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Attention deficit hyperactivity disorder (ADHD) is a common and highly heritable psychiatric disorder in children and adults. Recent meta-analyses have indicated an association between genes involved in dopaminergic signaling and childhood ADHD, but little is known about their possible role in adult ADHD. In this study of adults with ADHD, we evaluated the three most commonly studied ADHD candidate genetic polymorphisms; the dopamine receptor D4 (DRD4) exon 3 VNTR repeat, a microsatellite repeat 18.5 kb upstream of the DRD5 locus and the 3'UTR dopamine transporter SLC6A3 (DAT 1) VNTR. We examined 358 clinically diagnosed adult Norwegian ADHD patients (51% males) and 340 ethnically matched controls. We found a nominally significant overall association with adult ADHD for the DRD5 microsatellite marker (P = 0.04), and a trend toward increased risk associated with the 148-bp allele consistent with recent meta-analyses. The strongest overall association (P = 0.02) and increased risk for the 148-bp allele [odds ratio (OR) = 1.27 (95% CI: 1.00-1.61)] were seen in the inattentive and combined inattentive/hyperactive group as previously reported for childhood ADHD. No association was found for the DRD4 or SLC6A3 polymorphisms in this patient sample. In conclusion, our results among adults with a clinical diagnosis of ADHD support an association between ADHD and the DRD5 locus, but not the DRD4 or SLC6A3 loci. It is possible that the latter polymorphisms are associated with a transient form of ADHD with better long-term clinical outcome.

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While unilateral electroconvulsive therapy (U-ECT) is generally considered to induce negligible disturbances of memory as compared with bilateral bitemporal ECT, its relative antidepressant efficacy has been questioned. The aim of the present study was to compare, in a double-blind design, clinicians' ratings of global clinical impression of the antidepressant efficacy of the two treatment modalities. The treatment technique included avoidance of benzodiazepines, prolonged hyperventilation with oxygen, intermittent unidirectional pulses distributed in a long pulse train, permitting individualized and relatively high doses of electrical charge at each treatment occasion, and non-dominant long-distance (12-13 cm) parietotemporal (d'Elia) electrode placement in the U-ECT group. The results indicated no therapeutic advantage for either treatment modality, which was also in accordance with the symptom ratings by an independent nonblinded rater. The findings encourage the continued use of nondominant long-distance parietotemporal ECT with a treatment technique that induces fully generalized seizures as the modality of choice in the convulsive treatment of depression.

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Transient DST non-suppression during disulfiram-treatment was fortuitously observed in a depressed patient. A disulfiram-potentiated DST (DSTd) was constructed by giving 800 mg disulfiram on the dexamethasone and postdexamethasone days. DST and DSTd were compared intraindividually in 21 patients and 14 controls. Disulfiram-potentiation was significant in constantly depressed patients, and in questionable controls due to possible subclinical depression or somatic factors which may cause 'false-positive' results. It did not occur in depressed patients during marked improvement or long-term recovery, and not in accurately screened controls. DSTd was significantly correlated with depression ratings, whereas DST was not.

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The effect of pulse unilateral electroconvulsive therapy (ECT) on heart rate, blood pressure and the product of heart rate and systolic blood pressure, an index of myocardial oxygen consumption, was studied during 48 ECT sessions in 7 patients with major depression. Intra-individually, hyperventilation-induced hypocapnia compared with normocapnia markedly augmented the ECT-induced increase in heart rate (47% vs 28%) and the product of heart rate and systolic blood pressure (82% vs 60%). Over all ECT seizures, the maximum and increase in heart rate and the product of heart rate and systolic blood pressure were significantly correlated with seizure duration as determined by electroencephalography. However, significant correlations were only present for the seizures during hypocapnia and not during normocapnia. Combining measures of magnitude and length of ECT-induced tachycardia to motor responses may increase the potential for clinical seizure evaluation.

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Inadequate treatment of mood (affective) disorders is related to the mind/body dualism, desinformation about methods of treatment, the stigma of psychiatry, low funding of psychiatric research, low educational priority, and slow acquisition of new knowledge of psychiatry. The "respectable minority rule" has often been accepted without regard to the international expertise, and the consequences of undertreatment have not been weighed against the benefits of optimal treatment. The risk of chronicity increases with delayed treatment, and inadequately treated affective disorders are a leading cause of suicide. During the past 20 years the increase in suicide mortality in Norway has been the second largest in the world. Severe mood disorders are often misclassified as schizophrenia or other non-affective psychoses. Atypical mood disorders, notably rapid cycling and bipolar mixed states, are often diagnosed as personality, adjustment, conduct, attention deficit, or anxiety disorders, and even mental retardation. Neuroleptic drugs may suppress the most disturbing features of mood disorders, a fact often misinterpreted as supporting the diagnosis of a schizophrenia-like disorder. Treatment with neuroleptics is not sufficient, however, and serious side effects may often occur. The consequences are too often social break-down and post-depression syndrome.

