Stefano Pallanti

European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD

BackgroundAttention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe.MethodsThe European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated.ResultsBesides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated?ConclusionsADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.

Internet addiction: a descriptive clinical study focusing on comorbidities and dissociative symptoms

AIMS Internet addiction (IAD) is an emerging cause of morbidity and has been recently considered to merit inclusion in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Given the paucity of knowledge about IAD, we conducted a descriptive clinical analysis of patients focusing on clinical, demographic features, and comorbidities. The detachment has been suggested as a reason for the attractiveness of the Internet; thus, we assessed dissociative symptoms and their association with IAD disability. DESIGN AND SETTING A cohort of 50 adult outpatients were screened using the Internet Addiction Scale. Exclusion criterion was using the Internet for only one purpose such as gaming or gambling. PARTICIPANT Nine women and 6 men constituted the sample of Internet addicts; each of them had a score of 70 or higher on the Internet Addiction Scale. MEASUREMENT Comorbidities and subthreshold symptoms were screened carefully. Dissociative symptoms were analyzed with the Dissociative Experience Scale, and disability was assessed using the Sheehan Disability Scale. FINDINGS Hours/week spent on the Internet were 42.21 +/- 3.09. Clinical diagnoses included 14% attention deficit and hyperactivity disorder, 7% hypomania, 15% generalized anxiety disorder, 15% social anxiety disorder; 7% dysthymia, 7% obsessive compulsive personality disorder, 14% borderline personality disorder, and 7% avoidant personality disorder. One patient met criteria for binge eating disorder. Severity measures of IAD were associated with higher perception of family disability (r = 0.814; P <or= .001) and with higher Yale-Brown Obsessive Compulsive Severity score (r = 0.771; P <or= .001). Scores for the Dissociative Experience Scale were higher than expected (23.20 +/- 1.83) and were related to higher obsessive compulsive scores (r = 0.618; P <or= .001), hours per week on the Internet (r = 0.749; P <or= .001), and perception of family disability (r = 0.677; P <or= .001). CONCLUSION From a phenomenological point of view, IAD in our sample population seems to be more compulsory than rewarding or mood driven. Dissociative symptoms are related to severity and impact of IAD.

Risperidone augmentation in treatment-resistant obsessive-compulsive disorder: a double-blind, placebo-controlled study.

This double-blind, placebo-controlled trial was performed to determine the efficacy and tolerability of 8 wk of risperidone augmentation of serotonin reuptake inhibitor (SRI) treatment in adult subjects with treatment-resistant obsessive-compulsive disorder (OCD) (failure of at least two SRI trials). Sixteen adult treatment-resistant OCD patients were randomly assigned to augmentation with 8 wk of either risperidone (n=10) (0.5-3.0 mg/d) or placebo (n=6) following at least 12 wk of SRI treatment. Four patients on risperidone (40%) and none (0%) on placebo were responders with both a Clinical Global Impression - Improvement (CGI-I) score of 1 or 2 and a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) decrease >/=25%. Risperidone was generally well tolerated: there were 3 dropouts, 1 on risperidone and 2 on placebo. Better Y-BOCS insight score at baseline significantly correlated with a greater CGI-I score at endpoint on risperidone augmentation. Risperidone may be an effective and well-tolerated augmentation strategy in treatment-resistant OCD subjects, but larger sample size studies are required to demonstrate this.

The Shorter PROMIS Questionnaire and the Internet Addiction Scale in the assessment of multiple addictions in a high-school population: prevalence and related disability.

