Lorenzo Livianos

Influence of Stress in the Onset of Eating Disorders: Data From a Two-stage Epidemiologic Controlled Study

Background: We explore the role of stress in the onset of eating disorders (EDs) in a community sample of adolescents, the mediating role of psychiatric comorbidity and the quantitative evolution of stress in the year preceding the onset of an ED. Methods: The Life Events and Difficulties Schedule interview was applied to a sample with 32 cases and 32 controls selected from a two-phase epidemiologic study among a representative population of adolescents, followed by a decay model to assess acute and chronic stress in the year preceding the onset of ED. Psychiatric comorbidity was assessed using the SCAN interview. Results: Cases (46.9%) and 9.4% of controls were found to have associated psychiatric comorbidity (&khgr;2 = 11.74, p = .001). Of cases, 6.3% and none of the controls had at least one severe stressful event (N.S). Of cases, 18.8% and 3.1% of controls had at least one major difficulty (Fisher exact test = 0.05). Of cases, 25% and 3.1% of controls had a provoking stressful agent (Fisher exact test = 0.026). Psychiatric comorbidity partially mediated the relationship between stress and EDs. The Structural Equation Modeling Analysis shows that chronic stress is strongly associated with the onset of EDs, both directly (r2 = 0.38) and indirectly, through psychiatric comorbidity (r2 = 0.56). Conclusion: Chronic stress and psychiatric comorbidity are strongly associated with the onset of EDs. Psychiatric comorbidity is a partial mediating factor in the association of stress with eating disorders. ED = eating disorders; AN = anorexia nervosa; LEDS = Life Events and Difficulties Schedule; BN = bulimia nervosa; BED = binge eating disorder; SCAN = Schedules for Clinical Assessment in Neuropsychiatry; EAT = Eating Attitudes Test; SEM = structural equation modeling; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders; SPSS = Statistical Package for Social Science; AMOS = Analysis of Moment Structures.

Attentional biases toward emotional images in the different episodes of bipolar disorder: An eye-tracking study

Attentional biases toward emotional information may represent vulnerability and maintenance factors in bipolar disorder (BD). The present experimental study examined the processing of emotional information in BD patients using the eye-tracking technology. Bipolar patients in their different states (euthymia, mania, depression) simultaneously viewed four pictures with different emotional valence (happy, neutral, sad, threatening) for 20s while their eye movements were monitored. A group of healthy individuals served as the control. The data revealed the following: (i) a decrease in attention to happy images in BD patients in their depressive episodes compared to healthy individuals, and (ii) an increase in attention to threatening images in BD patients (regardless of their episode) relative to the healthy controls. These biases appeared in the late stages of information processing and were sustained over the 20s interval. Thus, the present findings reveal that attentional biases toward emotional information can be a key feature of BD, in that: (i) an anhedonic lack of sensitivity to positive stimuli during the bipolar depressive episode may be considered a maintaining factor of this clinical state, and (ii) the trait-bias toward threat, even in asymptomatic patients, may reflect a marker of vulnerability in BD.

Teasing and disordered eating behaviors in Spanish adolescents.

The purpose of this study is to investigate the associations between peer teasing and body dissatisfaction (BD), emotional symptoms, drive for thinness (DT), and abnormal eating behaviors, as well as to analyze the mediating role of gender and body mass index (BMI) in such disorders. We screened 57,997 school children between 13 and 16 years of age. Scores in weight-related teasing and competency-related teasing were higher among girls, as well as overweight or obese individuals. Weight-teasing correlated more strongly with abnormal eating attitudes and behaviors, whereas competency-teasing correlated with emotional symptoms. Multiple linear regression analysis showed that weight-teasing is significantly and independently associated with BD, especially in boys. Multivariate analysis revealed a significant association between weight-teasing and abnormal eating in girls, although its predictive value was very low (Exp(B) = 1.009). Mediation analysis and Path analysis showed the mediating role of DT in this association. Interventions on teasing do not seem to be a priority in eating disorder prevention programs.

