence adaptability to a springtime circadian challenge.

International multi-site survey on the use of online support groups in bipolar disorder

BACKGROUND

Peer support is an established component of recovery from bipolar disorder, and online support groups may offer opportunities to expand the use of peer support at the patient's convenience. Prior research in bipolar disorder has reported value from online support groups.

AIMS

To understand the use of online support groups by patients with bipolar disorder as part of a larger project about information seeking.

METHODS

The results are based on a one-time, paper-based anonymous survey about information seeking by patients with bipolar disorder, which was translated into 12 languages. The survey was completed between March 2014 and January 2016 and included questions on the use of online support groups. All patients were diagnosed by a psychiatrist. Analysis included descriptive statistics and general estimating equations to account for correlated data.

RESULTS AND CONCLUSIONS

The survey was completed by 1222 patients in 17 countries. The patients used the Internet at a percentage similar to the general public. Of the Internet users who looked online for information about bipolar disorder, only 21.0% read or participated in support groups, chats, or forums for bipolar disorder (12.8% of the total sample). Given the benefits reported in prior research, clarification of the role of online support groups in bipolar disorder is needed. With only a minority of patients using online support groups, there are analytical challenges for future studies.

Autistic Traits in Patients with Anorexia Nervosa, Bulimia Nervosa or Binge Eating Disorder: A Pilot Study

Introduction

Previous data showed higher autistic traits in individuals with anorexia nervosa (AN) compared to healthy controls (CTL). It is not known, however, whether this characteristic is shared by other feeding and eating disorders (FEDs) or it is uniquely associated to AN.

Objectives

To compare autistic traits among individuals with AN, bulimia nervosa (BN), binge eating disorder (BED) and CTL and to investigate which specific dimensions differentiate one group from another.

Methods

A total of 241 FED patients (53 AN, 41 BN, 42 BED) and 105 CTL were administered the autism-spectrum quotient (AQ), the adult autism subthreshold spectrum (AdAS Spectrum), the Ritvo autism and Asperger diagnostic scale 14-item (RAADS-14 Screen).

Results

FED subjects reported higher AQ, AdAS spectrum and RAADS-14 total and subscales scores compared to CTL (all P < .001). No differences were found amongst AN, BN and BED subjects in questionnaires’ total scores. BN group scored higher than AN in the hyper-/hyporeactivity to sensory input domain of the AdAS spectrum (P < .001); AN group scored higher than BED in the attention switching domain of the AQ (P < .001), and BED group scored lower than both AN and BN in the mentalizing deficit domain of the RAADS-14 (all P < .001).

Conclusions

We reported for the first time that not only AN but also BN and BED patients show greater autistic traits compared to CTL. Longitudinal studies are needed to confirm this preliminary report and to elucidate whether autistic traits either precede, co-occur or follow FEDs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Adult Autism Subthreshold Spectrum (AdAS Spectrum): Validation of a questionnaire investigating subthreshold autism spectrum

AIM

Increasing literature has shown the usefulness of a dimensional approach to autism. The present study aimed to determine the psychometric properties of the Adult Autism Subthreshold Spectrum (AdAS Spectrum), a new questionnaire specifically tailored to assess subthreshold forms of autism spectrum disorder (ASD) in adulthood.

METHODS

102 adults endorsing at least one DSM-5 symptom criterion for ASD (ASDc), 143 adults diagnosed with a feeding and eating disorder (FED), and 160 subjects with no mental disorders (CTL), were recruited from 7 Italian University Departments of Psychiatry and administered the following: SCID-5, Autism-Spectrum Quotient (AQ), Ritvo Autism and Asperger Diagnostic Scale 14-item version (RAADS-14), and AdAS Spectrum.

