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Background: Attention 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.Methods: The 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.Results: Besides 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?Conclusions: ADHD 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. © 2010 Kooij et al; licensee BioMed Central Ltd., SCOPUS: ar.j, info:eu-repo/semantics/published

In a chart review at a psychiatric out-patient department, latitude 59.3 degrees N, a sample of patients with tests of serum 25-hydroxy-vitamin D (25-OHD) and plasma intact parathyroid hormone (iPTH) was collected, together with demographic data and psychiatric diagnoses. During 19 months, 117 patients were included. Their median 25-OHD was 45 nmol/l; considerably lower than published reports on Swedish healthy populations. Only 14.5% had recommended levels (over 75). In 56.4%, 25-OHD was under 50 nmol/l, which is related to several unfavourable health outcomes. Seasonal variation of 25-OHD was blunted. Patients with ADHD had unexpectedly low iPTH levels. Middle East, South-East Asian or African ethnic origin, being a young male and having a diagnosis of autism spectrum disorder or schizophrenia predicted low 25-OHD levels. Hence, the diagnoses that have been hypothetically linked to developmental (prenatal) vitamin D deficiency, schizophrenia and autism, had the lowest 25-OHD levels in this adult sample, supporting the notion that vitamin D deficiency may not only be a predisposing developmental factor but also relate to the adult patients' psychiatric state. This is further supported by the considerable psychiatric improvement that coincided with vitamin D treatment in some of the patients whose deficiency was treated.

Objective: The occurrence of comorbid attention-deficit hyperactivity disorder (ADHD) might have an impact of the course of the bipolar disorder. Method: Patients with bipolar disorder (n = 159) underwent a comprehensive evaluation with respect to affective symptoms. Independent psychiatrists assessed childhood and current ADHD, and an interview with a parent was undertaken. Results: The prevalence of adult ADHD was 16%. An additional 12% met the criteria for childhood ADHD without meeting criteria for adult ADHD. Both these groups had significantly earlier onset of their first affective episode, more frequent affective episodes (except manic episodes), and more interpersonal violence than the bipolar patients without a history of ADHD. Conclusion: The fact that bipolar patients with a history of childhood ADHD have a different clinical outcome than the pure bipolar group, regardless of whether the ADHD symptoms remained in adulthood or not, suggests that it represent a distinct early-onset phenotype of bipolar disorder.

Background: Given that adults with ADHD continue to use stimulants for extended periods of time, studies on the long-term effectiveness and adverse events are warranted. The aims of this study were to investigate factors associated with persistence in treatment in an exploratory manner and to document side effects and reasons for discontinuation. Method: The current study describes the systematic follow-up of 133 psychiatric patients with DSM-IV-diagnosed ADHD treated with central stimulants at a specialized outpatient unit between January 1, 2001, and August 31, 2006. A standardized questionnaire, derived from the Targeted Attention-deficit Disorder Symptoms Rating Scale, was used in order to measure improvement of the following target symptoms: hyperactivity, impulsivity, irritability, distractibility, structure/organization problems, inattention, and restlessness. Results: Eighty percent of the patients were successfully treated with stimulants at the 6- to 9-month follow-up. Fifty percent remained in treatment after 2 years or more. Forty-five percent were treated for comorbid anxiety and/or depression during the study period. Only 15% dropped out because of lack of efficacy. The amount of clinical response over the first 6 to 9 months (but not at 6 weeks) predicted adherence to treatment at 2 years. The patients' heart rate increased from a least squares mean ± SE of 70 ± 2.2 to 80 ± 2.1 bpm (P=.00003) while blood pressure remained unchanged at the ≥ 2-year follow-up. Severe side effects or drug abuse were not detected in this cohort. Conclusions: The long-term treatment outcome shows that stimulants are effective in adult ADHD and side effects tend to be mild.

