- Email: [email protected]
E.04.01 Diagnosis and assessmentof adult ADHD
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Educational sessions
E.02 The role of psychiatry in disaster management E.02.01 Psychopharmaca in the management of the consequences of disasters J.J. L´opez-Ibor Jr. ° . Clinica L´opez-Ibor, Madrid, Spain The exposure to a disaster may elicit complex reactions at the biological, psychological and social levels. The reactions develop in stages and it has been claimed that what happens in early stages determines late consequences. Some reactions have to be considered normal, other are the expression of self-destructive mechanisms which should be identified and treated. Post-traumatic stress disorder (PTSD) is only one among several long term consequences of disasters. The mechanisms (biological, psychological and social) are only partially known, and therefore interventions proposed lack of sufficient scientific evidence. There are different approaches for the pharmacological treatment of psychopathological reactions to disasters: (a) the treatment patients suffering from PTSD, both short-term acute and longterm relapse prevention strategies to diminish the symptoms of the disorder. (b) Studies to identify if the nature of trauma (civilian, war related) or the populations affected (males, females, civilians, military personnel) plays a role in the response to psychotropic drugs; (c) treatments applied in early stages can prevent the emergence of late severe and chronic sequences. Data about efficacy of MAOIs and SSRIs in the treatment of PTSD are heterogeneous may be due to the different populations studied and the variety of exposure to trauma experienced. Nevertheless, research data supports antidepressant medication as the first-line pharmacotherapy for PTSD, with SSRIs (specially fluoxetine and sertraline) having the strongest body of empirical support. Other medications, such as MAOIs, nefazodone and combinations with second generation antipsychotics (risperidone) may also have a role in the management of these patients. Other drug groups offer interesting opportunities such as serotoninergic drugs, CRF or NPY antagonists, NMDA antagonists, anticonvulsants or other GABAergic agents. In any case pharmacotherapy has to be used in combination with other approaches to deal with the psychological and social consequences of disasters. This is not an easy task and clinicians should be trained in this very singular aspect of mental health. E.02.02 Cognitive behavioural interventions for acute and chronic PTSD E. Foa ° . University of Pennsylvania, Department of Psychiatry, Philadelphia, USA Empirical studies on the efficacy of acute and chronic Interventions for People Exposed to Trauma are summarised below. Acute interventions: Two types of psychological interventions delivered shortly after the traumatic events have been developed to alleviate acute distress shortly after the exposure to the traumatic
event and to prevent chronic PTSD in traumatized people and emergency personnel. The most widespread intervention has been psychological debriefing, especially Critical Incident Stress Debriefing (CISD). The populations targeted in these studies have been survivors of a traumatic experience (e.g., motor vehicle accident, miscarriage) irrespective of symptom severity. The other has been brief CBT similar to interventions developed for treating chronic PTSD. The populations targeted in these studies have been survivors of a traumatic experience (e.g., motor vehicle accident, rape) who either meet symptom criteria for PTSD or who meet full diagnostic criteria for acute stress disorder. Studies failed to provide support for the efficacy of psychological debriefing in preventing the development of later PTSD. Interventions for chronic PTSD: Evidence for efficacy and effectiveness in reducing chronic PTSD and other trauma related symptoms such as general anxiety and depression comes mostly from programs that utilized cognitive behavioral techniques. The CBT programs with the greatest empirical support include variants of exposure therapy, anxiety management, cognitive therapy, and their combinations. More recently, the efficacy of several programs for PTSD that include non-conventional exposure and cognitive therapy techniques have also been submitted to scientific examination. The most studied program is eye movement desensitization and reprocessing (EMDR). These programmes have shown relative efficacy in PTSD.