RESULTS

The AdAS Spectrum demonstrated excellent internal consistency for the total score (Kuder-Richardson's coefficient=.964) as well as for five out of seven domains (all coefficients>.80) and sound test-retest reliability (ICC=.976). The total and domain AdAS Spectrum scores showed a moderate to strong (>.50) positive correlation with one another and with the AQ and RAADS-14 total scores. ASDc subjects reported significantly higher AdAS Spectrum total scores than both FED (p<.001) and CTL (p<.001), and significantly higher scores on the Childhood/adolescence, Verbal communication, Empathy, Inflexibility and adherence to routine, and Restricted interests and rumination domains (all p<.001) than FED, while on all domains compared to CTL. CTL displayed significantly lower total and domain scores than FED (all p<.001). A significant effect of gender emerged for the Hyper- and hyporeactivity to sensory input domain, with women showing higher scores than men (p=.003). A Diagnosis* Gender interaction was also found for the Verbal communication (p=.019) and Empathy (p=.023) domains. When splitting the ASDc in subjects with one symptom criterion (ASD₁) and those with a ASD, and the FED in subjects with no ASD symptom criteria (FED₀) and those with one ASD symptom criterion (FED₁)_, a gradient of severity in AdAS Spectrum scores from CTL subjects to ASD patients, across FED₀, ASD₁, FED₁ was shown.

CONCLUSIONS

The AdAS Spectrum showed excellent internal consistency and test-retest reliability and strong convergent validity with alternative dimensional measures of ASD. The questionnaire performed differently among the three diagnostic groups and enlightened some significant effects of gender in the expression of autistic traits.

Internet use by patients with bipolar disorder: Results from an international multisite survey

There is considerable international interest in online education of patients with bipolar disorder, yet little understanding of how patients use the Internet and other sources to seek information. 1171 patients with a diagnosis of bipolar disorder in 17 countries completed a paper-based, anonymous survey. 81% of the patients used the Internet, a percentage similar to the general public. Older age, less education, and challenges in country telecommunications infrastructure and demographics decreased the odds of using the Internet. About 78% of the Internet users looked online for information on bipolar disorder or 63% of the total sample. More years of education in relation to the country mean, and feeling very confident about managing life decreased the odds of seeking information on bipolar disorder online, while having attended support groups increased the odds. Patients who looked online for information on bipolar disorder consulted medical professionals plus a mean of 2.3 other information sources such as books, physician handouts, and others with bipolar disorder. Patients not using the Internet consulted medical professionals plus a mean of 1.6 other information sources. The percentage of patients with bipolar disorder who use the Internet is about the same as the general public. Other information sources remain important.

Relationship between sunlight and the age of onset of bipolar disorder: an international multisite study

BACKGROUND

The onset of bipolar disorder is influenced by the interaction of genetic and environmental factors. We previously found that a large increase in sunlight in springtime was associated with a lower age of onset. This study extends this analysis with more collection sites at diverse locations, and includes family history and polarity of first episode.

METHODS

Data from 4037 patients with bipolar I disorder were collected at 36 collection sites in 23 countries at latitudes spanning 3.2 north (N) to 63.4 N and 38.2 south (S) of the equator. The age of onset of the first episode, onset location, family history of mood disorders, and polarity of first episode were obtained retrospectively, from patient records and/or direct interview. Solar insolation data were obtained for the onset locations.

RESULTS

There was a large, significant inverse relationship between maximum monthly increase in solar insolation and age of onset, controlling for the country median age and the birth cohort. The effect was reduced by half if there was no family history. The maximum monthly increase in solar insolation occurred in springtime. The effect was one-third smaller for initial episodes of mania than depression. The largest maximum monthly increase in solar insolation occurred in northern latitudes such as Oslo, Norway, and warm and dry areas such as Los Angeles, California.

LIMITATIONS

Recall bias for onset and family history data.

CONCLUSIONS

A large springtime increase in sunlight may have an important influence on the onset of bipolar disorder, especially in those with a family history of mood disorders.