OBJECTIVE Taking into account the importance of act prevention on the development of addictions, we assessed the presence of multiple addictions in an adolescent high-school population, also assessing the prevalence of Internet abuse and the impact on disability. INTRODUCTION Adolescence seems to be a critical period of addiction vulnerability, based on social but also neurobiological factors. The earlier onset of behavioral/substance dependence seems to predict greater addiction severity, morbidity, and multiple addictive disorders. METHODS Data were collected from a sample of 275 students in Florence, Italy, high schools through surveys distributed in classes. The sample had an average age of 16.67+/-1.85 years (52.4% males, 47.6% females). To assess multiple addiction we used the 16 subscales of the Shorter PROMIS Questionnaire, to assess Internet addiction prevalence we used the Internet Addiction Scale, and to quantify disability symptoms, we used the Sheehan Disability Scale. RESULTS Caffeine abuse, sex, relationship submissive, gambling, food starving, and food bingeing have raised highest scores. 5.4% of the students were found to be Internet addicted similar to other countries. Disability seemed strongly correlated to the subscale of alcohol, gambling, sex, tobacco, food starving and food bingeing, shopping, exercise, and Internet addiction. Gambling, sex, caffeine abuse, compulsive help dominant, work, Internet addiction, relationship dominant, and relationship submissive in this sample were strongly related to substance dependence. CONCLUSION Level of concerns unexpected compared to the level reported in other countries for the behavioral compulsions, have been highlighted. Behavioral addictions are multiple, a source of disability, and they are related to substance abuse. It has yet to be clarified if they are a temporary phenomenon occurring in adolescents or if they are a stable trait, accounting as marker for the development of substance abuse.

Reliability and Validity of the Pathological Gambling Adaptation of the Yale-Brown Obsessive-Compulsive Scale (PG-YBOCS)

The Yale Brown Obsessive Compulsive Scale adapted for Pathological Gambling (PG-YBOCS) was developed to measure the severity and change in severity of pathological gambling symptoms. The PG-YBOCS is a 10-item clinician-administered questionnaire that measures the severity of PG over a recent time interval (usually within the past one/two week(s)). In order to assess and validate the scale, it was administered to 337 subjects: 188 pathological gamblers and 149 healthy controls. Internal consistency and correlations between individual items and total score were assessed for various permutations of the sample. Other scales were administered to assess convergent, discriminant and content validity. Sensitivity to change was evaluated in treatment studies with fluovoxamine, lithium, and valproate. Each item was frequently endorsed across a range of severity. Good inter-rater reliability and internal consistency were obtained. The PG-YBOCS showed high validity and reliability for total score, item-total correlations, and for each subscale (Thoughts/Urges and Behavior). PG-YBOCS scores correlated with global severity and South Oaks Gambling Screen (SOGS) scores. The scale was also sensitive to change in pathological gambling severity. PG-YBOCS thus appears to be a reliable and valid measure of pathological gambling severity, and can be regarded as an important tool for clinicians and researchers treating pathological gamblers.

The lifetime impact of attention deficit hyperactivity disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND The aim of the study was to present nationally representative data on the lifetime independent association between attention deficit hyperactivity disorder (ADHD) and psychiatric co-morbidity, correlates, quality of life and treatment seeking in the USA. METHOD Data were derived from a large national sample of the US population. Face-to-face surveys of more than 34 000 adults aged 18 years and older residing in households were conducted during the 2004-2005 period. Diagnoses of ADHD, Axis I and II disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV version. RESULTS ADHD was associated independently of the effects of other psychiatric co-morbidity with increased risk of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, specific phobia, and narcissistic, histrionic, borderline, antisocial and schizotypal personality disorders. A lifetime history of ADHD was also associated with increased risk of engaging in behaviors reflecting lack of planning and deficient inhibitory control, with high rates of adverse events, lower perceived health, social support and higher perceived stress. Fewer than half of individuals with ADHD had ever sought treatment, and about one-quarter had ever received medication. The average age of first treatment contact was 18.40 years. CONCLUSIONS ADHD is common and associated with a broad range of psychiatric disorders, impulsive behaviors, greater number of traumas, lower quality of life, perceived social support and social functioning, even after adjusting for additional co-morbidity. When treatment is sought, it is often in late adolescence or early adulthood, suggesting the need to improve diagnosis and treatment of ADHD.

Epidemiology of mood disorders : a community survey in Florence

A structured interview designed to detect affective disorders and to produce both DSM-III and DSM-III-R diagnoses was administered to a community sample of 1000 people living in Florence. The interviews were carried out by physician-psychiatrists (qualified psychiatrists or 3rd-4th-year trainees) trained in the use of operational diagnoses. The 1-year prevalence and point prevalence were, respectively: 1.7% and 0.6% for bipolar disorder; 0.4% and 0.4% for cyclothymia; 6.2% and 2.8% for major depression; 2.6% and 0.8% for dysthymia; 5.2% and 1.8% for depressive disorder not otherwise specified. Most of the cases affected by mood disorder sought medical help, primarily through their GP. The large majority of them were specifically treated for it and, in almost 60% of the cases with a major form, were referred to a psychiatrist.