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Optimal treatment of mood disorders and prevention of suicide requires biological and psychosocial methods, therapeutic alliance and psycho-education. In moderate unipolar depression an antidepressant may be sufficient, if necessary potentiated by another antidepressant or triiodothyronine. In moderate bipolar depression lithium or carbamazepine are preferred. In severe unipolar and bipolar depression the combination of an antidepressant and lithium (or carbamazepine) or electroconvulsive therapy (ECT) is indicated, in psychotic depression neuroleptics, too. Non-selective monoamine oxidase inhibitors (MAOIs) are the most potent antidepressants. Moderate acute mania and mixed state may respond to lithium, carbamazepine or valproate only. In severe cases a neuroleptic and lithium are combined, or these drugs may be combined with carbamazepine or valproate. Electroconvulsive therapy is preferable in acute mixed states with marked confusion or depression. In chronic mixed state and rapid cycling, withdrawal of antidepressants and neuroleptics should be tried. Most patients will need a combination of lithium and carbamazepine or valproate. Added to these drugs, antidepressants are less risky. Adding thyroxin may stabilize rapid cycling. The combination of lithium and an antidepressant is the most potent prophylaxis in unipolar disorder and bipolar disorder dominated by depression.

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Measurement of the level of tricyclic antidepressants in the blood is useful in the treatment of affective disorders. We describe four patients, all of whom became intoxicated by the recommended therapeutic doses of tricyclic antidepressants. The only obvious sign of such gradual intoxication may be worsening of the depressive syndrome. Therefore, to enable administration of high enough doses without intoxication we recommend routine blood level measurements. We present therapeutic ranges and intoxication levels, based on the international literature.

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Cerebral computed tomography (CT) was performed before and after right-sided electroconvulsive therapy (ECT) in 40 patients aged 26-87 years with major affective disorders. Nine patients with a concomitant definite or possible non-acute organic brain disorder were included. Several patients had long seizure durations, maximum 6.5 min, caused by hyperventilation-induced hypocapnia. Twenty-nine patients received at least 16 treatments (maximum 46). No CT changes occurred following ECT. A questionable dilatation of the left temporal horn in a 69-year-old hypertensive man who recovered completely without side effects after 3 ECT sessions was probably unrelated to the ECT. Provided sufficient oxygenation, even relatively long ECT series and seizures lasting several minutes do not cause any brain damage visible on CT.

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45 members of self-help groups for persons with anxiety disorders were interviewed using Structured Clinical Interview of DSM-III-R. 21 interviews were video-recorded and rated by an independent rater. Panic disorder was the most common diagnosis, together with present or past serious depression. We discuss the relation between anxiety disorders and affective disorders. Interrater agreement was high for panic disorder, but not for the diagnoses generalized anxiety disorder and simple phobia. Questions are raised about the clinical validity of generalized anxiety disorder.

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Seizure duration in unilateral electroconvulsive therapy (ECT) was recorded by means of EEG in an intraindividual comparison of etomidate (dissolved in a soy-bean oil emulsion) 0.3 mg/kg and Althesin (alphaxalone 9 mg and alphadolone 3 mg/ml) 0.6 mg/kg with methohexitone 1 mg/kg body weight. The patients were intubated and alveolar CO2- and O2-concentrations kept constant at 3% (3 kPa) and 92% (92 kPa) respectively. Seizure duration was the same when either etomidate or methohexitone were used, whereas Althesin significantly shortened seizure duration in comparison with methohexitone. Local pain on injection and a subsequent superficial thrombophlebitis occurred frequently with methohexitone. This did not occur with etomidate or Althesin.

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Seizure duration in unilateral electroconvulsive therapy (ECT) was recorded by means of EEG in an intraindividual comparison under different alveolar O2- and CO2-concentrations. Hypocapnia induced by hyperventilation to an alveolar CO2-concentration of 2% (2 kPa) resulted in a highly significant increase in seizure duration compared to a normal CO2 of 5%, when the alveolar O2-concentration was constant at 92%. Oxygen ventilation to an alveolar O2-concentration of 92% gave no significant increase in seizure duration compared to 15%, obtained by ventilation with air, when the CO2-concentration was kept constant at 5%. Seizure duration seems to augment progressively with decreasing alveolar CO2-concentration.

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A 51-year-old man who died of Creutzfeldt-Jakob disease (CJD), had transient dyskinesias with intention myoclonus and exaggerated startle reaction in early life. This may suggest a link between myoclonic encephalopathy of infants and CJD, and an incubation period of more than 40 years of the transmissible agent of CJD.

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In a large family five affected males belonging to four different kinships exhibited a muscle wasting of varying degree and with a predominantly proximal distribution. The index case had a facio-scapulo-humeral and peroneal muscular atrophy, whereas one of his cousins suffered a more generalized involvement starting in infancy and similar to Werdnig-Hoffman disease. The other affected family members had only slight changes. The index case and his affected brother had a positive Babinski sign. In enzyme histochemical preparations, specimens from the index case showed small group atrophy of type 2 fibers along with pseudomyopathic changes (whorled and coiled fibers, splitting) of type 1 fibers. Similar findings were observed in his cousin. Ultrastructural investigation gave no further information. Since all patients were males and the offspring of unaffected sisters, an X-chromosomal mode of transmission is proposed for this illness.

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In a 32-year-old woman, cerebral angiography showed fibromuscular dysplasia of the left anterior and middle cerebral arteries. She had had epilepsy and subarachnoid hemorrhages with subsequent hemiplegia. Since she also had multiple enchondromas (Ollier disease), this may represent a case of Maffucci syndrome.

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