Influence of light exposure during early life on the age of onset of bipolar disorder

BACKGROUND

Environmental conditions early in life may imprint the circadian system and influence response to environmental signals later in life. We previously determined that a large springtime increase in solar insolation at the onset location was associated with a younger age of onset of bipolar disorder, especially with a family history of mood disorders. This study investigated whether the hours of daylight at the birth location affected this association.

METHODS

Data collected previously at 36 collection sites from 23 countries were available for 3896 patients with bipolar I disorder, born between latitudes of 1.4 N and 70.7 N, and 1.2 S and 41.3 S. Hours of daylight variables for the birth location were added to a base model to assess the relation between the age of onset and solar insolation.

RESULTS

More hours of daylight at the birth location during early life was associated with an older age of onset, suggesting reduced vulnerability to the future circadian challenge of the springtime increase in solar insolation at the onset location. Addition of the minimum of the average monthly hours of daylight during the first 3 months of life improved the base model, with a significant positive relationship to age of onset. Coefficients for all other variables remained stable, significant and consistent with the base model.

CONCLUSIONS

Light exposure during early life may have important consequences for those who are susceptible to bipolar disorder, especially at latitudes with little natural light in winter. This study indirectly supports the concept that early life exposure to light may affect the long term adaptability to respond to a circadian challenge later in life.

Celiac and non-celiac gluten sensitivity: a review on the association with schizophrenia and mood disorders

An association between many psychiatric and gluten-related disorders has been known for some time. In the case of schizophrenia and mood disorders, the major psychiatric disorders, there is much evidence, not without contradictions, of a possible association between schizophrenia and celiac disease. The association between mood disorders and gluten-related disorders, especially celiac disease, has only been studied for depression, often coupled with anxiety, and very recently for bipolar disorder. Since non-celiac gluten sensitivity is now known to be different from celiac disease, many studies have shown that gluten sensitivity is also associated with major psychiatric disorders. Here we review the literature on the association between schizophrenia/mood disorders and celiac disease/gluten sensitivity, pointing out the differences between these associations.

[Sexual dysfunctions, psychiatric diseases and quality of life: a review]

Sexual dysfunctions may have a significant effect on the quality of life, but are unreported and under-diagnosed. A review of recent literature highlights the correlation between dysfunction and a decreased quality of life in people with psychiatric comorbidity, and explores several aspects impacting care, from following the patient to pharmacological and non-pharmacological treatments. Sexual dysfunctions (SD) have been shown to be prevalent, but under-diagnosed and un-dertreated because of communication barriers between patients and physicians. Pharmacogenic and morbogenic causes of sexual problems are often difficult to differentiate. Psychiatric diseases may increase the risk of SD, and SD may further exacerbate psychiatric problems, suggesting a bi-directional relationship. Their effective treatment frequently involves combination of elements from psychotherapy, and behavioral along with pharmacotherapeutic intervention, if needed. The persistence of sexual problems has significant negative impact on patient's satisfaction and adherence with the treatment, quality of life and partnership. Routine assessment of sexual functioning needs to be integrated into ongoing care to identify and address problems early. If sexual dysfunction is ignored it may maintain the psychiatric disorder, compromise treatment outcome and lead to non-adherence and compromise treatment outcome.

[Diagnostic mistakes in post-traumatic stress disorder. The problem of symptom overlap with depression]

OBJECTIVES

The overlap between symptoms of PTSD and MDD is substantial. PTSD symptoms arise after a traumatic experience and the trauma is present in all of the diagnostic clusters. In individuals who have experienced a trauma a long time before, it is difficult to establish the exact moment of onset of their symptoms in relation to the trauma suffered. We proposed to raise awareness among operators who may encounter this problem, with the aim of providing them with valuable help in order to achieve a correct differential diagnosis.

METHODS

A sample of subjects suffering from PTSD without comorbidity was assessed to confirm the diagnosis and the severity of post-traumatic symptoms. The Kruskal-Wallis test was used to compare any modifications in the parameters analyzed through the Davidson Trauma Scale with the presence and severity of depressive symptoms as evaluated by the Hamilton-D scale.

