Anxiety in Dementia

Until recently, there is considerable mess regarding the nature of anxiety in dementia. However, anxiety is common in this population affecting from 8% to 71% of prevalence, and resulted in poor outcome and quality of life, even after controlling for depression. Because a presentation of anxiety in the context of dementia can be different from typical early-onset anxiety disorder, it is not easy one to identify and quantify anxiety reliably. Moreover, differentiating anxiety from the depression and/or dementia itself also can be formidable task. Anxiety gradually decreases at the severe stages of dementia and this symptom may be more common in vascular dementia than in Alzheimer's disease. Due to the lack of large randomized clinical trials, optimal treatment and the true degree of efficacy of treatment is not clear yet in this population. However, these treatments can reduce adverse impact of anxiety on patients and caregivers. This article provides a brief review for the diagnosis, evaluation and treatment of anxiety in dementia.

Depression and Cognition

Depression is a relatively common agonizing psychiatric disorder that affects the way we feel and think about ourselves and the world around us. Cognitive theories of depression have long posited that various cognitive biases are involved in the development and recurrence of depression. However, the current cognitive theory of depression has been reformulated and expanded from the previous cognitive model of depression based on the results from pharmacological, neuroimaging and neurocognitive studies. This review summarizes the evidence for cognitive dysfunctions in depression and the related pharmacological, neuroanatomical and genetic aspects which aim to integrate our knowledge about the cognitive aspects of depression and its treatment. The newly formulated cognitive theory of depression provides directions for future investigation to identify people at risk, to minimize recurrence, and to maximize long-term beneficial outcomes for those suffering from depression.

Late-Onset Psychosis; Is It Real?

The nature of late-onset psychosis in the absence of a dementia or secondary to organic dysfunctions in the fifth decade of life and beyond is contentious and unresolved. Different terminologies, diagnostic criteria and age cut-offs have been applied to late-onset psychosis, which have stymied clinicians and researchers. No official diagnostic designation for patients with late-onset psychosis is included in the current psychiatric diagnostic system (Diagnostic and Statistical Manual of Mental Disorders-V, International Classification of Diseases-10). The validity of this diagnostic exclusion has been questioned. Despite these problems, a relatively consistent clinical picture has reported. However, many questions remain regarding the underlying etiology, pathophysiological mechanisms, treatment and prognosis. Whether late-onset psychosis is distinct from schizophrenia and whether it might be a harbinger of dementia are unclear. Recent studies have suggested an underlying biological pathophysiology of late-onset psychosis.

Wandering in Dementia

Wandering is acknowledged as one of the most complex, challenging, and potentially dangerous dementia-related behaviors, and can result in elopement, injury, and even death. For the healthy people, walking is a common and a pleasurable leisure activity. However, wandering in dementia may be an exhausting behavior for caregivers and raise safety concerns. The term 'wandering' covers different types of behavior, including aimless movement without a discernible purpose. Although with respect to the etiology of wandering, biological, psychosocial and person-environment interaction has been suggested, the etiology of wandering is poorly understood. Although it is possible that management of coexistent psychopathology would help to ameliorate this problematic behavior, evidence on the effectiveness of pharmacological and non-pharmacological interventions is limited.

Depression in Alzheimer's Disease

Depression is one of the most common psychiatric complications of Alzheimer disease (AD), affecting from 30% to 50% of prevalence, with most estimates in the 20-30% range. Because of having a presentation in the context of AD that differs from typical early-onset depression, it is not easy one to detect and quantify reliably, and can be difficulty to differentiate depression from the other neuropsychiatric symptoms of AD. Due to the lack of large randomized trials, optimal treatment and the true degree of efficacy remains undetermined. However, these treatments can reduce adverse impact of depression on patients and caregivers. This article provides a practical discussion of the diagnosis, evaluation, differential diagnosis and treatment of depression in AD for the clinician.

Delusions in Alzheimer's Disease

Alzheimer's disease (AD) is associated with cognitive and functional impairment as well as neuropsychiatric complications, including psychotic symptoms such as delusions and hallucinations. Recent studies strongly suggest that delusions should be separated from hallucinations. While AD with delusions is a phenotypically distinct from AD without delusions, subtypes of delusions may also define further distinct clinical entities. There has been also considerable debate as to whether delusions in patients with AD differ etiologically, phenomenologically, and therapeutically from delusions in other primary psychiatric illnesses. In other words, whether they are caused by changes to key areas of the brain that have been linked to the presence of delusions. This has led to speculation that these symptoms may respond better to certain drugs such as cholinesterase inhibitors. Integrating the epidemiology, clinical phenomenology, neuropathological and genetic literature for delusions in AD allows us to speculate on pathophysiology and is essential to making progress in the area of delusions in AD.

