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Intracellular sodium homeostasis in rat campus: critical role for glial cells purchase 50 mg solian overnight delivery symptoms 10 dpo. Gap junctions equalize intracellular extracellular concentrations of glutamate and aspartate in rat Na concentration in astrocytes order solian 100 mg medicine 101. Effect of nerve impulses intracerebral microdialysis solian 50 mg with amex treatment non hodgkins lymphoma. Localization of neuronal (MCT1) expressing xenopus laevis oocytes purchase solian 50 mg online medicine ketoconazole cream. Enhancement of glutamate uptake tinct role of lactate as an energysubstrate for the neonatal vs transport byCO(2)/bicarbonate in the leech giant glial cell. The autoradiographic localization of L-[3H]glu- ling of brain glucose metabolism and glutamatergic neuronal tamate in rat brain tissue. The mechanisms vulnerabilityto glutamate toxicityin astrocyte-poor cultures of controlling physiologically stimulated changes in rat brain glu- rat cerebral cortex. Neurosci Lett 1989;103:162–168 [published cose and lactate: a microdialysis study. J Physiol 1996;496: erratum appears in Neurosci Lett 1990;116:399. Lactate rise detected glutamate transporters reveals a major role for astroglial trans- by1H NMR in human visual cortex during physiologic stimula- port in excitotoxicityand clearance of glutamate. ChaudhryFA, Lehre KP, van Lookeren Campagne M, et al. Science Glutamate transporters in glial plasma membranes: highlydif- 1988;241:462–464. Regulation of glycogen J Neurosci 1998;18:7709–7716. Block of glutamate transporters potentiates pathological aspects. Cellular bases of brain energymetabo- ences axon function and survival during glucose deprivation in lism and their relevance to functional brain imaging: evidence central white matter. Glycogen in astrocytes: stimulates aerobic glycolysis: a mechanism coupling neuronal possible function as lactate supplyfor neighboring cells. Glutamate uptake stimulates Na / stores and metabolism during complete global ischaemia. Neurol K -ATPase activityin astrocytes via activation of a distinct Res 1989;11:24–28. Lactate release from cultured astrocytes survival in CNS white matter during energydeprivation: a de- and neurons: a comparison. J Neurochem 1995;64: intestinal polypeptide induced glycogenolysis in mouse cortical 1734–1741. Proc Natl Acad Sci USA 1981;78: in the rat hippocampal slice preparation. Lactate released byMuller genolysis in mouse cerebral cortex: a possible coupling mecha- glial cells is metabolized byphotoreceptors from mammalian nism between neuronal activityand energymetabolism. Characterization of the glycogenolysis function and survival in CNS white matter during glucose dep- elicited byvasoactive intestinal peptide, noradrenaline and aden- rivation? Selective distribution zation: theory, procedure, and normal values in the conscious of lactate dehydrogenase isoenzymes in neurons and astrocytes and anesthetized albino rat. Comparison of lactate cytes: blockade by protein synthesis inhibition. J Neurosci 1992; transport in astroglial cells and monocarbosylate transporter 1 12:4923–4931. Vasoactive intestinal peptide, cortex of rats reared in a complex environment. Psychoneuroen- pituitary adenylate cyclase-activating peptide, and noradrenaline docrinology 1996;21:189–201. Ultrastructural evidence for in- tein (C/EBP)- and C/EBPd in mouse cortical astrocytes: in- creased contact between astrocytes and synapses in rats reared volvement in cAMP-regulated glycogen metabolism. Glial hypertrophy is and induction of mouse brain glycogen synthase. Brain Res Mol associated with synaptogenesis following motor-skill learning, Brain Res 1996;38:191–199. Spatial learning and physical in mouse cortical astrocytes. Glutamate neural substrates for increased cognition associated with exer- induces calcium waves in cultured astrocytes: long-range glial cise. Mechanisms and anatomical substrates of place learning. Neurobiol Learn Memory function of intercellular calcium signaling. Neuronal activitytriggers term potentiation on the spatial relationship between astrocyte calcium waves in hippocampal astrocyte networks. Neuron processes and potentiated synapses in the dentate gyrus neuropil 1992;8:429–440. Glial cell functions and activity-dependent plastic- 39–49. Direct signaling from astrocytes to neurons in brain: angiogenesis in the adult rat cerebellum after vigorous cultures of mammalian brain cells. Science 1994;263: physical activity and motor skill learning. Metabolic mapping glutamate-mediated activation of hippocampal neurons byglial of chick brain after imprinting using [14C]2-deoxyglucose tech- calcium waves. Local cerebral alterations cyte-neuron signalling [see comments]. Nature 1994;369: in [14C-2]deoxyglucose uptake following memory formation. Time-dependent sequential increases in synaptic plasticity. Long-term potentiation and spatial tures during memoryconsolidation of an operant training in training are both associated with the generation of new excita- mice. Curr Biol 1998;8: duces reversible changes of representational maps of vibrissae R151–R153. Factors govern- lism induced byrepeated spatial discrimination training in mice: ing activity-dependent structural plasticity of the hypothalamo- visualization of the memoryconsolidation process? Differential rearing effects on rat 1998;95:13290–13295. Increased volume area in visual cortex of young rats. Rapid