RESULTS

Half of the PSTD patients recruited showed values of HAM-D > 18, although an active Major Depressive Episode was clinically excluded. Symptom of "numbing", despite being different from the apathy experienced in depression, is identified as a depressive symptom by the HAM-D.

CONCLUSIONS

Giving prevalence to depressive symptoms may be misleading for diagnosis and may ultimately result in inappropriate treatment.

[Light therapy as a treatment for sexual dysfunctions--beyond a pilot study]

OBJECTIVES

Seasonal trends were demonstrated in reproduction and sexual activity. Through the secretion ofmelatonin the pineal gland plays an important role in the neuroendocrine control of sexual function and reproductive physiology. We hypothesized that inhibition of the pineal gland activity through a light treatment may favorably affect sexual function.

METHODS

We recruited 24 subjects with a diagnosis of hypoactive sexual desire disorder and/or primary sexual arousal disorder. The subjects were randomly assigned to either active light treatment (ALT) or placebo light treatment (L-PBO). Participants were assessed during the first evaluation and after 2 weeks of treatment, using the Structured Clinical Interview for Sexual Disorders DSM-IV (SCID-S) and a self-administered rating scale of the level of sexual satisfaction (1 to 10). Repeated ANOVA measures were performed to compare the two groups of patients. Post-hoc analysis was performed by Holm-Sidak test for repeated comparisons. Results. At baseline the two groups were comparable. After 2 weeks the group treated with Light Therapy showed a significant improvement in sexual satisfaction, about 3 times higher than the group that received placebo, while no significant improvement was observed in the group L-PBO. Conclusions. Our results confirm a potentially beneficial effect of Light Therapy on primary sexual dysfunction. In the future, we propose to correlate clinical findings with testosterone levels pre/post treatment.

Photosensitivity and panic-agoraphobic spectrum: a pilot study

BACKGROUND

The aims of this study were to assess photosensitivity (photophobia and photophilia) in panic disorder (PD) patients compared to healthy controls, and to evaluate the correlation between photosensitivity and panic-agoraphobic spectrum self-report (PAS-SR) scores.

METHODS

The PAS-SR and Photosensitivity Assessment Questionnaires were administered to 24 PD subjects and 33 healthy controls.

RESULTS

Compared to controls, PD patients showed significantly higher levels of photophobia and lower levels of photophilia items. The PAS-SR total score was positively correlated with the photophobia score.

CONCLUSIONS

This study shows a strong correlation between PD and photophobia. However, whether photophobia develops before or after the onset of PD remains unclear. Further research is warranted to assess the potential role of light stimuli exposure in the onset, course and outcome of PD.

Asenapine for the treatment of manic and mixed episodes associated with bipolar I disorder: from clinical research to clinical practice

INTRODUCTION

Asenapine is a sublingually administered second-generation antipsychotic with proven efficacy for the treatment of moderate to severe manic episodes associated with bipolar I disorder in adults. Its relatively favorable weight and metabolic profile, as well as the lack of appreciable activity at muscarinic cholinergic receptors and the sublingual administration are of clinical interest.

AREAS COVERED

This paper comprises a review and commentary regarding the use of sublingual asenapine in the treatment of acute manic and mixed episodes of bipolar disorder. Basic principles in dosing, switching, management of side effects and co-administration with other medications are provided.

EXPERT OPINION

Asenapine displays quick and reliable effects on manic symptoms, very low risk of depressive switches, efficacy on depressive symptoms during manic and mixed episodes, usually good tolerability and continued longer-term efficacy on residual and subthreshold symptoms. The fast-dissolving sublingual route of administration may favor those who have difficulties in swallowing medications. Also, the sublingual administration reduces the risk of overdose when more than the prescribed tablets are swallowed. The relatively low metabolic risk and the lack of anticholinergic side effects contribute to making this medication a useful tool for the treatment of patients with bipolar disorder.