The Reliability and Validity of the Korean Version of Apathy Evaluation Scale and its Application in Patients with Schizophrenia / 대한정신분열병학회지

OBJECTIVES: Apathy Evaluation Scale (AES) is one of the most frequently used scales to evaluate apathy. The purpose of this study was to evaluate the reliability and validity of the Korean version of the AES (K-AES) and to apply the K-AES in examining the characteristics of apathy in the Korean patients with schizophrenia. METHODS: 129 healthy people and 29 patients with schizophrenia have been evaluated using the K-AES, Physical Anhedonia Scale (PAS), Social Anhedonia Scale (SAS), and the Beck's Depression Inventory (BDI). Split-half reliability and internal consistency were evaluated and factor analysis and correlation analysis was conducted. Between-group comparison was conducted using independent sample t-tests. RESULTS: K-AES showed good reliability and validity. Factor analysis confirmed 3 factors, which represented interest and drive, initiative, self-awareness and self-assessment. Patients with schizophrenia showed significantly higher K-AES and BDI scores than the healthy group. K-AES scores in patients with schizophrenia were significantly correlated with the PAS score, but did not correlate with SAS and BDI scores. CONCLUSION: This study demonstrates the reliability and validity of the K-AES. Our findings also suggest that the K-AES may be a reliable instrument in assessing apathy as a negative symptom in patients with schizophrenia.

The Characteristics of Associative Learning of Reward Approach and Loss Aversion in Schizophrenia / 대한정신분열병학회지

OBJECTIVES: Schizophrenia patients have deficits of prediction and learning related to dopaminergic dysfunction. It is hypothesized that there would be different characteristics in associative learning of reward approach and loss aversion between controls and patients. METHODS: Participants were 23 healthy participants and 20 out-patients fulfilling criteria for schizophrenia according DSM-IV-TR. Using a monetary incentive contingency reversal task, successful learning rates, numbers of trials and errors till learning, numbers of trials of maintaining learning, response times were measured. Characteristics of learning were compared between controls and patients. RESULTS: Physical anhedonia and PANSS negative symptom scores correlated with the number of trials while loss aversion was maintained. Overall correct response rates were decreased in patient group, particularly during reward approach learning. Patients required more trials and errors to learn reward approach than controls. There were no significant differences in learning performance and reaction times between groups during loss avoidance learning. CONCLUSION: These results support previous reports of deficits in reward-driven learning in schizophrenia. However, anhedonia and negative symptoms were associated with the preserved function of loss avoidance learning.

Clinical Predictors of Drug Response in Patients with Obsessive-Compulsive Disorder

OBJECTIVE: The aim of this study was to evaluate which clinical variables might influence the antiobsessional responses to proserotonergic drugs in a sample of patients with obsessive-compulsive disorder (OCD). METHODS: Two hundred forty-nine patients with DSM-IV OCD under-gone mean 13-month treatments with selective serotonin reuptake inhibitors. According to the treatment response, defined as a reductions of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) total score > or =35%, patients were divided into two groups. RESULTS: One hundred fourteen patients responded to the treatment and the other one hundred thirty five patients did not. Responders had a significant long duration of medication in YUMC OCD clinic, short total duration of past treatment in other institutes, and higher frequency of drug naive cases and lower baseline Y-BOCS scores. CONCLUSION: The pre-treatment factors including total duration of past treatment, drug naive or not, baseline OCD symptoms and the factor of duration of the treatment may influence drug treatment response in OCD patients.

