The burden of cyclothymia on alcohol dependence.

BACKGROUND: The relationship between cyclothymic temperament and alcoholism remains insufficiently explored. METHODS: A sample of 125 alcohol-dependent patients diagnosed according to DSM-IV-TR criteria (APA, 2000) was recruited from a clinical setting. Cyclothymic temperament was diagnosed according to the Portuguese version of the Akiskal and Akiskal (2005) temperament scale. RESULTS: Alcohol dependent patients who score positive (above mean) for CT present to some extent a more severe profile of alcohol-related problems. LIMITATIONS: Correlational study CONCLUSIONS: CT traits in alcohol dependents seems to influence whether subjects engage earlier in pathological alcohol use and present particular alcohol-related problems, in particular Cloninger type II alcoholism phenotype.

Post-stroke apathy: an exploratory longitudinal study.

INTRODUCTION: Post-stroke apathy is a disturbance of motivation evidenced by low initiative, difficulties in starting, sustaining or finishing any goal-directed activity, low self-activation or self-initiated behavior and emotional indifference. Apathy is a common behavioral disturbance in stroke survivors. We aimed to analyze the relationship between post-stroke apathy at 1 year after stroke and (1) apathy in acute phase; (2) demographic, pre-stroke predisposing conditions (previous mild cognitive impairment, alcohol abuse, mood/anxiety disorder) and clinical features (stroke type and location, neurological symptoms); (3) post-stroke depression and post-stroke cognitive impairment, and (4) post-stroke functional outcome, quality of life and the perception of health. METHODS: Consecutive stroke (infarct/intracerebral hemorrhage) patients without aphasia or consciousness disturbances were included in the acute phase of stroke and assessed at 1 year after stroke. We assessed apathy with the clinically rated version of the Apathy Evaluation Scale. We also assessed post-stroke depression (Montgomery Asberg Depression Rating Scale) and post-stroke cognitive impairment (attention, mental flexibility, verbal, motor and graphomotor initiative, and non-verbal and verbal abstract reasoning, and Mini-Mental State Examination), functional outcome (Barthel Index), quality of life and perception of health (EuroQol). Data were analyzed using bivariate associations (χ(2) and t test) and stepwise multivariate analysis. RESULTS: We included 76 stroke patients [32.9% women, mean age 62.9 years (SD = 10.9) and a mean of 6.9 (SD = 4.3) years of education]. Apathy was present in 17 patients in the acute phase and in 18 (23.7%) patients at 1 year after stroke. At 1 year after stroke, 41% of the acute apathetic patients remained apathetic. Sixty-one percent of new cases of post-stroke apathy were detected. Post-stroke apathy was associated only with previous cognitive impairment, apathy in acute stroke, post-stroke cognitive impairment, verbal abstract reasoning and with worse Barthel Index scale scores. In the multivariate logistic regression model, verbal abstract reasoning (odds ratio, OR = 7.03) and apathy in acute stroke (OR = 3.8) were identified as independent factors for post-stroke apathy at 1 year. Apathetic patients did not report worse quality of life or health. CONCLUSION: Apathy in acute stroke phase was a reliable indicator of post-stroke apathy. Apathy should be assessed in both phases. Verbal abstract reasoning impairment was also an independent factor for post-stroke apathy impairing patients' ability to reason about goal-directed activity. Even though apathetic patients had worse post-stroke functional outcome, they did not report losing quality of life or having worse health.

The relationship between temperament, diabetes and depression.

BACKGROUND: Temperament is the stable core of personality and it may represent the underlying continuity between how the person typically is (trait) and how the person temporarily changes (state). Comorbid depression in patients with Type 2 diabetes is important because of the negative consequences on the prognosis of diabetes. Little research has explored the relationships between temperament, depression and type 2 diabetes. The aims of the present paper are first to describe current research that has examined the relationship between temperament, diabetes and depression, and second to make recommendations for future research. METHODS: Literature search from Medline and references in published papers. RESULTS: Current research has described the relationship of temperament with cyclothymia, bipolar disorder, mood instability and suicidality. Studies on the relationship between temperament and depressive disorders are scarce. Nevertheless, there is likely a continuum between depressive temperament and related personality traits and subthreshold and clinical depressive states and disorders and diabetes outcomes. LIMITATIONS: The greatest limitation concerns the scarcity of papers on this issue. There are also methodological limitations in accurately assessing depressive temperament versus current depressive disorders and residual symptoms from these disorders. CONCLUSION: Depressive temperament may be a promising construct to understand better the interplay between depression and diabetes.