[Evaluation study of clinical and neurobiological efficacy of EMDR in patients suffering from post-traumatic stress disorder]

Strong evidences support use of EMDR in patients suffering from post-traumatic stress disorder (PTSD).

AIM

To evaluate clinical and neurobiological-structural efficacy of EMDR on drug-naïve PTSD without comorbidity.

MATERIALS AND METHODS

We made clinical evaluation and hippocampal volume measurement by MRI on 29 subjects suffering from PTSD and on 30 healthy control-subjects. Then, patients were treated with EMDR and after three months of psychotherapy the clinical evaluation and the MRI exam were replied.

RESULTS AND DISCUSSION

Our results demonstrated that the diagnosis of PTSD was no more possible on all the patients who terminated the psychotherapy (n=18). At the same time, all the patients showed an average increase of 6% in hippocampal volumes.

CONCLUSIONS

Our reaserach suggests that EMDR treatment correlates not only with a significant improvement of symptoms of PTSD, but also with a significant increase of hippocampal volumes.

Impact of sunlight on the age of onset of bipolar disorder

OBJECTIVE

Although bipolar disorder has high heritability, the onset occurs during several decades of life, suggesting that social and environmental factors may have considerable influence on disease onset. This study examined the association between the age of onset and sunlight at the location of onset.

METHOD

Data were obtained from 2414 patients with a diagnosis of bipolar I disorder, according to DSM-IV criteria. Data were collected at 24 sites in 13 countries spanning latitudes 6.3 to 63.4 degrees from the equator, including data from both hemispheres. The age of onset and location of onset were obtained retrospectively, from patient records and/or direct interviews. Solar insolation data, or the amount of electromagnetic energy striking the surface of the earth, were obtained from the NASA Surface Meteorology and Solar Energy (SSE) database for each location of onset.

RESULTS

The larger the maximum monthly increase in solar insolation at the location of onset, the younger the age of onset (coefficient= -4.724, 95% CI: -8.124 to -1.323, p=0.006), controlling for each country's median age. The maximum monthly increase in solar insolation occurred in springtime. No relationships were found between the age of onset and latitude, yearly total solar insolation, and the maximum monthly decrease in solar insolation. The largest maximum monthly increases in solar insolation occurred in diverse environments, including Norway, arid areas in California, and Chile.

CONCLUSION

The large maximum monthly increase in sunlight in springtime may have an important influence on the onset of bipolar disorder.

Dysfunctions of cortical excitability in drug-naïve posttraumatic stress disorder patients

BACKGROUND

The investigation of a wide set of transcranial magnetic stimulation (TMS)-related variables in both hemispheres might help to identify a pattern of cortical excitability changes in posttraumatic stress disorder (PTSD) patients, reflecting gamma-amino-butiric acid (GABA)/glutamate balance and dysfunction, and to determine whether some of these variables are related to clinical features.

METHODS

In 20 drug-naive PTSD patients without comorbidity and 16 matched healthy control subjects we tested bilaterally with standard TMS procedures: resting motor threshold (RMT) to single-pulse TMS (reflecting ion channel function), paired-pulse short-latency intracortical inhibition (SICI; mainly reflecting GABA(A) function) and intracortical facilitation (ICF; mainly reflecting glutamatergic function), single-pulse cortical silent period (CSP; mainly reflecting GABA(B)-ergic function), and paired-pulse short-latency afferent inhibition (SAI; reflecting cholinergic mechanisms and their presynaptic GABA(A)-mediated modulation).

RESULTS

The PTSD patients showed widespread impairment of GABA(A)-ergic SICI, which was reversed toward facilitation in both hemispheres in one-half of the patients, marked increase of glutamatergic ICF in the right hemisphere, and right-sided impairment of SAI. Illness duration and avoidance symptoms but not anxiety correlated with right-lateralized dysfunctions of cortical excitability.