E.04 Educational update on adult ADHD E.04.01 Diagnosis and assessmentof adult ADHD J.K. Buitelaar ° . Radboud University Nijmegen Medical Centre, Dept. of Psychiatry (333), Nijmegen, The Netherlands Attention-deficit/hyperactivity disorder in adults (ADHD) has been established as a relevant and valid diagnostic entity in general psychiatry in the last decade. The aim of this presentation is review data on issues of clinical validity, assessment and treatment planning. ADHD is a developmental disorder with impairing symptoms of inattention, disorganisation, hyperactivity and impulsivity. ADHD starts in early childhood and persists in about 50% through the lifespan into adulthood. Prevalence estimates in adulthood range from 1–5%. In 75% of adults with ADHD, there is at least one other disorder and 30−50% has two or more comorbid conditions, especially learning disablities, mood disorders, anxiety disorders, substance use disorders and personality disorder. The validity of ADHD in adults would be indicated by similarity to the childhood disorder with regard to patterns of psychiatric, cognitive and neurobiologic findings. This has indeed found to be the case. The clinical correlates of adults with ADHD are very similar to those seen in children with the disorder, as are the comorbid disorders. Family studies have shown that parents of children with ADHD children have a significantly increased risk for having the disorder themselves; treatment studies have indicated that stimulants are also reasonably effective in ADHD in adults. Laboratory studies
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E.06 Gender in relation to treatment in psychopharmacology
have established similar neuropsychological dysfunctions in adults and children with ADHD, brain-imaging studies showed abnormalities of brain regions that have been implicated in the etiology of ADHD in studies with children, and molecular genetic studies have implicated similar genes in adults and children with ADHD. References [1] Boonstra AM, Oosterlaan J, Sergeant JA, Buitelaar JK, 2005. Executive functioning in adult ADHD: a meta-analytic review. Psychol Med. 35: 1097–108. [2] Asherson P, 2005. Clinical assessment and treatment of attention deficit hyperactivity disorder in adults. Expert Rev Neurother. 5: 525−39.
E.04.02 Treatment of adult ADHD E. Taylor ° . King’s College London Institute of Psychiatry, Department of Child and Adolescent Psychiatry, London, United Kingdom Clinicians for adults are increasingly asked to treat ADHD, either because a patient is graduating from children’s services or because of a new presentation. People diagnosed as children often continue symptoms into adult life. Randomised controlled trials show that stimulants and atomoxetine are superior to placebo in reducing core symptoms of hyperactivity. Meta-analysis shows similar effect sizes to that seen in child and adolescent samples. Clinical experience suggests that some will benefit also in overall social adjustment. Nevertheless, medication in adult life is rare and controversial. Most drug treatments are not licensed for use for adults in any European country – though this situation will probably change in the near future. Atomoxetine (Strattera) is licensed for use in adults but only when treatment was initiated in childhood or adolescence. Titration of stimulants to an effective dose is important; the commonest dose range used in Europe for IR methylphenidate is 10 – 20 mg taken three to five times daily, but both higher and lower doses are very often required in individual cases. Extended-release preparations are popular. Atomoxetine is usually given at 100 mg daily. Longitudinal population studies have shown both that untreated hyperactive behaviour is a risk for several kinds of adolescent and adult maladjustment, and that the majority of cases are unrecognised. Presentation for the first time in adult life needs careful diagnosis to distinguish ADHD from other types of personality disorder, learning disabilities, bipolar disorder and substance abuse. When recognised, however, treatment follows the same lines as for those where treatment was started in childhood and can be as effective.
E.05 Focus on noradrenaline E.05.02 Assessing the noradrenalin system in humans D. Nutt ° . University of Bristol, Psychopharmacology Unit, Bristol, United Kingdom Since its discovery in the 1950s there has been many attempts to understanding the actions and role of noradrenaline in CNS functions. Initial studies on noradrenaline used urinary excretion of it and metabolites as a proxy for CNS noradrenaline turnover finding
reduced activity in bipolar disorder and increased activity in withdrawal states e.g. from alcohol and opiates. Plasma noradrenaline measures are less predictive, but can be elevated in depression as well as anxiety and withdrawal states. More recently focus has been on brain noradrenaline receptors with many studies using challenge tests with a2 agonists especially clonidine. The measures of sensitivity include growth hormone release, fall in blood pressure and heart rate and sedation (including measures such as slowing of saccadic eye movements). Important findings include the sub sensitivity of a2 receptors in many brain disorders including panic [Nutt 1989] and opiate dependence and after antidepressant treatment. Many brain functions including attention [Smith and Nutt 1996], sleep and hormone release are useful measures of central noradrenaline. More recently blocking the synthesis of noradrenaline with a-methyl-para-tyrosine has been used to explore the role of noradrenaline in the action of antidepressant drugs. It has not yet proved possible to image with either PET of SPECT the brain noradrenaline system. However drug actions on the peripheral transporter can be measured using the tracer 11 CMHED – a substrate for the site. Ongoing work offers the possibility to develop central PET tracers that may be used to quantitate central a3 receptor density and measure noradrenaline release [Malizia et al. 2000]. References [1] Malizia AL, Melichar JK, Rhodes CG, Haida A, Reynolds AH, Jones T, Nutt DJ, 2000. Desipramine binding to noradrenaline reuptake sites in cardiac sympathetic neurons in man in vivo, Eur.J.Pharmacol. 391: 263–267. [2] Nutt DJ, 1989. Altered central alpha 2-adrenoceptor sensitivity in panic disorder, Arch.Gen.Psychiatry 46: 165–169. [3] Smith A, Nutt D, 1996. Noradrenaline and attention lapses, Nature 380: 291.