Depressive temperament, distress, psychological adjustment and depressive symptoms in type 2 diabetes.

Major depression, depressive symptoms, distress with diabetes and psychological adjustment to type 2 diabetes (T2DM) are somehow overlapping constructs with shared covariance. Nevertheless, diabetes distress remains the most prevalent long-lasting factor associated with hyperglycemia in T2DM. This ought to be taken on account when treatment is planned, namely when one is looking for metabolic control and emotional distress integrative care. Temperament or other long-term individual characteristics may support the interplay of distress, psychological adjustment and depressive states in T2DM. Depressive temperament may constitute a vulnerability factor to behavioral or biological T2DM outcome or even a potential risk factor to T2DM later incidence.

The role of affective temperaments in metabolic control in patients with type 2 diabetes.

BACKGROUND: In non-diabetic populations, anxious and depressive affective temperaments are associated with stress and distress disorders (anxious and depressive). In type 2 diabetes, distress with diabetes and distress disorders have been associated with metabolic control. There are few studies undertaken on temperament and metabolic control in patients with type 2 diabetes. The aim of our study was to examine the independent association between affective temperaments and metabolic control in patients with type 2 diabetes. METHODS: The sample included 90 patients with type 2 diabetes from two outpatient clinics aged 53.54 (SD ± 8.05) years and with 66.7% female gender. Depression was evaluated by using the MADRS observer rating scale (mean value: 16.38 ± 11). RESULTS: Patients with excessive depressive and anxious temperaments had more depressive symptoms, worse psychological adjustment to diabetes and worse metabolic control. In logistic regression (crude model), only depressive temperament was independently associated with metabolic control. CONCLUSIONS: Affective temperaments are associated with psychological adjustment to diabetes and metabolic control in patients with type 2 diabetes. Patients above threshold on depressive temperament should be considered for greater scrutiny and psycho-education by the diabetes clinic staff.

Mania and stroke: a systematic review.

BACKGROUND: Mania is a rare consequence of stroke and according to the sparse published information it is difficult to describe its demographic, clinical and prognostic characteristics. METHODS: We performed a systematic review of all cases of mania and stroke to describe those characteristics. Studies were identified from comprehensive searches of electronic databases, reference lists of the studies collected and handbooks. Two authors independently assessed abstracts, and collected and extracted data. RESULTS: From 265 abstracts, 139 were potentially relevant. For the first analysis, which tries to answer the clinical question of the relationship between mania and stroke, 49 studies met the inclusion criteria and described 74 cases. For the second analysis, we looked for an explicit temporal and causal relationship between manic symptoms and stroke, and selected 32 studies describing 49 cases. In both analyses, the typical patient was male, without a personal or family history of psychiatric disorder, with at least one vascular risk factor, but without subcortical atrophy and had suffered a right cerebral infarct. The majority of patients (92%) presented elevated mood as the first symptom. The other frequent symptoms were an increased rate or amount of speech (71%), insomnia (69%) and agitation (63%). CONCLUSIONS: Post-stroke mania should be considered in any manic patient who presents concomitant neurological focal deficits and is older than expected for the onset of primary mania. The results of a systematic study of mania in acute stroke with subsequent follow-up and data from diffusion MR or perfusion CT in a multicenter study with a central database would be relevant.

Temperament in Portuguese university students as measured by TEMPS-A: implications for professional choice.