CONCLUSIONS

Although the neurobiological complexity of each TMS variable makes current results theoretical, the pattern of cortical excitability accompanying PTSD symptoms suggests a bilateral decrease of the GABA(A)-ergic function. This prevails in the right hemisphere, in association with a relative prevalence of the glutamatergic tone, a new finding that current neuroimaging investigations cannot provide due to the lack of reliable glutamate tracers. Results might help to disclose new pathophysiological aspects of PTSD symptoms, providing a rationale for future neuromodulatory strategies of treatment.

Photosensitivity in panic disorder

BACKGROUND

The objective of this study is to evaluate abnormal light-related behavior in patients with panic disorder (PD).

METHODS

We administered the Photosensitivity Assessment Questionnaire to 30 subjects with PD and to 40 healthy subjects. The Photosensitivity Assessment Questionnaire is a self-report questionnaire that evaluates two dimensions of photosensitivity: photophilia and photophobia.

RESULTS

Compared to healthy controls, PD subjects reported significantly higher scores on the photophobia (P<.003) and significantly lower scores on the photophilia (P<.001) questions.

CONCLUSIONS

Subjects with PD indicated that they tolerate and seek light to a significantly lower degree than normal controls.

Magnetic resonance imaging volumes of the hippocampus in drug-naïve patients with post-traumatic stress disorder without comorbidity conditions

Most brain imaging studies have showed smaller hippocampal volume in adults with chronic PTSD; however, some other studies have not replicated this finding. Most of these investigations included subjects with other psychiatric comorbidities, such as major depression or alcohol abuse. The prevalence of psychiatric comorbidities in PTSD is generally high and this makes it difficult, if not impossible, to disentangle the contribution of other disorders to hippocampal volume. Therefore, the main goal of the current study is to compare hippocampal volumes of healthy subjects and drug-naïve patients with PTSD caused by different types of mixed civilian traumas (i.e. car accident, physical abuse, sudden death of a family member, assault or robbery, natural disaster and traumatic abortion) and without comorbidity conditions. Magnetic resonance imaging (MRI) was used to measure the hippocampi, total cerebrum, gray matter, white matter and cerebrospinal fluid volumes in 34 patients with single diagnosis of PTSD, and 34 case-matched non-PTSD comparison subjects. The patients with single diagnosis of PTSD had an 11.8% smaller left hippocampus (p<0.001) and an 8.7% smaller right hippocampus (p=0.003) than the healthy controls. The results were controlled for the total brain volume and for gray matter volumes. Subjects with PTSD also displayed lower overall gray matter volume (p=0.006). There were no significant correlations between hippocampal volumes and illness duration or severity of PTSD. The findings indicate the presence of smaller hippocampal volumes in drug-naïve patients with single diagnosis of PTSD, compared with healthy subjects.

Activity of citalopram on adenosine and serotonin circulating levels in depressed patients

Citalopram is a selective serotonin reuptake inhibitor used in the treatment of depression. Recent investigations have shown that it reduces in rat brain the release of excitatory amino neurotransmitters acid glutamate and aspartate by the involvement of the inhibitory neuromodulator adenosine. In this study, we described citalopram and serotonin levels in plasma and platelets, as well as plasma adenosine levels, in depressive patients during acute and chronic administration of citalopram. Twelve patients affected by Major Depression (DSM-IV) received a single oral dose of citalopram in the morning, 5 mg in the first 5 days, 10 mg from the 6th to the 10th day, and 20 mg from the 11th to the 40th day. Blood samples for citalopram, serotonin, and adenosine were collected at Time 0 and 4, 12 and 24 hours after drug administration on the first day of citalopram 5 mg, and on the first and the last day of citalopram 20 mg. Citalopram, serotonin, and adenosine concentrations in plasma increased after citalopram administration, and the highest levels were observed on the last day of treatment. Citalopram was detectable in platelets with concentrations showing a time variation similar to plasma values. Serotonin levels in platelets decreased after drug administration, reaching the lowest values on the last day of treatment.