Prodromal Symptoms to Relapse in Bipolar Disorder

In a cyclical and recurring illness such as bipolar disorder, prodrome detection is of vital importance. This paper describes manic and depressive prodromal symptoms to relapse, methods used in their detection, problems inherent in their assessment, and patients’ coping strategies. A review of the literature on the issue was performed using MEDLINE and EMBASE databases (1965–May 2006). ‘Bipolar disorder’, ‘prodromes’, ‘early symptoms’, ‘coping’, ‘manic’ and ‘depression’ were entered as key words. A hand search was conducted simultaneously and the references of the articles found were used to locate additional articles. The most common depressive prodromes are mood changes, psychomotor symptoms and increased anxiety; the most frequent manic prodromes are sleep disturbances, psychotic symptoms and mood changes. The manic prodromes also last longer. Certain psychological interventions, both at the individual and psychoeducational group level, have proven effective, especially in preventing manic episodes. Bipolar patients are highly capable of detecting prodromal symptoms to relapse, although they do find the depressive ones harder to identify. Learning detection, coping strategies and idiosyncratic prodromes are elements that should be incorporated into daily clinical practice with bipolar patients.

Prevalence and comorbidity of eating disorders among a community sample of adolescents: 2-year follow-up

The previous literature about comorbidity between eating disorders (ED) and other DSM-IV psychiatric disorders in adolescence has employed cross-sectional studies with clinical samples, where the comorbid disorders were diagnosed retrospectively. The present study aims to overcome these limitations by the analysis of comorbidity in a community population during 2-year follow-up. A semi-structured interview was applied to a teenager sample. Firstly, a cross-sectional and non-randomized study on psychiatric morbidity was conducted with 993 teenagers between the ages of 12 and 16 from five schools. Secondly, 326 students between 14 and 17 years old of one school were reassessed 2 years later in order to detect ED new cases and find associations with previous psychiatric disorders. The ED prevalence was 3.6%. Cross-sectional analysis revealed that 62.9% of individuals with an ED had comorbid disorders: anxiety disorders (51.4%), Attention Deficit Hyperactivity Disorder (31.4%), oppositional defiant disorder (11.4%), and obsessive compulsive disorder (8.6%). Prospective longitudinal analysis showed an ED incidence rate of 2.76% over the course of 2 years. 22.2% of new cases had received previous psychiatric diagnoses, of which all were anxiety disorders. Thus, ED exhibited a high comorbidity rate among adolescent populations and anxiety disorders were the most common comorbid diagnosis.

Is melatonin an adjunctive stabilizer

A 61-YEAR-OLD WOMAN with Alzheimer’s dementia (AD) was admitted semi-mutistic having ceased eating, drinking, and taking oral medications over 2 weeks before. DSMIV-TR criteria for major depression were not met. Hostile/ aggressive features as well as any signs of emotional distress were unapparent. Thus, upon admission, apathy syndrome was diagnosed with indolence, requirement of prompts to initiate physical and mental activity and a complete lack of goaldirected behavior. Medical and neurological examination revealed tachycardia and clinical signs of dehydration but she was otherwise normal. Laboratory work-up was normal. A computed tomography scan showed no acute pathological findings. Intravenous fluid and electrolyte replacement was installed. Treatment with intramuscular lorazepam (1 mg b.i.d.) and haloperidol (5 mg q.d.) had no effect and was discontinued after 5 days. Intravenous administration of citalopram 20 mg q.d. was started after 5 drug-free days. Three days later, responsiveness increased, and spontaneous speech and emotional reactions occurred. After 8 days, the patient ate and drank. She was switched successfully to oral citalopram 40 mg q.d. after 14 days. Although emotional blunting persisted, she became accessible and cooperative. Her Mini Mental State Examination score was 15/30, consistent with moderate dementia. After 30 days of oral citalopram, she was referred to a nursing home with sufficient daily food and fluid intake, having gained 1.9 kg of bodyweight. Apathy is one of the most common behavioral symptoms in AD representing a significant burden to patients and caregivers. Severe forms, such as the reported case, with distinct key symptoms as highlighted above are well separable from other AD-related behavioral disturbances, above all, depression. Treatment options include psychostimulants and dopaminergics which, however, are not available for parenteral administration and bear the risk of other behavioral complications. Selective serotonin reuptake inhibitors (SSRI), such as citalopram or sertraline, are well tolerated in geriatric populations. However, most likely due to differentially impaired neural pathways, they appear not to be effective in depression in AD. Nevertheless, SSRI have shown efficacy for treating irritability and psychotic symptoms in AD. Furthermore, cholinergic and glutamatergic disturbances, a profound alteration of serotonergic (5-HT) activity, for example via 5-HT1A receptor and/or 5-HT transporter reduction in AD, has been demonstrated and linked to the aforementioned neurobehavioral symptoms. Thus, and given the possibility of parenteral administration, SSRI should be considered as an alternative treatment option for such conditions over less well-tolerated drug classes. Our case suggests that intravenous citalopram may be a treatment option in severe AD-related apathy.