laminar-depen- chronic antipsychotic drug exposure. Biol Psychiatry 1999;46: dent changes in GFAP immunoreactive astrocytes in the visual 161–172. MALENKA The most fascinating and important property of the mam- SHORT-TERM SYNAPTIC PLASTICITY malian brain is its remarkable plasticity, which can be thought of as the ability of experience to modify neural Virtually every synapse that has been examined in organisms circuitry and thereby to modify future thought, behavior, ranging from simple invertebrates to mammals exhibits nu- and feeling. Thinking simplistically, neural activity can merous different forms of short-term synaptic plasticity that modify the behavior of neural circuits by one of three mech- last on the order of milliseconds to a few minutes (for de- anisms: (a) by modifying the strength or efficacy of synaptic tailed reviews, see 1 and 2). In general, these result from a transmission at preexisting synapses, (b) by eliciting the short-lasting modulation of transmitter release that can growth of new synaptic connections or the pruning away occur by one of two general types of mechanisms.

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The elevation of opioid peptide secretion may con- ceptors (316) discount solian 50mg on-line treatment quadratus lumborum. This analge- the anxiogenic effects of CCK-4 than are control subjects sic effect shows evidence of sensitization discount solian 50mg without a prescription treatment 911, because subse- (317 buy solian 100 mg visa medications ritalin,318) 100mg solian free shipping medications bipolar. Although the mechanism un- Potentially consistent with these data, Pitman et al. In by endogenous opiate release during symptom provoca- PTSD, CCK-4–induced panic was associated with a lower tion). In the baseline state, the CSF -endorphin levels were ACTH response in the PTSD study subjects than in healthy abnormally elevated in PTSD relative to control samples controls, and cortisol concentrations increased in both the (328). The elevation in the corti- evening plasma -endorphin levels in a PTSD group versus sol concentrations attenuated more rapidly in the PTSD healthy control samples (329). Another study found no dif- group than in the control group. Neither PD that some patients with combat-related PTSD experience an subgroup showed significant changes in the plasma cortisol attenuation of their hyperarousal symptoms (331). The elevation preclinical studies in experimental animals have shown that of ACTH concentrations suggested that CRH secretion in- opiates potently suppress central and peripheral noradrener- creases in CCK-4–induced panic in PD (consistent with gic activity, these data appear compatible with the hypothe- preclinical evidence regarding the role of CRH in stress and sis that some PTSD symptoms are mediated by noradrener- anxiety and the interaction of CRH and CCK in modulat- gic hyperactivity (discussed earlier). EVIDENCE OF ALTERATION IN OTHER those of opiate withdrawal (170). NEUROTRANSMITTER SYSTEMS IN ANXIETY DISORDERS PTSD Panic Disorder Neuropeptide Y Benzodiazepine NPY administered in low doses intraventricularly attenuates Increased symptomatology with – ++ experimentally induced anxiety in a variety of animal benzodiazepine antagonist models (332). Consistent with these data, transgenic rats Decreased number of + +++/– that overexpress hippocampal NPY show behavioral insensi- benzodiazepine receptors tivity to restraint stress and absent fear suppression of behav- using SPECT-iomazenil or PET-flumazenil binding ior in a punished drinking task (333). In healthy humans Opiate subjected to uncontrollable stress during military training Naloxone-reversible analgesia + NS exercises, plasma NPY levels increased to a greater extent Reduced plasma β-endorphin + NS in persons rated as having greater stress resilience (334). Elevated levels of CSF β-endorphin + – During stress exposure, the NPY plasma levels were posi- Serotonin Decreased serotonin reuptake site ++ +/– tively correlated with plasma cortisol concentrations and binding in platelets behavioral performance, and they were negatively correlated Decreased serotonin transmitter – +/– with dissociative symptoms (334). In contrast, patients with combat-related Increased anxiogenic responses to /– PTSD had lower plasma NPY concentrations both at base- 5-HT agonists line and in response to yohimbine challenge than healthy Thyroid controls (336). In the PTSD group, the baseline NPY levels Increased baseline indices of + – thyroid function were inversely correlated with PTSD and panic symptoms Increased TSH response to TRH + – and with yohimbine-induced increases in MHPG and sys- Somatostatin tolic blood pressure (336). If this finding proves reproduci- Increased somatostatin levels at + – ble, it suggests that a deficit in endogenous NPY secretion baseline in CSF may be involved in the generation of anxiety and sympa- Cholecystokinin Increased anxiogenic responses to + +++ thetic autonomic symptoms in PTSD. CCK agonists –, One or more studies did not support this finding (with no positive Thyrotropin-Releasing Hormone and the studies), or the majority of studies do not support this finding; +/–, an equal number of studies support this finding and do not support Thyroid Axis this finding; +, at least one study supports this finding and no studies do not support the finding, or the majority of studies In the early twentieth century, Graves described cases in support