E.06 Gender in relation to treatment in psychopharmacology E.06.01 Gender differences: focus on addiction G. Fischer ° , N. Ebner, B. Winklbaur, K. Thau. Medical University of Vienna, Department of Psychiatry, Vienna, Austria Accumulating evidence suggests that the antecedents, consequences, and mechanisms of drug abuse and addiction are not identical in males and females and that gender is an important variable in treatment and prevention. But not only the fact that gender differences are revealed in prevalence, incidence, age of onset, severity and mortality, major challenges are defined through biological differences – e.g. hormonal differences or also in opioid receptor binding capacity. Nicotine has been shown to be metabilized differently in men and women, with faster pathways in women. Also the higher prevalence of affective disorders in female substance dependent individuals needs special consideration * adequate psychopharmacological treatment of depression & anxiety disorders enables physicians to treat successful substance dependence disorder. Limited but proven evidence in prospective trials with antidepressants provided the information that gender differences are occurring between tricyclic and serotininreuptake inhibitors (SSRI); the combination with opioid maintenance therapy showed that the interaction with SSRI yielded to gender sensitive plasma elevation of the administered opioid. Repetitivley reconfirmed is the finding of opioid dependence and methadone
Educational sessions
E.02 The role of psychiatry in disaster management E.02.01 Psychopharmaca in the management of the consequences of disasters J.J. L´opez-Ibor Jr. ° . Clinica L´opez-Ibor, Madrid, Spain The exposure to a disaster may elicit complex reactions at the biological, psychological and social levels. The reactions develop in stages and it has been claimed that what happens in early stages determines late consequences. Some reactions have to be considered normal, other are the expression of self-destructive mechanisms which should be identified and treated. Post-traumatic stress disorder (PTSD) is only one among several long term consequences of disasters. The mechanisms (biological, psychological and social) are only partially known, and therefore interventions proposed lack of sufficient scientific evidence. There are different approaches for the pharmacological treatment of psychopathological reactions to disasters: (a) the treatment patients suffering from PTSD, both short-term acute and longterm relapse prevention strategies to diminish the symptoms of the disorder. (b) Studies to identify if the nature of trauma (civilian, war related) or the populations affected (males, females, civilians, military personnel) plays a role in the response to psychotropic drugs; (c) treatments applied in early stages can prevent the emergence of late severe and chronic sequences. Data about efficacy of MAOIs and SSRIs in the treatment of PTSD are heterogeneous may be due to the different populations studied and the variety of exposure to trauma experienced. Nevertheless, research data supports antidepressant medication as the first-line pharmacotherapy for PTSD, with SSRIs (specially fluoxetine and sertraline) having the strongest body of empirical support. Other medications, such as MAOIs, nefazodone and combinations with second generation antipsychotics (risperidone) may also have a role in the management of these patients. Other drug groups offer interesting opportunities such as serotoninergic drugs, CRF or NPY antagonists, NMDA antagonists, anticonvulsants or other GABAergic agents. In any case pharmacotherapy has to be used in combination with other approaches to deal with the psychological and social consequences of disasters. This is not an easy task and clinicians should be trained in this very singular aspect of mental health. E.02.02 Cognitive behavioural interventions for acute and chronic PTSD E. Foa ° . University of Pennsylvania, Department of Psychiatry, Philadelphia, USA Empirical studies on the efficacy of acute and chronic Interventions for People Exposed to Trauma are summarised below. Acute interventions: Two types of psychological interventions delivered shortly after the traumatic events have been developed to alleviate acute distress shortly after the exposure to the traumatic