Comparative neurocognitive effects of lithium and anticonvulsants in long-term stable bipolar patients

BACKGROUND The aim of choosing a mood-stabilizing drug (lithium or anticonvulsants) or a combination of them with minimal neurocognitive effects is to stimulate the development of criteria for a therapeutic adequacy, particularly in Bipolar Disorder (BD) patients who are clinically stabilized. METHOD Three groups of BD patients were established according to their treatment: (i) lithium monotherapy (n=29); (ii) lithium together with one or more anticonvulsants (n=28); and (iii) one or more anticonvulsants (n=16). A group of healthy controls served as the control (n=25). The following tests were applied: Wechsler Adult Intelligence Scale, Trail Making Test, Wechsler Memory Scale, Rey Complex Figure Test, Stroop color-word test, Wisconsin Card Sorting Test, Tower of Hanoi, Frontal Assessment Battery, and Reading the Mind in the Eyes Test. RESULTS Relative to healthy controls, BD patients showed the following: (i) those on lithium monotherapy, but not other BD groups, had preserved short-term auditory memory, long-term memory, and attention; (ii) those who took only anticonvulsants showed worse findings in short-term visual memory, working memory, and several executive functions; and (iii) all BD patients showed worse performance in processing speed, resistance to interference, and emotion recognition. LIMITATIONS Medication alone cannot explain why all BD patients showed common cognitive deficits despite different pharmacological treatment. CONCLUSION The impairment on some executive functions and emotion recognition is an inherent trait in BD patients, regardless of their pharmacological treatment. However, while memory, attention, and most of the executive functions are preserved in long-term stable BD patients, these cognitive functions are impaired in those who take anticonvulsants.

Auditory hallucinations in anorexia nervosa

The paper describes two case studies of patients with anorexia nervosa who suffer from auditory hallucinations as the only psychotic symptom. A review of the literature regarding clinical cases of anorexic patients with hallucinations is discussed. Hallucinations in anorexic patients are conceptualized according to different theoretical models which point to a dimensional view of eating disorders.

Cuál es la relevancia real y el manejo de las principales alteraciones tiroideas en los pacientes bipolares

Thyroid disfunction affects negatively emotional stability and worsens the clinical course of bipolar affective disorder. The main stabilizer used in this illness, lithium carbonate has numerous effects on the physiology of the thyroid, with the most significant being the inhibition of thyroid hormone release that may occur at therapeutic levels. These dysfunctions have also been reported most frequently in bipolar patients not undergoing treatment with lithium, and was not completely explained by the effects of this drug. Apart from the numerous medical complications and mood disturbances, the cognitive or perceptual system may also be affected. In fact, the presence of thyroid disease increases the rates of obsessive compulsive disorder, phobias, panic disorder, major depressive disorder, cyclothymia, or bipolar disorder. In severe cases of hypothyroidism, the clinical symptoms and signs can be similar to a melancholic depression or dementia. It is therefore important to know well all these possible complications in daily clinical practice. This review will cover the main thyroid dysfunctions present in bipolar patients, whether ot not produced by treatment with lithium carbonate, and will provide a series of recommendations for clinical management.

Hypoesthesia of the malleolus as a soft sign in depression

BACKGROUND Physical signs often are present in many psychiatric conditions, making up a fundamental part of them and accompanying the psychiatric manifestations themselves. Identifying minor neurological signs is especially of interest due to they are easily accessible through simple neurological examination and could be a useful if underused tool for the diagnostic process and patient therapy. METHOD A group of depressed patients (n=85) and group of healthy individuals (n=101) that served as control were examined using the Wartenberg wheel, a medical device for neurological use, in order to determine the presence of hypoesthesia on both sides of their ankles. RESULTS The data revealed: (i) patients with depression are generally more likely to present malleolar hypoesthesia than healthy participants; and (ii) participants who presented malleolar hypoesthesia presented greater depressive symptomatology as well as greater anxiety symptomatology at the time of assessment. LIMITATIONS Although all patients in this study were taking psychotropic medication, anxiolytics and antidepressants are not associated with skin sensitivity. As is usual, the categorization of hypoesthesia is based on participant subjectivity. However, this subjectivity cannot explain the differences between depressed patients and healthy individuals. CONCLUSIONS The present findings corroborate that localized tactile sensitivity is altered in depression and correlates with anxiety-depressive symptomatology, even on a subclinical level. The observation of neurological soft signs such as the detection of malleolar hypoesthesia in patients with depressive symptomatology is easily accessible using a simple neurological examination, and it could became a powerful tool that could provide objective information on affective disorders.