Sinikka Luutonen

Striatal dopamine D1 and D2 receptors in burning mouth syndrome

&NA; Animal studies have indicated that the nigrostriatal dopaminergic system is involved in central pain modulation. In a recent positron emission tomography (PET) study, we demonstrated presynaptic dysfunction of the nigrostriatal dopaminergic pathway in burning mouth syndrome, which is a chronic pain state. The objective of the present study was to examine striatal dopamine D1 and D2 receptors in these patients. We used 11C‐NNC 756 and 11C‐raclopride to study D1 and D2 receptor binding in a PET study in ten burning mouth patients and 11 healthy controls. Patients underwent a structured psychiatric evaluation and an electrophysiological test for the excitability of the blink reflex. The striatal uptake of 11C‐NNC 756 did not differ between patients and controls. In a voxel‐level analysis, the uptake of 11C‐raclopride was statistically significantly higher in the left putamen in burning mouth patients (corrected P‐value 0.038 at cluster‐level). In the region of interest analysis, the D1/D2 ratio was 7.7% lower in the right putamen (0.64±0.04 vs. 0.69±0.04, P=0.01) and 6.4 % lower in the left putamen (0.65±0.05 vs. 0.70±0.05, P=0.05) when compared to controls. Increased 11C‐raclopride uptake and the subsequent decrease in the D1/D2 ratio may indicate a decline in endogenous dopamine levels in the putamen in burning mouth patients.

Axis I diagnoses and transition to psychosis in clinical high-risk patients EPOS project: prospective follow-up of 245 clinical high-risk outpatients in four countries.

BACKGROUND In selected samples, a considerable number of patients at clinical high risk of psychosis (CHR) are found to meet criteria for co-morbid clinical psychiatric disorders. It is not known how clinical diagnoses correspond to or even predict transitions to psychosis (TTP). Our aim was to examine distributions of life-time and current Axis I diagnoses, and their association with TTP in CHR patients. METHODS In the EPOS (European Prediction of Psychosis Study) project, six European outpatient centres in four countries examined 245 young help-seeking patients, who fulfilled the inclusion criteria for clinical risk of psychosis according to the Structured Interview for Prodromal Syndromes (SIPS 3.0) or the Bonn Scale for the Assessment of Basic Symptoms - Prediction List basic symptoms (BASBS-P). Patients who had experienced a psychotic episode lasting more than one week were excluded. Baseline and life-time diagnoses were assessed by the Structured Clinical Interview for DSM-IV (SCID-I). TTP was defined by continuation of BLIPS for more than seven days and predicted in Cox-regression analysis. RESULTS Altogether, 71% of the CHR patients had one or more life-time and 62% one or more current SCID-I diagnosis; about a half in each category received a diagnosis of life-time depressive and anxiety disorder. Currently, 34% suffered from depressive and 39% from anxiety disorder. Four percent received a current SCID diagnosis of bipolar, and 6.5% of somatoform disorder. During follow-up, 37 (15.1%) patients had developed full-blown psychosis. In bivariate analyses, current non-psychotic bipolar disorder associated significantly with TTP. In multivariate analyses, current bipolar disorder, somatoform and unipolar depressive disorders associated positively, and anxiety disorders negatively, with TTP. CONCLUSIONS Both life-time and current mood and anxiety disorders are highly prevalent among clinical help-seeking CHR patients and need to be carefully evaluated. Among CHR patients, occurrence of bipolar, somatoform and depressive disorders seems to predict TTP, while occurrence of anxiety disorder may predict non-transition to psychosis.

Psychiatric (axis I) and personality (axis II) disorders in patients with burning mouth syndrome or atypical facial pain