Background Comorbidity between Attention Deficit Hyperactivity Disorder (ADHD) and mood disorders is common. Alterations of the cerebellum and frontal regions have been reported in neuro-imaging studies of ADHD and major depression. Methods Thirty chronically depressed adult females of whom 16 had scores below, and 14 scores above, cut-offs on the 25-items Wender Utah Retrospective Scale (WURS-25) and the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) were divided into subgroups designated "Depression" and "Depression + ADHD", respectively. Twenty-one of the patients had some audiological symptom, tinnitus and/or hearing impairment. The patients were investigated with other rating scales and 99mTc-HMPAO SPECT. Controls for 99mTc-HMPAO SPECT were 16 healthy females. SPECT was analyzed by both statistical parametric mapping (SPM2) and the computerized brain atlas (CBA). Discriminant analysis was performed on the volumes of interest generated by the CBA, and on the scores from rating scales with the highest group differences. Results The mean score of a depression rating scale (MADRS-S) was significantly lower in the "Depression" subgroup compared to in the "Depression + ADHD" subgroup. There was significantly decreased tracer uptake within the bilateral cerebellum at both SPM and CBA in the "Depression + ADHD" subgroup compared to in the controls. No decrease of cerebellar tracer uptake was observed in "Depression". Significantly increased tracer uptake was found at SPM within some bilateral frontal regions (Brodmann areas 8, 9, 10, 32) in the "Depression + ADHD" subgroup compared to in "Depression". An accuracy of 100% was obtained for the discrimination between the patient groups when thalamic uptake was used in the analysis along with scores from Socialization and Impulsivity scales. Conclusion The findings confirm the previous observation of a cerebellar involvement in ADHD. Higher bilateral frontal 99mTc-HMPAO uptake in "Depression + ADHD" compared to in "Depression" indicate a difference between these subgroups. 99mTc-HMPAO uptake mechanisms are discussed.

In the original description of Asperger's disorder (AD), clumsiness was an associated feature. Several studies of children have shown deficits in motor control, whereas research regarding adults is scarce. The aim of the present study was to compare motor function in adults with AD, with a normal comparison group. Gross and fine motor skills were examined by a standardized, norm referenced test developed for children, but also used in young adults, the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP). In addition, a questionnaire regarding the participants' physical activity during leisure time was administered. We found that adults (age 21-35) with AD (N = 15) performed significantly worse than the normal comparison group (N = 29) in six of eight subtests in the BOTMP. Males with AD were less physically active than males in the comparison group. Among females, physical activity did not differ between the groups. There was a positive association between physical activity and gross motor function in the AD group. Participants with AD were encouraged by the assessments. Physical coaching may be an important future field for improving quality of life in adults with AD.

Background: Social phobia and obsessive-compulsive disorder (OCD) share several similarities: both are categorized as anxiety disorders, avoidant personality disorder and depression are common in both, they have a similar age of onset and course, and both disorders respond to treatments with serotonin reuptake inhibitors and cognitive behavioural therapy. However, OCD and social phobia differ in respect to their relation to autism spectrum disorders (ASD; i.e. Asperger’s syndrome, autism, pervasive disorder not otherwise specified). Findings that suggest a link between OCD and ASD have no parallel in social phobia. Moreover, obsessive-compulsive, paranoid and schizotypal personality disorders are prevalent in OCD and in ASD, but not in social phobia. Individuals with ASD are known to be frequent targets of bullying. We hypothesised that individuals with autistic traits would have been frequent targets for bullies during their childhood, as opposed to people without such traits. Methods: Adult patients with social phobia (n = 63) or OCD (n = 65) were assessed regarding autistic traits, and interviewed about being bullied at school. A reference group (n = 551) responded to questions about being bullied. Results: There was a significant difference in the prevalence of being bullied between OCD (50%), social phobia patients (20%) and the reference group (27%). Autistic traits were more common in OCD than in social phobia. A history of being bullied was related to autistic traits among patients. Conclusions: Falling victim to bullying is not a random event. Autistic traits, i.e. low social skills, may be a predictor of being bullied in school. The high rate of bullying victims in persons who later develop OCD is suggested to be related to the overlap between OCD and ASD.