Parental Alcohol Problems and Children's Behavior & Psychosocial Characteristics

OBJECTIVES: Alcohol problems of parents have an influence on not only their psychological problems but also on their children's psychosocial adaptation. The purpose of this study was to compare the emotional and behavioral problems, including school bullying and social skills, between children of alcoholics (COAs) and children of non-alcoholics (non-COAs). METHODS: We recruited 4th grade children (n=741) from 7 primary schools in Seoul and their parents as subjects. The self-rated psychiatric symptoms were assessed with the Korean version of the Children of Alcoholics Screening Test (CAST-K), the Children's Depression Inventory (CDI), the Rosenberg's Self-esteem Scale (RSES), the School Bullying Scale, the Social Skill Rating Scale and the Korean version of Alcohol Expectancy Questionnaire-Adolescent (AEQ-A). The Attention-deficit Hyperactivity Disorder Rating Scale-IV (ARS) was completed by the parents. RESULTS: 518 children were non-COAs and 223 were COAs. The COAs showed higher CDI and ARS-IV scores and lower RSES scores than the non-COAs. Especially, the COAs also showed higher school bullying scale scores and lower cooperative scale scores on the social skill rating scales. But there was no difference of alcohol expectancy between the COAs and non-COAs. CONCLUSION: It was plausible that the COAs had more behavioral & psychosocial problems than the non-COAs among the school aged children. It is important to identify and intervene to solve the problems of peer relationships of school age COAs in order to prevent victimization by bullying and to improve psychosocial adaptation.

Erratum: Modern Psychiatric Understanding of the Psychopathology of Psychosis in Oriental Medicine / 신경정신의학

No abstract available.

Modern Psychiatric Understanding of the Psychopathology of Psychosis in Oriental Medicine / 신경정신의학

OBJECTIVES: Oriental medicine has affected the way in which Koreans seek psychiatric help and how they understand psychiatric symptoms and mental illnesses. In this study, we investigated the concept of psychosis in traditional oriental medicine and compared it with how modern western medicine understands the same concept. METHODS: We searched for descriptions of psychotic symptoms or illnesses in traditional medical documents of various periods. Four psychiatrists then analyzed the contents of these descriptions in terms of DSM-IV. RESULTS: The concept of psychosis in oriental medicine has two symptom domains: positive and negative symptoms, which are similar to the positive and negative symptoms of schizophrenia in modern psychiatry. However, there were differences in the basic concepts of disease entities and in the approaches to the illness. CONCLUSION: This descriptive study showed that, in oriental medicine, psychopathology is based on oriental philosophy, and that this creates wide differences between oriental and western medicine.

An Analysis of In-Training Examination for the Psychiatric Residents in Korea: Five-year Cumulative Results / 신경정신의학

OBJECTIVES: The in-training examination (Performance Examination, PE) for psychiatric residents in Korea was launched 5 years ago by the Korean Neuropsychiatric Association (KNPA). This article analyzes 5-year accumulated data on the PE, and tries to make some suggestions for further development of the PE. METHODS: The 5-year data, previously utilized for the generation of formal annual reports were reanalyzed, with an emphasis on longitudinal trends. RESULTS: The analyses indicated the following; 1) Higher-year residents earned definitely higher scores than their lower-year colleagues on the PE. This trend was especially prominent in the area of psychopharmacology-biological psychiatry, geriatric psychiatry, child and adolescent psychiatry, and the emergency-organic psychiatry. There was no year-related performance difference in the area of psychoses. 2) In the area of anxiety-somatization disorder, psychophysiological disorder, and geriatric psychiatry, the residents in the university-affiliated hospitals outperformed those in the specialized psychiatric hospitals. 3) Through analyzing multiple-times examinees, it was found that their first-and second-time performances were moderately correlated, and that their ranks tended to improve, demonstrating a continuously improving performance according to the training year. CONCLUSION: These result suggested that the KNPA PE is a feasible measure for the estimation of an individual resident's performance as well as the adequacy of the environment provided by the training institutes.

Association between Dopamine D4 Receptor Gene Polymorphism and Scores on a Continuous Performance Test in Korean Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE: The aim of this study was to evaluate the association between a variable number of tandem repeats polymorphism at the dopamine D4 receptor gene (DRD4) and the performance of children with attention deficit hyperactivity disorder (ADHD) in a continuous performance test (CPT). METHODS: This study included 72 ADHD children (mean age=9.39+/-2.05 years) who were recruited from one child psychiatric clinic. The omission errors, commission errors, reaction time and reaction standardization in the CPT were computed. The number of 48-base pairs tandem repeats in the exon III of DRD4 was analyzed in a blind manner. RESULTS: The homozygosity of the 4-repeat allele at DRD4 was significantly associated with fewer commission errors (t=2.364, df=28.685, p=0.025) and standard deviation of reaction time (t=2.351, df=24.648, p=0.027) even after adjusting for age. The results of analyses of CPT measured values among three groups showed that the group with higher frequency of the 4-repeat allele showed a lower mean score of commission errors (F=4.268, df=2, p=0.018). CONCLUSION: These results suggest a protective role of 4-repeat allele of the DRD4 polymorphisms on commission errors in the CPT in children with ADHD.