BACKGROUND: The structure of temperament displays subaffective traits as attributes of adaptive value. There are few studies on how different professions compare on temperaments. Our aim was to examine the relationship between the choices of Portuguese students in their fields of study, and their respective temperaments. METHODS: The sample included 1386 students from six different universities (law, engineering, arts, medicine, psychology, and nursing), of both genders (67% female), and ages between 17 and 58 (X + or - SD = 21 + or - 3.4). RESULTS: Law and art students presented a cyclothymic or irritable temperament. Engineering students presented a hyperthymic temperament. Psychology and nursing students presented predominantly depressive and anxious temperaments. Medicine students were least extreme in temperament scores or frequencies. LIMITATIONS: Nursing students came largely from one university located in a Portuguese city (northeast from Lisbon) which could be a potential limitation to be confirmed. CONCLUSIONS: Distinct temperamental profiles of students enrolled in different professional fields could be identified in our sample taking into account the presence or absence of excessive temperaments. Future physicians did not present a predominant temperament, future lawyers and artists presented predominantly a cyclothymic or irritable temperament, future engineers presented a hyperthymic temperament and, future psychologists and nurses presented predominantly depressive and anxious temperaments.

From psychosomatic to psychological medicine: what's the future?

PURPOSE OF REVIEW: Recent research findings into putative psychobiological mechanisms of emotional disorders as the future development of psychosomatic medicine are discussed. RECENT FINDINGS: Recent studies reinforce the communication between the immune and central nervous systems and identify the large set of peptide and nonpeptide neurotransmitters and ligands they share. Cytokines are seen as humoral mediators that may explain the interaction between endocrine and immune systems. The hypothalamic-pituitary axis has been investigated as part of the regulatory circuits that interact with autonomic regulation to expose immunologic processes related to stress or depression, and also to several diseases. Immune dysregulation and psychological distress have been linked to each other in disease, chronic stress, bereavement and other major life events. Research findings in depressive disorders and cancer may generate new theoretical paradigms in psychosomatic medicine. SUMMARY: The clinical understanding and management of distress or emotional disorders associated with physical illness may change in future because of the results of interdisciplinary research, where environmental factors will be integrated with psychological and biological systems, mainly of endocrine or neuroimmunological nature. The ultimate goal of psychosomatic medicine may be the integration of different levels of individual functioning on a systemic basis.

Validation of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A): Portuguese-Lisbon version.

BACKGROUND: The TEMPS-A has been validated in 8 languages, the original being American English, and includes among others such Latin languages as Italian, French, and Spanish-Buenos Aires. This is the first Portuguese-Lisbon validation. METHODS: The sample included 1173 students from six different universities and representing most disciplines (such as medicine, law, humanities, engineering, etc.), both sexes (67% female), and ages between 17 and 58 (x+/-SD=21+/-4). Standard psychometric tests were used for internal consistency, validity, and factor analysis. RESULTS: The study upheld the 5 Factor proposed structure of TEMPS-A. Cronbach alpha varied from 0.67 for the depressive and 0.83 for the anxious, with the others in-between. We could retain all 110 items of the Interview Schedule. The highest mean scores were found for the hyperthymic, and the lowest for the irritable. As expected, depressive and anxious subscales had strong correlations, followed by the cyclothymic and anxious, and cyclothymic and irritable; in exploratory factor analysis, these subscales constituted Factor I, contrasted to the depressive and the hyperthymic as a biphasic continuum (Factor II). Females scored higher on the depressive, cyclothymic and anxious, and the males on hyperthymic and irritable. Overall, however, no temperament was "dominant" in this population, all temperaments z-scores being 3.3-4%! LIMITATIONS: Study limited to university students of young age. CONCLUSIONS: TEMPS-A Lisbon is a reliable and valid instrument. The only relatively weak factor is the depressive, which is similar to other language versions. Gender differences and correlations of temperaments are generally similar to other countries. What appears relatively special to the Portuguese is the relatively "balanced" mix of temperaments in this university student population.

NETER 1 alcoholic 5 subtypes: Validity with Lesch four evolutionary subtypes.