This article focuses on the possibility that autism spectrum disorder (ASD: Asperger syndrome, autism and atypical autism) in its milder forms may be clinically important among a substantial proportion of patients with obsessive-compulsive disorder (OCD), and discusses OCD subtypes based on this proposition. The hypothesis derives from extensive clinical experience of OCD and ASD, and literature searches on MEDLINE. Neuropsychological deficits are more common in OCD than in panic disorder and depression. Moreover, obsessive-compulsive and schizotypal personality disorders are over-represented in OCD. These may constitute misperceived clinical manifestations of ASD. Furthermore, repetitive behaviours and hoarding are common in Asperger syndrome. It is suggested that the comorbidity results in a more severe and treatment resistant form of OCD. OCD with comorbid ASD should be recognized as a valid OCD subtype, analogous to OCD with comorbid tics. An odd personality, with paranoid, schizotypal, avoidant or obsessive-compulsive traits, may indicate these autistic dimensions in OCD patients.

The aim of this study was to examine Temperament and Character Inventory (TCI) profiles in patients with social phobia (DSM-IV) and to outline patterns of change following intensive group cognitive therapy (IGCT), individual cognitive therapy (ICT) and treatment as usual (TAU). One hundred patients recruited by advertisements in local papers were randomized to IGCT, ICT and TAU. Patients (n=59) who completed diagnostic evaluation and TCI assessments at baseline and 1-year follow-up were examined in this study. Patients differed from healthy controls in novelty seeking (NS), harm avoidance (HA), self-directedness (SD), cooperativeness (C), and self-transcendence (ST). Treatments overall were associated with decrease in HA, while increase in SD was observed after psychotherapy only. Reduced social anxiety was correlated with decrease in HA and increase in SD. High HA at baseline was related to poor treatment outcome in all treatments. To conclude, patients with social phobia show a temperamental vulnerability for developing anxiety and character traits associated with personality disorders. Successful treatment is related to decrease in HA and increase in SD. High HA at baseline may suggest a need for extensive treatment in order to achieve remission.

There is growing evidence that obsessive–compulsive disorder and/or tics is associated with immune response following streptococcal infections (PANDAS, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). This case report describes a woman with debut of headaches and anorexia at age 15. Two years later after throat infections, she developed acute severe motor and vocal tics and difficulties in walking but MR and EEG were normal. Symptoms persisted five months until 2 weeks penicillin V treatment was initiated due to elevated streptococcus titers in serum. Treatment resulted in several months of improvement, however after termination symptoms gradually reoccurred. In addition a range of psychiatric symptoms including auditory and visual hallucinations were diagnosed. At the age of 22 she occasionally used crutches and had a magnitude of motor symptoms, relapsing-remitting attacks of pain, confusion and regressive behaviors and thus was diagnosed with conversion disorder by a psychiatrist. However, laboratory check-up showed increased concentration of calcium-calmodulin dependent protein (CaM) kinase II activity in serum and CSF, supportive of a PANDAS diagnose. Flow cytometry of CSF showed increase of phosphatidylserine containing microparticles and HMGB-1, and scanning electron microscopy displayed spherical particles with a diameter of about 1 μm. Neuropsychological assessment revealed impaired visuospatial functioning and signs of cognitive deterioration. Current treatment with Amoxicillin with clavulanic acid has not resulted in improvement and intravenous immune globulin treatment (IVIG) is planned.

Psychiatric patients are significantly more often smokers than the general population, the only known exception being obsessive-compulsive disorder (OCD) and catatonic schizophrenia. We have investigated nicotine use in subjects with autism spectrum disorders (ASD). Ninety-five subjects (25 females and 70 males) consecutively diagnosed with any ASD and of normal intelligence were included in the study. Only 12.6% were smokers, compared with 19% in the general population and 47% in a control group of 161 outpatients diagnosed with schizophrenia or a schizophreniform disorder. The results suggest that smoking is rare among subjects with ASD, while the opposite was shown for schizophrenia. If replicated, this finding could suggest biological differences between non-catatonic schizophrenia and ASD, and support the theory of a biological link between ASD and a subtype of OCD, and between ASD and catatonic schizophrenia.