Panic-agoraphobic spectrum and light sensitivity in a general population sample in Italy

OBJECTIVE

This study aimed to verify a possible correlation between panic symptoms and photosensitivity, not only in panic disorder (PD) but also in the panic-agoraphobic spectrum.

METHOD

One hundred and sixty-nine healthy and drug-free subjects completed the Structured Clinical Interview for Panic-Agoraphobic Spectrum-Lifetime version (SCI-PAS-Lifetime) and the Photosensitivity Assessment Questionnaire (PAQ).

RESULTS

The SCI-PAS-Lifetime total score was positively correlated with the total score of the PAQ photophobia subdimension (r = 0.44; P < 0.001); the SCI-PAS-Lifetime total score was not significantly correlated with the photophilia subdimension. As photophobia increased, we observed significant score increases in all SCI-PAS-Lifetime domains. Bivariate correlation showed higher coefficient correlation between the panic-like symptoms domain and photophobia (r = 0.44; P < 0.001).

CONCLUSIONS

A high total score in the SCI-PAS-Lifetime, which denotes more typical features of the spectrum, is associated with a higher level of light sensitivity and intolerance toward bright stimuli. This finding reflects clinical evidence that widely documents photophobic behaviours in subjects with PD and the importance of light stimuli exposure during the onset and course of such a disorder. Bright stimulation seems to be relevant both in PD diagnosed according to current DSM criteria and in the entire panic-agoraphobic spectrum, from nuclear elements of the disorder through subclinical states to the normal condition.

Attachment and panic disorder

A dysfunctional relationship between parents and children can influence cognitive and emotional development and contribute to the development of psychiatric disorders, particularly panic disorder (PD). With the aim of exploring childhood experiences of parenting in PD patients, we compared subjectively perceived climate and objective recall by administering the Parental Bonding Instrument and 10 adjunctive items to 22 out-patients and 22 matched controls. Our analysis showed that DSM-III-R-diagnosed PD patients reported their parents to be significantly less caring than did the control group, while there was no significant difference in objective recall of parenting experiences.

Electroretinogram B-wave amplitude in panic disorder

Abnormal light-related behaviors have been described for patients with panic disorder (PD). The present study was undertaken to investigate the retinal light response in PD using electroretinography (ERG). The authors conducted b-wave ERG measurements with a bright light (after dark adaptation) in 28 patients with PD and 28 control subjects. There were no significant differences in the mean b-wave amplitude between the two groups, but the retinal response to light in PD patients was generally lower than in healthy subjects. A large interindividual variability was found; also noted was a significant difference in the mean b-wave amplitude between the right and left eyes in the control group. The data indicate subtle variation of retinal photosensitivity in a subgroup of patients with PD. Because dopaminergic retinal activity affects b-ERG amplitude, the authors hypothesize that the dopaminergic system is involved in the response to light in PD patients.

Melatonin in psychiatric disorders: a review on the melatonin involvement in psychiatry

In normal subjects, the secretion of melatonin, the pineal hormone that regulates the rhythm of many functions, exhibits a circadian pattern synchronized with the day-night cycle. An alteration of this secretory pattern has been found in various psychiatric disorders (seasonal affective disorder, bipolar disorder, unipolar depression, bulimia, anorexia, schizophrenia, panic disorder, obsessive compulsive disorder). At present, it is not known if such alterations have an etiological role or are secondary to the dysfunctions underlying the different disorders. In addition, we do not know if the involvement of melatonin in several disorders has the same significance in the pathophysiology of each disorder. An understanding of the role of the pineal hormone and of its alterations in psychiatric diseases could help to identify the biological mechanisms underlying such disorders.