Abstract Background and aims Burning mouth syndrome (BMS) and atypical facial pain (AFP) are often persistent idiopathic pain conditions that mainly affect middle-aged and elderly women. They have both been associated with various psychiatric disorders. This study examined current and lifetime prevalence of psychiatric axis I (symptom-based) and II (personality) disorders in patients with chronic idiopathic orofacial pain, and investigated the temporal relationship of psychiatric disorders and the onset of orofacial pain. Method Forty patients with BMS and 23 patients with AFP were recruited from Turku university hospital clinics. Mean age of the patients was 62.3 years (range 35–84) and 90% were female. BMS and AFP diagnoses were based on thorough clinical evaluation, and all patients had undergone clinical neurophysiological investigations including blink reflex and thermal quantitative tests. Current and lifetime DSM-IV diagnoses of axis I and II disorders were made on clinical basis with the aid of SCID-I and II-interviews. The detected prevalence rates and their 95% confidence intervals based on binomial distribution were compared to three previous large population-based studies. Results Of the 63 patients, 26 (41.3%) had had an axis I disorder that preceded the onset of orofacial pain, and 33 (52.4%) had had a lifetime axis I disorder. Rate of current axis I disorders was 36.5%, indicating that only about 16% of lifetime disorders had remitted, and they tended to run chronic course. The most common lifetime axis I disorders were major depression (30.2%), social phobia (15.9%), specific phobia (11.1%), and panic disorder (7.9%). Twelve patients (19.0%) had at least one cluster C personality disorder already before the emergence of orofacial pain. Patients with cluster C personality disorders are characterized as fearful and neurotic. None of the patients had cluster A (characterized as odd and eccentric) or B (characterized as dramatic, emotional or erratic) personality disorders. The most common personality disorders were obsessive–compulsive personality (14.3%), dependent personality (4.8%), and avoidant personality (3.2%). The majority of the patients (54%) had also one or more chronic pain conditions other than orofacial pain. In almost all patients (94%) they were already present at the onset of orofacial pain. Conclusions Our results suggest that major depression, persistent social phobia, and neurotic, fearful, and obsessive–compulsive personality characteristics are common in patients with chronic idiopathic orofacial pain. Most psychiatric disorders precede the onset of orofacial pain and they tend to run a chronic course. Implications We propose that the high psychiatric morbidity, and comorbidity to other chronic pain conditions, in chronic idiopathic orofacial pain can be best understood in terms of shared vulnerability to both chronic pain and specific psychiatric disorders, most likely mediated by dysfunctional brain dopamine activity.

Prediction of psychosis in clinical high-risk patients by the Schizotypal Personality Questionnaire. Results of the EPOS project

OBJECTIVE Schizotypal features indicate proneness to psychosis in the general population. It is also possible that they increase transition to psychosis (TTP) among clinical high-risk patients (CHR). Our aim was to investigate whether schizotypal features predict TTP in CHR patients. METHODS In the EPOS (European Prediction of Psychosis Study) project, 245 young help-seeking CHR patients were prospectively followed for 18 months and their TTP was identified. At baseline, subjects were assessed with the Schizotypal Personality Questionnaire (SPQ). Associations between SPQ items and its subscales with the TTP were analysed in Cox regression analysis. RESULTS The SPQ subscales and items describing ideas of reference and lack of close interpersonal relationships were found to correlate significantly with TTP. The co-occurrence of these features doubled the risk of TTP. CONCLUSIONS Presence of ideas of reference and lack of close interpersonal relations increase the risk of full-blown psychosis among CHR patients. This co-occurrence makes the risk of psychosis very high.

Childhood trauma and premorbid adjustment among individuals at clinical high risk for psychosis and normal control subjects

Traumatic childhood experiences are associated with psychotic illness and are frequently reported in patients at clinical high risk (CHR) for psychosis. Moreover, deteriorating premorbid functioning from childhood, and through adolescence, is related to greater severity of overall symptomatology and poorer outcomes in patients with psychosis. We studied the prevalence of traumatic childhood experiences and premorbid adjustment and their association with each other in patients at CHR for psychosis and normal control subjects (NCSs).

Anger and depression—Theoretical and clinical considerations

The Freudian idea of inhibited anger being central to the pathogenesis of depression has been one of the cornerstones of psychiatric thinking. The aim of this article is to review the literature on psychotherapy theory and the relevant research with regard to the association of anger and depression, and to discuss clinical implications in treating depressive patients. Choice of research articles was based on systematic search of databases. Psychotherapy theories are mostly found in books not included in databases. Literature on psychotherapy theory was selectively chosen. Over-control, under-control and mixtures of the two may be present in depression, indicating problems in anger regulation. The links between anger and depression form a complex network. When treating patients with depression, explicit or implicit dealing with anger often seems to be helpful. In clinical reality, the relative amounts of elicitation of anger experience and training in expressive control needed by depressive patients may vary between different types of patients, different phases of depressive disorder, and different phases of therapy.

Breast cancer patients receiving postoperative radiotherapy: Distress, depressive symptoms and unmet needs of psychosocial support

BACKGROUND AND PURPOSE The diagnosis and treatment of breast cancer can cause considerable psychological consequences, which may remain unrecognized and untreated. In this study, the prevalence of depressive symptoms and distress, and unmet needs for psychosocial support were assessed among breast cancer patients receiving postoperative radiotherapy. MATERIAL AND METHODS Out of 389 consecutive patients, 276 responded and comprised the final study group. Depressive symptoms were assessed with the Beck Depression Inventory. Distress was measured with the Distress Thermometer. Hospital records of the patients were examined for additional information. RESULTS Nearly one third of patients (32.1%) displayed depressive symptoms, and more than a quarter of patients (28.4%) experienced distress. Younger age (p=0.001) and negative hormone receptor status (p=0.008) were independent factors associated with distress. One quarter of the patients expressed an unmet need for psychosocial support, which was independently associated with depressive symptoms and/or distress (p=0.001) and younger age (p=0.006). CONCLUSIONS During radiotherapy for breast cancer, the staff should have awareness of the higher risk of depression and distress in their patients and should consider screening tools to recognise distress and depressive symptoms. Special attention should be paid to younger patients.