As opposed to other psychiatric populations, subjects with obsessive-compulsive disorder (OCD) smoke less than the general population. The present study aims at further investigating the relationship between smoking in OCD subjects and personality traits.Sixty-four subjects with OCD were interviewed concerning their smoking habits. Personality traits were evaluated using the Karolinska Scales of Personality, and specific obsessive-compulsive personality traits were elicited through self-report questionnaires.Non-smokers were more easily fatigued, more inclined to worry, more remorseful, less self-confident, less impulsive and became uneasy more frequently when urged to speed up, than smokers with OCD.Additionally, non-smokers fulfilled significantly more obsessive-compulsive personality disorder criteria as compared to the smokers (P< 0.001).We propose a clinical subtype of OCD related to non-smoking, psychasthenia, anxiety, and pronounced obsessive-compulsive personality disorder traits.

To the Editor .— We were pleased to see that bullying again was discussed in the July issue of Pediatrics .1 The authors showed that bully victimization is associated with the prevalence of headache, stomachache, sleeping problems, nervousness, and more frequent use of medication. Previous longitudinal studies have confirmed that bullying leads to increased risk of physical symptoms, whereas the direction of causality for psychological factors remains uncertain. Unfortunately, the results from this study shed no additional light on this complex issue. Although the directionality of bullying and emotional problems is complicated, it is, according to our view, essential to prevent bullying. As adult psychiatrists we know that exposure to severe bullying in childhood will continue to influence the person's self-image and trust in others in adulthood. Also, those who have only been afflicted by milder forms of bullying will probably remember this humiliation all through their lives. A relationship between bully victimization and having poor social skills has been shown,2,3 but to determine if poor social …

We report a severe case of obsessive-compulsive disorder (OCD) that responded to very high doses of citalopram (160 mg/day) after a poor response to clomipramine 250 mg/day for several years, alone or in combination with buspirone 30 mg/day or flupenthixol 4 mg/day. The patient had previously been submitted for capsulotomy which was declined, probably due to the magical content of her obsessions, which resembled delusions.

The 'extreme male brain theory of autism' describes an extreme male pattern of cognitive traits defined as strong systemising abilities paired with empathising weaknesses in autism spectrum disorder. However, beyond these cognitive traits, clinical observations have suggested an ambiguous gender-typed pattern regarding several sexually dimorphic traits. The aim of the present study was to investigate if patterns of non-cognitive sexually dimorphic traits differed between the autism spectrum disorder and control groups. Fifty adults with autism spectrum disorder and intelligence within the normal range, and 53 neurotypical controls responded to questions on gender role, self-perceived gender typicality and gender identity, as well as sexuality. Measures used were a Swedish modification of the Bem Sex Role Inventory and questions on sexuality and gender designed for the purpose of this study. Our results showed that one common gender role emerged in the autism spectrum disorder group. Masculinity (e.g. assertiveness, leadership and competitiveness) was weaker in the autism spectrum disorder group than in the controls, across men and women. Self-perceived gender typicality did not differ between the groups but tomboyism and bisexuality were overrepresented amongst women with autism spectrum disorder. Lower libido was reported amongst both male and female participants with autism spectrum disorder compared with controls. We conclude that the extreme male patterns of cognitive functions in the autistic brain do not seem to extend to gender role and sexuality. A gender-atypical pattern for these types of characteristics is suggested in autism spectrum disorder.