Objective. To validate NAT (NETER's alcoholic typology), taking into account the differentiated distribution of the measures used as external criteria in alcohol-dependent sub-groups and its relationship with Lesch's alcoholic typology (LAT). Method. A sample of 133 alcohol-dependent patients integrated in the alcoholism unit of the Psychiatric Service of Santa Maria University Hospital were included in the study. Results and Conclusions. Convergent validity was assured by the agreement between the subtypes of the two typologies (NAT and Lesch), considering the same underlying model of alcoholism development: anxiopathic subtype of NAT and Type II (model of anxiety, alcohol as conflict solution) of Lesch and the tymopathic subtype of NAT and type III (model of depression, alcohol as antidepressant) of Lesch. Discriminant analysis (external criteria) showed significant differences between the subtypes in the following variables: gender; tobacco; beer and whisky consumption; daily average of drinks; clinical conditions such as delirium tremens, alcoholic blackouts and seizures; severity of alcohol-related problems; psychological dimensions such as psychological maturity and extroversion; and suicidal ideation during the alcohol consumption period. A more exhaustive description of alcoholic sub-groups may improve genetic studies of alcoholism and provide the alcoholic patient with an adequate specific therapeutic protocol.

[Differences between SSRI's pharmacokinetics and pharmacodinamics]. / Diferenças farmacodinâmicas e farmacocinéticas entre os SSRI: implicações na prática clínica.

Selective serotonin reuptake inhibitors (SSRI) are nowadays the preferred treatment for patients with depression and anxiety disorders, when compared with traditional tricyclic antidepressants. All the SSRIs were designed to selectively potentiate serotonin [5-hydroxytryptamine (5-HT)] activity through inhibition of the 5 -HT neuronal reuptake transporter. However, despite a common mode of proven antidepressant efficacy and a similar range of indications, each SSRI has individual properties, not only pharmacodinamics, but also pharmacokinetics, which contributes for different pattern of clinical indications, side effects and interactions. The authors pretended to review the differences between each SSRI, in terms of metabolism and clinical goals. They analyzed several studies published in the last years, obtained through MedLine research. The authors describe how the unique secondary binding properties of each SSRI account for clinical significant differences in tolerability and side-effects profiles, particularly in some patients. Secondary properties within the class of SSRIs include some combinations of actions at noradrenergic, dopaminergic, muscarinic, cholinergic, histaminergic and sigma receptors. In addition, most SSRI inhibit al least one of the cytochrome P450 enzymes, resulting in potential pharmacokinetics interactions with co-prescribed drugs.

Depression in acute stroke.

OBJECTIVE: Depression is one of the most frequent neuropsychiatric disturbances in stroke patients. The clinical aspects and correlations of depression in the first days after acute stroke are less known. This study aimed to 1) assess the frequency of depression, 2) describe the profile of depression of stroke patients and 3) analyze the relation between depression and demographic, predisposing and precipitating conditions, and clinical and imaging data, in acute stroke patients. METHODS: We used the Montgomery-Asberg Depression Rating Scale to assess depression in 178 consecutive acute ( 0.45) of depression between control subjects and acute stroke patients. CONCLUSIONS: Depression was present in almost one-half of the acute stroke patients and was related to previous mood disorder but not not to stroke type or location. Apathy/loss of interest was the predominant clinical feature.

Denial in the first days of acute stroke.

Denial is a disorder of self-awareness that is frequent after acute stroke, with potential negative influence in the care of patients. The aim of this study was to describe the presence and correlates of denial in acute stroke. We assessed denial in a sample of 180 consecutive acute stroke patients (< or =4 days) and in a control group of 50 acute coronary patients using the Denial of Illness Scale (DIS).41% (74) acute stroke patients (mean DIS score=4.1, SD=2.2, range 0 to 10) and 24% (12) acute coronary patients (mean DIS score=3.2, SD=1.5, range 0 to 10) presented denial (chi(2)=4.19, p=.04; U=3405.50, p=.01). Denial was more frequent and severe in patients with lower educational level (chi(2) = 5.04, p=.04; U=2110.50; p=.01), neglect (chi(2) = 21.38, p=.00; U=1130.50; p=.00), cognitive impairment (chi(2) = 6.27, p=.02; U=1181.50; p=.01) and after hemispherical lesions (chi(2) =4.68, p=.05; U=1982.50; p=.04). In logistic regression low educational level, neglect and cognitive impairment were independent factors predicting denial in stroke patients (R(2)= 21%). Patients with denial can express depressive symptoms. Patients with denial had a worse outcome at discharge (chi(2) =4.91, p=.04; U=2918.00; p=.03). Denial is a frequent phenomenon after acute stroke. We propose that there is a multifactorial model for the emergence of denial, lower educational as a predisposing condition, and acute stroke due to hemisphere lesion and causing neglect and cognitive impairment as precipitating events. All these factors limit patients' assessment of their condition and body functions.