the finding; ++, two or more studies support this finding, which thyroid hormone hypersecretion was associated with and no studies do not support the finding; +++, three or more studies support this finding, and no studies do not support the anxiety, palpitations, breathing difficulties, and rapid heart finding; +++/–, three or more studies support this finding, and rate in persons recently exposed to traumatic stress. Never- one study does not support the finding; cAMP, cyclic adenosine 3, 5-monophosphate; CCK, cholecystokinin; CSF, cerebrospinal fluid;′ ′ theless, systematic epidemiologic studies of the relationship NS, not studied; PTSD, posttraumatic stress disorder; SPECT, single between stress and thyroid disease have not been conducted. The most straightforward forms of respira- tory stimulation that produce panic anxiety produce eleva- tions of carbon dioxide pressure (hypercapnia). Thus, panic Respiratory System Dysfunction in Panic attacks can be consistently induced in patients with PD by Disorder rebreathing air, inhaling 5% to 7% carbon dioxide in air Associations between respiratory perturbation and acute (343,344), or inhaling a single deep breath of 35% carbon anxiety have been demonstrated in PD, in which various dioxide (345,346). Other panicogenic chemical challenges forms of respiratory stimulation consistently produce panic have also been hypothesized to induce anxiogenic effects Chapter 63: Neurobiological Basis of Anxiety Disorders 921 through respiratory stimulation (340,341,347). Although enous mechanisms for modulating the neural transmission the panicogenic mechanism of intravenous administration of information about aversive stimuli and responses to such of sodium lactate remains unclear, it may also involve respi- stimuli. Novel treatments being developed to exploit the ratory stimulation (339,340). Nevertheless, these pathophysiology of specific anxiety disorders and the neural data partly depend on subjective ratings of dyspnea during pathways involved in anxiety and fear processing, the devel- stress or respiratory stimulation, and the mechanisms under- opment of therapeutic strategies that combine both types lying this sensitivity remain unclear. One possibility is that of approaches may ultimately provide the optimal means this hypersensitivity reflects an overall sensitivity to somatic for reducing the morbidity of anxiety disorders. The associations between respiratory perturbation and REFERENCES acute anxiety are not specific to PD. In: Mills J, Mountcastle VB, Plum F, et to respiratory perturbation has also been reported in anxi- al. Baltimore: ety-disordered patients with some simple phobias, limited Williams & Wilkins, 1987:373–417. Annu Rev der, or limited-symptom anxiety attacks and in nonpsychi- Psychol 1995;46:209–235. Four systems for emotion activation: cognitive and noncognitive processes. Fear and the brain: where have we been, and where tion anxiety disorder exhibit greater changes in somatic are we going? Are different parts of the extended amygdala involved correlate with increases in respiratory rate, tidal volume, in fear versus anxiety? Fear conditioning induces minute ventilation, end-tidal carbon dioxide pressure, and associative long-term potentiation in the amygdala. Nature irregularity in respiratory rate during room-air breathing 1997;390:604–607. Networks related to the orbital and medial prefrontal cortex: a substrate for emotional behavior? Control of response CONCLUDING REMARKS selection by reinforcer value requires interaction of amygdala and orbital prefrontal cortex. The inconsistency in the results of biological investigations 9. Interactions between the of anxiety disorders highlights the importance of addressing amygdala and ventral striatum in stimulus-reward associations: the neurobiological heterogeneity inherent within criteria- studies using a second-order schedule of sexual reinforcement. Single neuron responses in neity will be facilitated by the continued development and amygdala of alert monkey during complex sensory stimulation application of genetic, neuroimaging, and neurochemical with affective significance. A theory of emotion and consciousness, and its appli- can elucidate the genotypes associated with these disorders. The cognitive neurosciences, Cambridge, MA: MIT Application of these experimental approaches will also facili- Press, 1995:1091–1106. Organization of projections to the anxiety therapies. Anterior cingulate cortex in rodents: connections, visceral control functions, and which the development of new therapeutic approaches can implications for emotion. In general, anxiolytic treatments appear to ology of cingulate cortex and limbic thalamus. Boston: Birkhauser, inhibit neuronal activity in the structures mediating fear 1993:206–223. Differential effects of amyg- 922 Neuropsychopharmacology: The Fifth Generation of Progress dala lesions on early and late plastic components of auditory 36. Organization of intra- cortex spike trains during fear conditioning. J Neurosci 1998; amygdaloid circuitries in the rat: an emerging framework for 18:2592–2601. Intrinsic connections storage: a critical involvement of the amygdala. Biol Psychiatry of the rat amygdaloid complex: projections originating in the 1999;46:1140–1152. Differential contribution of dorsal sory basal nuclei: a light and electron microscopy study. Neuro- and ventral medial prefrontal cortex to the acquisition and ex- science 1997;77:767–781.