Alexithymia and Childhood Abuse Among Patients Attending Primary and Psychiatric Care: Results of the RADEP Study

BACKGROUND Some authors have suggested that the background of alexithymia is related to affective development during early childhood. OBJECTIVE Authors studied the associations between alexithymia and childhood emotional neglect and sexual and physical abuse, also taking into account the significance of concomitant psychopathology. METHOD Associations between childhood difficulties and adulthood alexithymia were studied with samples of primary-care (N=1,033) and mental-health center (N=243) outpatients assessed by The Toronto Alexithymia Scale and questionnaires for depressive, manic, and psychotic symptoms, and childhood difficulties. RESULTS No association between alexithymia and childhood abuse was found in mental-health center patients. Among primary-care patients, alexithymia total score and difficulty in identifying feelings and difficulty in describing feelings were associated with childhood emotional, sexual, and physical abuse. CONCLUSION After controlling for psychopathology, there still remained an association with difficulty in identifying feelings and most abuse and neglect variables. These findings serve to strengthen the theory of alexithymia as a developmental process starting in childhood.

The outcomes of interpersonal counselling on depressive symptoms and distress after myocardial infarction

Aims: Depression is not treated adequately after myocardial infarction (MI). This study evaluates the interpersonal counselling (IPC) implemented by a registered nurse on outcomes for depressive symptoms and distress in MI patients. Methods: We studied MI patients (n = 103) randomized into intervention group (n = 51) and control group (n = 52) in hospital and at 6 and 18 months after discharge using validated questionnaires, Becks Depression Inventory (BDI) and the Symptom Checklist-25 (SCL-25). Results: During the 18-month follow-up, depressive symptoms decreased statistically significantly (P = 0.009) in the intervention group compared with the control group. In the IPC intervention group, depressive symptoms decreased from 37.3% to 20.4% at 6 months (P = 0.014), and to 16.7% at 18 months (P = 0.001), while distress decreased from 37.3% to 26.5% (P = 0.132) during the 6-month follow-up, and to 20.8% (P = 0.015). In the control group with normal care, the number of patients with depressive symptoms and distress varied slightly at the three measurements, from 30.2 to 39.6%. Conclusions: The number of patients with depressive symptoms and distress decreased in the intervention group and remained high in the control group. The progress of severity level of depressive symptoms was toward milder symptoms in the intervention group during the 18-month follow-up. This brief intervention that can rapidly be adopted may result in enduring benefits of clinical value.

Psychometric properties of the Trauma and Distress Scale, TADS, in an adult community sample in Finland

Background There is increasing evidence that a history of childhood abuse and neglect is not uncommon among individuals who experience mental disorder and that childhood trauma experiences are associated with adult psychopathology. Although several interview and self-report instruments for retrospective trauma assessment have been developed, many focus on sexual abuse (SexAb) rather than on multiple types of trauma or adversity. Methods Within the European Prediction of Psychosis Study, the Trauma and Distress Scale (TADS) was developed as a new self-report assessment of multiple types of childhood trauma and distressing experiences. The TADS includes 43 items and, following previous measures including the Childhood Trauma Questionnaire, focuses on five core domains: emotional neglect (EmoNeg), emotional abuse (EmoAb), physical neglect (PhyNeg), physical abuse (PhyAb), and SexAb. This study explores the psychometric properties of the TADS (internal consistency and concurrent validity) in 692 participants drawn from the general population who completed a mailed questionnaire, including the TADS, a depression self-report and questions on help-seeking for mental health problems. Inter-method reliability was examined in a random sample of 100 responders who were reassessed in telephone interviews. Results After minor revisions of PhyNeg and PhyAb, internal consistencies were good for TADS totals and the domain raw score sums. Intra-class coefficients for TADS total score and the five revised core domains were all good to excellent when compared to the interviewed TADS as a gold standard. In the concurrent validity analyses, the total TADS and its all core domains were significantly associated with depression and help-seeking for mental problems as proxy measures for traumatisation. In addition, robust cutoffs for the total TADS and its domains were calculated. Conclusions Our results suggest the TADS as a valid, reliable, and clinically useful instrument for assessing retrospectively reported childhood traumatisation.