A Validation Study of the Korean-version of Symmetry, Ordering and Arranging Questionnaire / 신경정신의학

OBJECTIVES: The Symmetry, Ordering and Arranging Questionnaire (SOAQ) has been reported as a valid tool for the assessment of symmetry, ordering and arranging compulsive behaviors of patients with obsessive compulsive disorder. It was introduced by Radomsky and Rachman in 2004. The aim of this study was to assess the reliability, validity and psychometric properties of the Korean-version of the SOAQ (K-SOAQ). METHODS: Two hundreds twenty eight under-graduate college students were enrolled in this study. They were assessed with K-SOAQ, Obsessive-Compulsive Inventory-Revised (OCI-R), Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). Statistical analysis was done using calculation of Cronbach's alpha, Spearman Correlation Coefficient and Principal Components Analysis. RESULTS: There were no significant differences in sex, education, and total scores of BDI and BAI. The Cronbach's alpha coefficient of K-SOAQ was high, Cronbach's alpha=0.96. There was strong evidence for a one-factor solution, accounting for 60.3% of the variance. Convergent validity was examined through correlations between the SOAQ and the OCI-R (r=0.61). Divergent validity was examined through correlations between the SOAQ and two self report measures; BDI (r=0.12) and BAI (r=0.19). CONCLUSION: The K-SOAQ showed good reliability and validity for the assessment of severity of compulsive characteristics regarding symmetry, ordering and arranging. The K-SOAQ is a useful instrument for assessing compulsive symptoms related with symmetry, ordering and arranging in Korea.

Association Study between Obsessive-Compulsive Disorder and Val-158-Met Catechol-O-Methyltransferase Gene Polymorphism in Korea / 신경정신의학

OBJECTIVES: The definite cause of obsessive-compulsive disorder (OCD) is still unknown. Evidences from familial, twin and segregation studies support the role of a genetic factor. There are also growing evidence indicating that OCD has specific neurochemical and neuroanatomical basis. Derived from the effectiveness of treatment with dopamine receptor blocker in certain part of OCD patients (eg. SSRI treatment-resistant OCD), several candidate genes related to dopamine dysregulation have been hypothesized to play an important role in the development of OCD. One of them is the Catechol-O-Methyltransferase (COMT) gene. The aim of this study was to investigate the association between COMT and OCD in Korean population. METHODS: 124 OCD patients and 170 normal controls participated in this study. Genomic DNA was extracted from their blood. The genotypes and allele frequencies of the COMT polymorphism between OCD group and control group were compared. We investigated the association between severity of OCD assessed by Yale-Brown obsessive compulsive symptom scale (YBOCS) and Hamilton depression rating scale (HDRS) scores and COMT polymorphism. RESULTS: In this case-control study, we could not find any association between COMT gene polymorphism and development of OCD. In OCD group, patients with H/H genotype had significantly higher scores for the HDRS than those with H/L or L/L genotype. CONCLUSION: In this study, there was no difference in genotype distributions of COMT between OCD and control groups. However, H/H genotype of COMT gene polymorphism might be related to depressive symptoms in OCD patients.

The Relationship of Alcohol Use and Stress / 신경정신의학

OBJECTIVES: This study was designed to assess the relationship between alcohol use and stress. METHODS: The study subjects were 1,261 people who drink among the 2,565 people who lived in Gangneung. We investigated the sociodemographic characteristics, Short Form-12 (SF-12), Global Assessment of Recent Stress (GARS) and Alcohol Use Disorder Identification Test (AUDIT). RESULTS: In Problem drinking group the GARS was significantly positively associated with the AUDIT (p=0.02). In Social drinking group sex (p<0.001) and age (p=0.02) is significantly associated with the AUDIT. CONCLUSION: This study showed the significantly positively association between stress and alcohol use. We think that the intervention and active management of the stress can prevent the alcohol problem.

Gender-Related Clinical Differences in Obsessive-Compulsive Disorder / 대한정신약물학회지

OBJECTIVE: Some reports have shown the gender-related clinical differences in Obsessive-compulsive disorder (OCD), but no study has yet been done in Korea. The purpose of this study was to investigate the gender-related differences of clinical features in the obsessive-compulsive patients in Korea. METHODS: Two hundred forty nine patients with OCD were included in this study; 180 subjects were male and 69 subjects were female. The two groups were analyzed in terms of demographic data including clinical variable, Y-BOCS (Yale-Brown Obsessive Compulsive Scale) scores, clinical course and treatment response. RESULTS: We found the earlier age at onset of OC symptoms in males and the more frequent washing and somatization type in female. There were no gender difference in comorbidity, clinical course and the treatment response. CONCLUSION: We could observe some of the gender-related clinical differences in Korean OCD patients. The further studies would be required to evaluate the gender difference in the long-term clinical course and therapeutic response of Korean OCD patients.