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Two uncontrolled stud­ by either citalopram or placebo 100 mg solian with mastercard medicine and health, and citalopram was well tolerated by the elderly subjects in this study solian 100mg mastercard medications like tramadol. In another ies of buspirone in dementia patients with agitated behavior study of demented patients with AD or vascular dementia have been reported order solian 100mg mastercard medications contraindicated in pregnancy. A modest but statistically significant anxiety purchase solian 50mg online medications used to treat migraines, fear/panic, mood level, and restlessness. The differ­ overall reduction of agitated behaviors was noted, as was a ences between fluvoxamine and placebo, however, failed substantial variability in response, with 4 of the 10 patients to reach statistical significance. Although more studies are demonstrating marked declines in disruptive behaviors. In needed to evaluate the possible roles of the SSRIs for disrup­ a similar study, Hermann and Eryavec (82) prescribed tive agitation, results to date do not support their use as buspirone to a group of elderly nursing home residents with first-line agents for this indication. All subjects had demonstrated severe behavioral Other Serotoninergic Drugs disturbances, including agitation and aggression, and all had Trazodone is a sedating antidepressant with serotoninergic failed to improve with previous trials of other types of psy­ agonist activity. Simpson and Foster (88) treated four de- Chapter 88: Alzheimer Disease: Treatment of Noncognitive Behavioral Abnormalities 1261 mented patients who manifested disruptive behaviors with superiority of carbamazepine compared with placebo was trazodone after antipsychotic drug treatment had proved attributable primarily to a greater decrease in agitation and ineffective. In this anecdotal report, trazodone in doses of aggression in the carbamazepine group. Pinner and Rich (89) treated seven demonstrated antimanic activity. Again, all subjects had failed to improve with tated behaviors with doses of valproate ranging from 500 antipsychotic drug therapy. Three of the seven patients mg twice daily to 500 mg three times daily; treatment lasted demonstrated an apparent marked decrease in aggressive for 1 to 3 months. Substantial behavioral improvement was behavior following 4 to 6 weeks of trazodone at doses rang­ noted in two of the four patients, and adverse effects did ing from 200 to 350 mg/d. A recently reported multisite study of the anti­ study comparing haloperidol, trazodone, behavioral man­ convulsant valproate sodium has been less encouraging (97). In a double-blinded, placebo-controlled crossover turely. Although at the end of the study agitation was re­ study, Lawlor et al. Methodologically, this study a small but significant behavioral improvement in compari­ was designed to address 'mania-like' symptoms in persons son with placebo, whereas buspirone had no apparent ef­ with AD, and the higher doses of valproate typically pre- fect. Lower doses of valproate may have beneficial therapeutic effects with a more tolerable adverse effect pro- Anticonvulsant Drugs file. Because the hyperactive and aggressive behaviors encoun­ tered in the manic phase of bipolar disorder at least superfi­ Cholinergic Enhancement cially can resemble agitated behaviors in AD and other de­ mentias, the anticonvulsant drugs effective in the treatment That drugs that enhance cholinergic neurotransmission in of mania may benefit behaviorally disturbed patients with the central nervous system decrease agitation and psychotic dementia. Lithium has not been helpful for behavioral symptoms in persons with mild to moderate AD has been symptoms in AD (91). Marin and Greenwald (92) treated an unanticipated finding of large, multisite outcome trials two AD patients and one MID patient with carbamazepine demonstrating modest positive effects of these agents on in an attempt to reduce combative, agitated behaviors. The contribution of a presy­ Within 2 weeks of carbamazepine treatment at doses rang­ naptic cholinergic deficit to memory and other cognitive ing from 100 to 300 mg/d, behavioral improvement was impairments in AD (69,70) has been a cornerstone of AD noted in all subjects. In a larger open study of AD patients drug development. Interest in a potential contribution of who had failed to respond to antipsychotic drugs (93), re­ this cholinergic deficit to noncognitive behavioral problems duction in hostility, agitation, and uncooperativeness was in AD increased after Cummings (101) observed that the noted in five of