event and to prevent chronic PTSD in traumatized people and emergency personnel. The most widespread intervention has been psychological debriefing, especially Critical Incident Stress Debriefing (CISD). The populations targeted in these studies have been survivors of a traumatic experience (e.g., motor vehicle accident, miscarriage) irrespective of symptom severity. The other has been brief CBT similar to interventions developed for treating chronic PTSD. The populations targeted in these studies have been survivors of a traumatic experience (e.g., motor vehicle accident, rape) who either meet symptom criteria for PTSD or who meet full diagnostic criteria for acute stress disorder. Studies failed to provide support for the efficacy of psychological debriefing in preventing the development of later PTSD. Interventions for chronic PTSD: Evidence for efficacy and effectiveness in reducing chronic PTSD and other trauma related symptoms such as general anxiety and depression comes mostly from programs that utilized cognitive behavioral techniques. The CBT programs with the greatest empirical support include variants of exposure therapy, anxiety management, cognitive therapy, and their combinations. More recently, the efficacy of several programs for PTSD that include non-conventional exposure and cognitive therapy techniques have also been submitted to scientific examination. The most studied program is eye movement desensitization and reprocessing (EMDR). These programmes have shown relative efficacy in PTSD.
E.04 Educational update on adult ADHD E.04.01 Diagnosis and assessmentof adult ADHD J.K. Buitelaar ° . Radboud University Nijmegen Medical Centre, Dept. of Psychiatry (333), Nijmegen, The Netherlands Attention-deficit/hyperactivity disorder in adults (ADHD) has been established as a relevant and valid diagnostic entity in general psychiatry in the last decade. The aim of this presentation is review data on issues of clinical validity, assessment and treatment planning. ADHD is a developmental disorder with impairing symptoms of inattention, disorganisation, hyperactivity and impulsivity. ADHD starts in early childhood and persists in about 50% through the lifespan into adulthood. Prevalence estimates in adulthood range from 1–5%. In 75% of adults with ADHD, there is at least one other disorder and 30−50% has two or more comorbid conditions, especially learning disablities, mood disorders, anxiety disorders, substance use disorders and personality disorder. The validity of ADHD in adults would be indicated by similarity to the childhood disorder with regard to patterns of psychiatric, cognitive and neurobiologic findings. This has indeed found to be the case. The clinical correlates of adults with ADHD are very similar to those seen in children with the disorder, as are the comorbid disorders. Family studies have shown that parents of children with ADHD children have a significantly increased risk for having the disorder themselves; treatment studies have indicated that stimulants are also reasonably effective in ADHD in adults. Laboratory studies
S206
E.06 Gender in relation to treatment in psychopharmacology
have established similar neuropsychological dysfunctions in adults and children with ADHD, brain-imaging studies showed abnormalities of brain regions that have been implicated in the etiology of ADHD in studies with children, and molecular genetic studies have implicated similar genes in adults and children with ADHD. References [1] Boonstra AM, Oosterlaan J, Sergeant JA, Buitelaar JK, 2005. Executive functioning in adult ADHD: a meta-analytic review. Psychol Med. 35: 1097–108. [2] Asherson P, 2005. Clinical assessment and treatment of attention deficit hyperactivity disorder in adults. Expert Rev Neurother. 5: 525−39.