Superfluous Use of Benzodiazepines in Patients with Major Depression Treated with Mirtazapine / 대한정신약물학회지

OBJECTIVE: The purpose of this study is to evaluate the usefulness of administration of benzodiazepines in patients with major depression being treated with the antidepressant mirtazapine. METHODS: The subjects of this study included 503 patients between 18 and 65 years of age. They were diagnosed with major depression according to the ICD-10 and scored over 18 at baseline on the 17-item HAM-D scale. They were among the 925 patients who have participated in the Remeron (mirtazapine) post-marketing surveillance carried out between September 1999 and December 2000 at 33 institutes in Korea. The patients were initially started on 15 mg/day or 30 mg/day of mirtazapine orally and the dosages could be changed according to clinical judgment during the trial. Benzodiazepines could also be administrated according to clinical judgment. The clinical effects were evaluated before and 1, 2 and 6 weeks after treatment initiation. The therapeutic action of mirtazapine was evaluated using the 17-item HAM-D and CGI. The adverse effects were rated according to patient reports. RESULTS: Their mean age was 45 years old and 61.6% were women. 391 subjects (77.3%) from a total of 503 patients completed the trials. 313 (62.2%) patients were administrated benzodiazepines during the trial. These were alprazolam 37.0%, lorazepam 12.5%, clonazepam 9.1% and diazepam 7.0%. The reasons for prescribing benzodiazepines were: anxiety 43.1%, insomnia 18.3% and somatic symptoms 3.8%. The HAM-D scores of total patients were reduced from 26.1 to 10.9, and CGI scores from 4.5 to 3.0 after 6 weeks with significant changes beginning after 1 week of treatment. No significant differences were found in terms of each interval changes on the HAM-D and CGI scores between the groups with and without benzodiazepines. There were no significant differences of each interval changes of anxiety/agitation factors and sleep disturbance factors between the two groups. The occurrence of side effects was not significantly different between the two groups. CONCLUSION: Administration of benzodiazepines in patients with major depression being treated with mirtazapine may not be useful in reducing depressive symptoms, even for anxiety/agitation and sleep disturbance symptoms.

Superfluous Use of Benzodiazepines in Patients with Major Depression Treated with Mirtazapine / 대한정신약물학회지

OBJECTIVE: The purpose of this study is to evaluate the usefulness of administration of benzodiazepines in patients with major depression being treated with the antidepressant mirtazapine. METHODS: The subjects of this study included 503 patients between 18 and 65 years of age. They were diagnosed with major depression according to the ICD-10 and scored over 18 at baseline on the 17-item HAM-D scale. They were among the 925 patients who have participated in the Remeron (mirtazapine) post-marketing surveillance carried out between September 1999 and December 2000 at 33 institutes in Korea. The patients were initially started on 15 mg/day or 30 mg/day of mirtazapine orally and the dosages could be changed according to clinical judgment during the trial. Benzodiazepines could also be administrated according to clinical judgment. The clinical effects were evaluated before and 1, 2 and 6 weeks after treatment initiation. The therapeutic action of mirtazapine was evaluated using the 17-item HAM-D and CGI. The adverse effects were rated according to patient reports. RESULTS: Their mean age was 45 years old and 61.6% were women. 391 subjects (77.3%) from a total of 503 patients completed the trials. 313 (62.2%) patients were administrated benzodiazepines during the trial. These were alprazolam 37.0%, lorazepam 12.5%, clonazepam 9.1% and diazepam 7.0%. The reasons for prescribing benzodiazepines were: anxiety 43.1%, insomnia 18.3% and somatic symptoms 3.8%. The HAM-D scores of total patients were reduced from 26.1 to 10.9, and CGI scores from 4.5 to 3.0 after 6 weeks with significant changes beginning after 1 week of treatment. No significant differences were found in terms of each interval changes on the HAM-D and CGI scores between the groups with and without benzodiazepines. There were no significant differences of each interval changes of anxiety/agitation factors and sleep disturbance factors between the two groups. The occurrence of side effects was not significantly different between the two groups. CONCLUSION: Administration of benzodiazepines in patients with major depression being treated with mirtazapine may not be useful in reducing depressive symptoms, even for anxiety/agitation and sleep disturbance symptoms.