nine patients. In this study, two patients agitation and psychotic symptoms characteristic of delirium whose agitated behaviors decreased manifested ataxia and induced by anticholinergic drug toxicity resemble some confusion, which resolved with reduction of the carbamaze­ noncognitive behavioral symptoms occurring sponta­ pine dose. The mean dose of carbamazepine in this study neously in AD (e. In contrast to enthusiastic authors of these reasoned that enhancing brain cholinergic neurotransmis­ small reports, Chambers et al. Empiric from carbamazepine in 19 elderly patients with dementia support for this hypothesis came from a carefully performed who were prescribed carbamazepine at doses of 100 to 300 single-case study in which the cholinesterase inhibitor phy­ mg/d. Target symptoms in this study were wandering, over- sostigmine reduced psychotic symptoms in a patient with activity, and restlessness. Further support has come in long-term care facilities with disruptive agitated behav­ from post hoc and secondary outcome analyses of large, mul­ iors. The modal carbamazepine dose at 6 weeks was 300 ticenter cholinesterase inhibitor outcome trials in AD. Statistical addition to demonstrating modest effects on cognitive func- 1262 Neuropsychopharmacology: The Fifth Generation of Progress tion, the cholinesterase inhibitors tacrine (104), galantam­ AD remains limited despite the prevalence of these prob­ ine (105), donepezil (106), metrifonate (107), and (in DLB lems and their impact on patient management. Extrapolat­ subjects) rivastigmine (108) significantly improved such ing from psychopharmacologic outcome studies in younger, noncognitive behaviors as delusions, hallucinations, pacing, nondemented patients with such diseases as depression and and uncooperativeness more than did placebo. However, schizophrenia has not been a satisfactory approach to devel­ these large, multicenter cholinesterase inhibitor studies ex­ oping effective pharmacologic treatments for noncognitive cluded AD patients with substantial noncognitive behav­ behavioral disturbances in elderly patients with AD and ioral problems. It is just such severely disturbed patients other dementing disorders. The clear placebo responses who must be studied prospectively to establish the clinical noted in several carefully performed pharmacologic trials in importance of cholinesterase inhibitors in the management AD patients with noncognitive behavioral problems empha­ of noncognitive behavioral problems in AD. More must be learned about fects of cholinergic enhancement on noncognitive symp­ the neurobiological substrates of psychotic and disruptive toms in AD come from a multicenter trial of the selective agitated behaviors in AD. Such knowledge is essential to M1 muscarinic cholinergic agonist xanomeline (109). Al­ the rational development of more effective pharmacothera­ though the effects of xanomeline on cognitive function dis­ peutics for these disturbing and costly problems. Raskind receives research support and/or consultant observed over the three doses of xanomeline administered. About a peculiar disease of the cerebral cortex �-Adrenergic Antagonists [1907 article translated by L. Despite substantial loss of noradrenergic locus ceruleus neu­ 2. Neuropsychiatric as­ rons in AD, studies measuring the concentrations of norepi­ pects of multi-infarct dementia and dementia of the Alzheimer type. Pharmacotherapy of agitation tissue or cerebrospinal fluid (110–112) suggest that nora­ in dementia. Behavioral symptomatology AD manifest an enhanced behavioral agitation response to in dementia of the Alzheimer type. In a recently reported placebo-controlled pilot 153:1438–1443. Mental and be­ havioral disturbances in dementia: findings from the Cache placebo in reducing disruptive agitated behaviors in elderly County study on memory in aging. Am J Psychiatry 2000;157: nursing home residents with AD. Propranolol was well tolerated nursing home admission because of disruptive behavior. J Clin placebo-controlled trials of propranolol in AD patients with Psychiatry 1987;48[Suppl 5]:9–15. Identifying patterns of disruptive behavior in long-term care residents. J Am Geriatr The database supporting guidelines for the pharmacologic Soc 1999;47:830–836. A new rating scale for medication and the quality of care in rest homes. Psychoactive medication sertraline and nortriptyline in the treatment of major depressive use in intermediate-care facility residents. JAm depression in dementia patients: a controlled clinical trial. Imipramine in the treatment in nursing home residents.

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