Obsessive-compulsive disorder and obsessive-compulsive spectrum disorders: diagnostic and dimensional issues.

Although obsessive-compulsive disorder (OCD) is classified as an anxiety disorder in the DSM-IV , recent considerations for a reclassification into an obsessive-compulsive spectrum disorders (OCSDs) cluster are gaining prominence. Similarities in symptomatology, course of illness, patient population, and neurocircuitry of OCD and OCSD are supported by comorbidity, family, and neurological studies, which also offer a critical re-evaluation of the relationship between OCD and anxiety disorders. This review examines potential classifications of OCD among the wider spectrum of affective disorders and at the interface between affective disorders and addiction. In addition, it has been suggested that the categorical diagnostic approach would be enhanced by an additional dimensional approach, including parameters such as stability of mood and ability to sustain attention. With further studies, it is ultimately the goal to define OCD and related disorders based on endophenotypes. Despite efforts in this field, there are several fundamental unresolved issues, including the question of which disorders should be grouped together in this category and which characteristics to include as their shared common features. A reclassification of OCD among the OCSDs would allow for better scrutiny of distinct obsessive-compulsive symptoms, as currently this disorder often goes undetected in patients who complain of a broad symptom of anxiety. Advantages and disadvantages of establishing OCSDs and its implications for diagnosis, treatment, and research are discussed.

MDMA (Ecstasy) Precipitation of Panic Disorder

The authors describe three patients whose panic disorder began during recreational use of MDMA (Ecstasy) and was subsequently complicated by agoraphobic avoidance that continued autonomously after cessation of the drug. Their panic disorder responded well to serotoninergic antidepressant drugs. Theoretical and practical implications are discussed.

Double-blind, placebo-controlled trial of topiramate augmentation in treatment-resistant obsessive-compulsive disorder.

BACKGROUND From 40% to 60% of obsessive-compulsive disorder (OCD) patients fail to tolerate or respond to selective serotonin reuptake inhibitors (SSRIs). Preclinical and neuroimaging studies have shown abnormally high glutamatergic concentrations in OCD patients and an association between decreased caudate glutamatergic concentrations and reduced OCD symptom severity after SSRI treatment. Topiramate inhibits glutamatergic conduction. METHOD Thirty-six adult patients with DSM-IV-defined OCD were randomly assigned to topiramate (n = 18) and placebo (n = 18) groups in this 12-week, double-blind, placebo-controlled, parallel-groups trial. Subjects were taking the maximum SSRI dose they could tolerate for at least 12 weeks and their current dose for at least 6 weeks, which was maintained throughout the study. Primary outcome measures were changes in the Yale-Brown Obsessive Compulsive Scale (YBOCS) total score and compulsions and obsessions subscores. Patients were recruited and followed up between April 1, 2003, and April 13, 2006. RESULTS Using mixed regression models (time [weeks] × treatment), we found a significant treatment effect on the YBOCS compulsions (P = .014) subscale, but not the obsessions (P = .99) subscale or the total score (P = .11). Over the 12-week trial, the topiramate group (mean endpoint dose = 177.8 ± 134.2 mg/d; range, 50-400 mg/d) showed an average linear decrease of 5.38 points on the compulsions subscale compared to 0.6 points in the placebo group. Thirteen topiramate and 14 placebo subjects completed the study. Topiramate was not well tolerated in this trial: 28% (5/18) of the subjects discontinued the drug for adverse effects, and 39% (7/18) had a dose reduction for this reason. CONCLUSIONS The results of this first double-blind, placebo-controlled trial of topiramate augmentation for treatment-resistant OCD suggest that topiramate may be beneficial for compulsions, but not obsessions. Modifications in glutamatergic function may be responsible, at least in part, for the improved response in compulsions seen with topiramate. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00211744.