Delirium in acute subarachnoid haemorrhage.

BACKGROUND: Delirium may be a presenting feature in acute subarachnoid haemorrhage (SAH). The aim of this study was to investigate the risk factors for delirium in acute SAH and to analyse the relation between delirium and location and amount of haematic densities and hydrocephalus. METHODS: We assessed delirium in a sample of 68 consecutive patients with acute (< or =4 days) SAH (33 aneurysmal, 33 non-aneurysmal, including 9 with perimesencephalic haemorrhage), before aneurysmal treatment, using DSM-IV-R criteria and the Delirium Rating Scale (DRS). DRS scores were related to: (1) the total amount of haematic densities at 10 basal cisterns/fissures and in the 4 ventricles, using a validated rating scale, (2) the haematic densities in the prepontine cistern and the convexity of the brain and (3) hydrocephalus, using the bicaudate index, obtained from a review of admission CT scans. RESULTS: Eleven acute SAH patients presented with delirium. Older age (U = 316.5, p = 0.04), alertness disturbance (chi(2) = 5.1, p = 0.02, OR = 7.6, 95% CI = 1.5-37.3), aphasia (U = 61.5, p = 0.007) and a Hunt and Hess score >2 (U = 362.5, p = 0.02) were associated with delirium. Higher amounts of intraventricular haematic densities (chi(2) = 4.43, p = 0.04, U = 158, p = 0.001) and hydrocephalus (U = 215, p = 0.009) were also associated with higher DRS scores. Two delirious patients had basofrontal haematomas. CONCLUSIONS: Delirium was detected in 16% of acute SAH patients. Intraventricular bleeding, hydrocephalus and basofrontal haematomas contribute to the pathogenesis of delirium, through damage to anatomical networks subserving sustained attention, declarative memory and the expression of emotional behaviour.

Delirium in the first days of acute stroke.

BACKGROUND AND PURPOSE: Delirium is an acute, transient disorder of cognition and consciousness with fluctuating intensity. The aim of this study was to investigate the presence and the risk factors for delirium in the first days after stroke onset. PATIENTS AND METHODS: We assessed delirium prospectively in a sample of 218 consecutive patients (mean age 57 years) with an acute (/= 10). RESULTS: 29 (13%) acute stroke patients (mean DRS score = 13.2, SD = 2.3) and only one (2 %) acute coronary patient had delirium (chi(2) = 5.2, p = 0.02). In nine patients delirium was secondary to stroke without any additional cause, in 10 patients there were also medical complications and in the remaining 10 there were multiple potential causes for delirium. Delirium was more frequent after hemispherical than after brainstem/cerebellum strokes (p = 0.02). No other statistically significant associations with stroke locations were found. Medical complications (OR = 4.3; 95% CI = 1.8 to 10.2), neglect (OR = 3.5; 95% CI = 1.3 to 9.2), intracerebral haemorrhage (OR = 3.1; 95% CI = 1.3 to 7.5) and age >/= 65 (OR = 2.4; 95% CI = 1.0 to 5.8) were independent factors to the development of delirium in stroke patients. CONCLUSION: Delirium was more frequent in stroke than in coronary acute patients. Among stroke patients, delirium was most frequent in older patients, in those with neglect, with medical complications and with intracerebral haemorrhages. These findings indicated that delirium in acute stroke patients 1) is not a non-specific consequence of acute disease and hospitalisation and 2) is secondary to hemisphere brain damage and to metabolic disturbances due to medical complications.