Endocrine disruptors, the increase of autism spectrum disorder and its comorbidity with gender identity disorder : a hypothetical association

Approximately six percent of all children are regarded as having poor motor skills, though the aetiology may vary. Furthermore, the severity of motor skill problems predicts the increased likelihood of coexisting problems. This suggests that motor problems per se could be regarded as a specific vulnerability sign. In an era of managed health care, pay for performance, and focus on discrete diagnostic entities, motor skill problems have been greatly overlooked in treatment programs and psychiatric research. Recently however, Gillberg argued against such compartmentalized thinking and proposed that any preschool child with major problems (regarding general development, communication, language, social interrelatedness, attention, activity, behaviour, mood, sleep, or motor coordination) should be assessed for additional problems because these are likely to exist and are intercorrelated. With this in mind, Gillberg introduced the concept Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations (ESSENCE). Children with poor motor skills have a three-fold risk of being bullied, and bully victimization often coincides with poor social skills. This suggests that coordination, crucial for motor skills, may also be crucial for the development of social skills and that the cerebellum is of central interest. The notion that the cerebellum is purely a motor control device is not supported in the stroke literature. Cerebellar lesions can result in a cognitive affective syndrome including executive, visuospatial, and linguistic impairments, and affective dysregulation. The cerebellum is involved in temporal information processing, motor sequencing and planning, working memory, shifting of attention, implicit learning, emotional regulation and responses, and executive functions, areas that are highly affected in people with neurodevelopmental disorders. Also, abnormalities in the cerebellum are a consistent finding in imaging studies of individuals with autism spectrum disorders. In an interesting study, Livingstone and McPhillips show that children with partial hearing experience significant motor deficits. Moreover, the results suggest that children with cochlear inplants may be at particular risk where more complex motor control is required, as compared to children with hearing aids. The conventional vestibular deficit theory that states that motor problems in a child with partial hearing originate in a damaged or poorly functioning vestibular system is questioned by the authors. Instead they put forward that other sensory systems could be involved, and constraints in motor development could originate in a dynamic interaction between the level of hearing impairment, the task, and development. Not only children with partial hearing or with pervasive developmental disorders are at risk of impaired motor control; this is also the case in children with obesity, dyslexia, and emotional or behaviour problems. Conversely, children with motor coordination problems have high rates of internalizing disorders and attention-defiict–hyperactivity disorder. Insight into these relationships suggests, hypothetically, that motor skill training could increase performance not only in motor skills but influence other areas as well. This is supported by a study of persistence of primitive reflexes, particularly the asymmetrical tonic neck reflex (ATNR), which is highly persistent in children with specific reading problems. Repetition of primary-reflex movement training 10 minutes daily, for 12 months, not only attenuated the ATNR but improved reading. Moreover, in children in mainstream schools persistence of ATNR predicted reading and mathematical abilities, in addition movement training improved the academic results. Considering that the border between normality and pathology is blurred, overlapping conditions in psychiatry are often the rule and may reflect atypical brain development; internalizing and motor coordination problems are associated, and ‘clumsy’ children are less likely to participate in activities which require good motor skills. Thus, the impact of motor control and motor training are worthy of rigorous longitudinal studies in various groups in future research.

Background:Functional studies in Autism Spectrum Disorder (ASD) have shown localised focal hypoperfusion and abnormalities in the anatomo-functional connectivity of limbic-striatal “social” brain. However, no common regional abnormalities have been found across studies.The aim of this study was to investigate the cerebral blood flow (CBF) at rest in subjects with ASD as compared to a group of healthy controls.Methods:In this preliminary investigation six normal intelligence patients with ASD and 5 age and sex matched healthy controls (HC) were examined using PET/CT camera and, as CBF tracer, 11C-butanol, a radiopharmaceutical produced on-site. The combination of these two methodologies reduced the whole examination time to less than 10 minutes. Statistical Parametric Mapping was implemented to analyse the data.Results:As compared to HC, ASD showed a highly significant CBF increase (height threshold p=0.001, p< 0.0001 at voxel-level), bilaterally, in large portions of the cerebellum, of the visual associative cortex and of the posterior parietal lobe.Conclusions:This preliminary study was performed by the state-of-the-art neuroimaging methodologies that reduced considerably the examination time and resulted in less stress and more reliable investigations. The occipital and parietal associative cortex as well as the cerebellum showed an increased CBF in ASD, underscoring their involvement in the disease and raising methodological and diagnostic issues to be considered when exploring the neuroanatomy of ASD.