E.04.02 Treatment of adult ADHD E. Taylor ° . King’s College London Institute of Psychiatry, Department of Child and Adolescent Psychiatry, London, United Kingdom Clinicians for adults are increasingly asked to treat ADHD, either because a patient is graduating from children’s services or because of a new presentation. People diagnosed as children often continue symptoms into adult life. Randomised controlled trials show that stimulants and atomoxetine are superior to placebo in reducing core symptoms of hyperactivity. Meta-analysis shows similar effect sizes to that seen in child and adolescent samples. Clinical experience suggests that some will benefit also in overall social adjustment. Nevertheless, medication in adult life is rare and controversial. Most drug treatments are not licensed for use for adults in any European country – though this situation will probably change in the near future. Atomoxetine (Strattera) is licensed for use in adults but only when treatment was initiated in childhood or adolescence. Titration of stimulants to an effective dose is important; the commonest dose range used in Europe for IR methylphenidate is 10 – 20 mg taken three to five times daily, but both higher and lower doses are very often required in individual cases. Extended-release preparations are popular. Atomoxetine is usually given at 100 mg daily. Longitudinal population studies have shown both that untreated hyperactive behaviour is a risk for several kinds of adolescent and adult maladjustment, and that the majority of cases are unrecognised. Presentation for the first time in adult life needs careful diagnosis to distinguish ADHD from other types of personality disorder, learning disabilities, bipolar disorder and substance abuse. When recognised, however, treatment follows the same lines as for those where treatment was started in childhood and can be as effective.
E.05 Focus on noradrenaline E.05.02 Assessing the noradrenalin system in humans D. Nutt ° . University of Bristol, Psychopharmacology Unit, Bristol, United Kingdom Since its discovery in the 1950s there has been many attempts to understanding the actions and role of noradrenaline in CNS functions. Initial studies on noradrenaline used urinary excretion of it and metabolites as a proxy for CNS noradrenaline turnover finding
reduced activity in bipolar disorder and increased activity in withdrawal states e.g. from alcohol and opiates. Plasma noradrenaline measures are less predictive, but can be elevated in depression as well as anxiety and withdrawal states. More recently focus has been on brain noradrenaline receptors with many studies using challenge tests with a2 agonists especially clonidine. The measures of sensitivity include growth hormone release, fall in blood pressure and heart rate and sedation (including measures such as slowing of saccadic eye movements). Important findings include the sub sensitivity of a2 receptors in many brain disorders including panic [Nutt 1989] and opiate dependence and after antidepressant treatment. Many brain functions including attention [Smith and Nutt 1996], sleep and hormone release are useful measures of central noradrenaline. More recently blocking the synthesis of noradrenaline with a-methyl-para-tyrosine has been used to explore the role of noradrenaline in the action of antidepressant drugs. It has not yet proved possible to image with either PET of SPECT the brain noradrenaline system. However drug actions on the peripheral transporter can be measured using the tracer 11 CMHED – a substrate for the site. Ongoing work offers the possibility to develop central PET tracers that may be used to quantitate central a3 receptor density and measure noradrenaline release [Malizia et al. 2000]. References [1] Malizia AL, Melichar JK, Rhodes CG, Haida A, Reynolds AH, Jones T, Nutt DJ, 2000. Desipramine binding to noradrenaline reuptake sites in cardiac sympathetic neurons in man in vivo, Eur.J.Pharmacol. 391: 263–267. [2] Nutt DJ, 1989. Altered central alpha 2-adrenoceptor sensitivity in panic disorder, Arch.Gen.Psychiatry 46: 165–169. [3] Smith A, Nutt D, 1996. Noradrenaline and attention lapses, Nature 380: 291.
E.06 Gender in relation to treatment in psychopharmacology E.06.01 Gender differences: focus on addiction G. Fischer ° , N. Ebner, B. Winklbaur, K. Thau. Medical University of Vienna, Department of Psychiatry, Vienna, Austria Accumulating evidence suggests that the antecedents, consequences, and mechanisms of drug abuse and addiction are not identical in males and females and that gender is an important variable in treatment and prevention. But not only the fact that gender differences are revealed in prevalence, incidence, age of onset, severity and mortality, major challenges are defined through biological differences – e.g. hormonal differences or also in opioid receptor binding capacity. Nicotine has been shown to be metabilized differently in men and women, with faster pathways in women. Also the higher prevalence of affective disorders in female substance dependent individuals needs special consideration * adequate psychopharmacological treatment of depression & anxiety disorders enables physicians to treat successful substance dependence disorder. Limited but proven evidence in prospective trials with antidepressants provided the information that gender differences are occurring between tricyclic and serotininreuptake inhibitors (SSRI); the combination with opioid maintenance therapy showed that the interaction with SSRI yielded to gender sensitive plasma elevation of the administered opioid. Repetitivley reconfirmed is the finding of opioid dependence and methadone