Background:Several studies have reported limbic structures volume decrease in Post-Traumatic Stress Disorder (PTSD). However, in PTSD the effect of therapy on brain structures has seldom been investigated. The aim of the study was to evaluate the grey matter (GM) loss in occupational related PTSD and to assess the volumetric differences between patients responding (R) and non-responding (NR) to psychotherapy.Methods:Pre-EMDR MRI data of 21 train drives who did develop PTSD (S) and 22 who did not develop PTSD (NS) after person-under-the-train accidents were compared. Within S further comparisons were made between 10 R to Eye Movement Desensitisation Reprocessing (EMDR) therapy and 5 NR. Data were analysed by optimised voxel-based morphometry as implemented in Statistical Parametric Mapping.Results:As compared to NS, S showed a significant GM volume reduction in precuneus, lingual gyrus, posterior cingulate and parahippocampal cortex. The R>NR comparison highlighted a significant GM reduction in NR in bilateral posterior cingulate, left middle frontal cortex and right parahippocampal, insular and temporal cortices.Conclusions:Comparing two large groups of subjects significant GM volumetric reductions were found in PTSD in posterior limbic structures. NR showed, as compared to R, volume reduction in cortical structures including posterior cingulate and parahippocampal cortex. These latter two structures seem to be the hallmark for both PTSD diagnosis and therapy outcome prediction.

Background: Obsessive-compulsive disorder (OCD) is a common disabling mental disorder.Personality disorders are frequent in OCD. Asperger syndrome and high-functioning autism share similarities wit ...

The aims of the present study were to examine the frequency of personality disorders in 36 patients with obsessive-compulsive disorder (OCD), and to investigate whether patients with a coexisting personality disorder could be characterized by certain personality traits assessed by means of the Karolinska Scales of Personality (KSP). In total, 27 (75%) of the OCD patients fulfilled the DSM-III-R criteria for a personality disorder, and 13 patients (36%) had an obsessive-compulsive personality disorder. Subjects with a comorbid personality disorder had significantly higher scores on most of the KSP scales, including all anxiety scales, as well as scales measuring indirect aggression, irritability, guilt and detachment, whereas subjects without personality disorders did not differ significantly from healthy controls with regard to personality traits.

Tobacco smoking is common among psychiatric patients, especially among those with schizophrenia, where the prevalence is extremely high, 74% to 88%, compared with 45% to 70% in patients with other psychiatric diagnoses. Patients with anxiety disorders are less well investigated in this respect, particularly obsessive-compulsive disorder (OCD) patients. Eighty-three psychiatric outpatients with OCD and 110 members of the Swedish OCD Association responded to questions concerning their smoking habits. Among OCD patients, 14% were current smokers (compared with 25% in the general population of Sweden), 72% had never smoked, and 11 previous smokers had stopped, mostly without any difficulties. Since a decreased smoking rate among OCD subjects was confirmed, the smoking prevalences in schizophrenia and OCD, respectively, seem to represent either end of a continuum, and OCD may also differ significantly from other anxiety disorders in this respect. Possible implications of this finding for the purported frontal lobe dysregulation in OCD are discussed.

The occurrence of personality disorders was investigated in 36 patients with obsessive-compulsive disorder by means of the SCID Screen questionnaire. In addition, the personality dimensions were explored by means of the Temperament and Character Inventory (TCI). In total, 75% of the patients fulfilled the criteria for a personality disorder according to the SCID Screen questionnaire, mostly (55%) within cluster C. Several significant correlations were found between the separate personality disorders (PD) and subscales of the TCI, the most pronounced being between avoidant and obsessive-compulsive PD and novelty-seeking and self-directedness. Strong correlations were also found between self-directedness and paranoid and borderline PD. In multiple regressions where the presence of PD in clusters A, B and C, respectively, were used as dependent variables and where the separate subscales of the TCI were used as independent variables, the multiple R reached 0.68, 0.76 and 0.80 in clusters A, B and C, respectively. Thus 46-64% of the variance in the personality disorder clusters could be explained by the TCI subscales.