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Lisa Capaldini, a physician who treats HIV-positive patients in San Francisco, discusses the multiple causes of fatigue. HIV-related fatigue is easy to overlook because it is attributed to be a normal part of HIV disease and begins slowly, worsening over time. It is important for HIV-positive patients and their doctors to maintain a fatigue inventory every few months to chronicle and compare energy levels to previous periods. For most patients, the cause of fatigue can be identified and treated. Fatigue can be categorized into several types, including: physical, psychological, morning, depression, and hypogonadism. Physical fatigue, usually evident after performing a specific activity, may be caused by anemia, chronic diarrhea or pain, or malaise from HIV treatments. Psychological fatigue can be divided into two categories: motivational, no will to do anything because the activities no longer are pleasurable (termed anhedonia), and mental, classified as diminished attention span, inability to concentrate, or difficulty calculating. Morning fatigue is evidenced by waking up tired and remaining tired, signaling a possible symptom of depression. Hypogonadism, caused by low levels of androgens and/or other sex hormones, produces a listless, depressed mood, and trouble concentrating. Treatment for hypogonadism differs for men and women, but consists of measuring androgens and restoring them to an adequate level with testosterone replacement. Testosterone replacement is available in an intramuscular shot, Testoderm and Androderm patches, or gels. Testosterone therapy for women requires the interaction of a primary physician who is familiar with hormone replacement therapy. Capaldini recommends CBCs, testosterone levels, DHEA levels, chemistry panels, and echocardiograms to diagnose fatigue.
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PMID:Fatigue and HIV: interview with Lisa Capaldini, M.D. Interview by John S. James. 1136 45

Depression is difficult to diagnose in the terminally ill patient. As a result, it frequently is not treated. This has can have an adverse effect on quality of life and make the palliation of physical symptoms more difficult. In an effort to improve the detection of depression, many palliative care teams are using the Hospital Anxiety and Depression (HAD) scale as a screening tool. The HAD was devised for use in general medical settings and has not been validated for use in palliative care patients. One hundred patients receiving palliative care with an estimated prognosis of 6 months or less were invited to complete the HAD and a semi-structured psychiatric interview, the Present State Examination. The depression and anxiety subscales of the HAD showed poor efficacy for screening when used alone. The optimum threshold was at a combined cut-off of 19, which had a sensitivity of 68% and specificity of 67%. The major construct of the HAD is anhedonia, which may be present at the end of life due to increasing physical illness and may not be pathognomic of a depressive illness in this population. We recommend, therefore, that if the HAD is used as a screening tool in palliative care, it should be as a combined scale, but low sensitivity and specificity may lead to poor efficacy as a screening tool.
J Pain Symptom Manage 2001 Dec
PMID:An analysis of the validity of the Hospital Anxiety and Depression scale as a screening tool in patients with advanced metastatic cancer. 1173 61

Evolutionary biologists use Darwinian theory and functional design ("reverse engineering") analyses, to develop and test hypotheses about the adaptive functions of traits. Based upon a consideration of human social life and a functional design analysis of depression's core symptomatology we offer a comprehensive theory of its adaptive significance called the Social Navigation Hypothesis (SNH). The SNH attempts to account for all intensities of depression based on standard evolutionary theories of sociality, communication and psychological pain. The SNH suggests that depression evolved to perform two complimentary social problem-solving functions. First, depression induces cognitive changes that focus and enhance capacities for the accurate analysis and solution of key social problems, suggesting a social rumination function. Second, the costs associated with the anhedonia and psychomotor perturbation of depression can persuade reluctant social partners to provide help or make concessions via two possible mechanisms, namely, honest signaling and passive, unintentional fitness extortion. Thus it may also have a social motivation function.
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PMID:Toward a revised evolutionary adaptationist analysis of depression: the social navigation hypothesis. 1220 12

Diagnosing depression in cancer patients has been challenging because the diagnostic criteria include somatic symptoms frequently attributed to the cancer itself or its treatment. However, few studies have explored how to appropriately deal with individual somatic symptoms. The authors used data from 220 cancer patients with major depression to examine the intercorrelations among the DSM-IV somatic and nonsomatic symptom criteria as well as whether the presence of an individual somatic symptom could discriminate the severity of major depression. Appetite changes and a diminished ability to think were positively associated with anhedonia. Sleep disturbance and fatigue were not significantly associated with nonsomatic symptoms. These associations were consistent after adjusting for physical functioning and pain. Only patients with appetite changes showed a higher severity of depression. These results suggest that individual somatic symptoms differ in nature and that appetite-related symptoms and a diminished ability to think may be useful for diagnosing depression in cancer patients, whereas sleep disturbances and fatigue may not be as useful.
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PMID:Somatic symptoms for diagnosing major depression in cancer patients. 1272 6

In this paper, an extraordinary mother-son relationship involving 46 year-old, married, male patient with three children is discussed. He had never had any psychiatric complaint until his mother's death. However, he developed severe depressive and somatic symptoms following his 80 year-old mother's death. He showed no significant improvement after previous outpatient treatments and was admitted to the Psychiatric Department of Ege University School of Medicine with complaints of tension, insomnia, fatigue, anhedonia, hopelessness and pain all over his body. It was discovered that this man, who was loved and respected by both his family and his peers, used to suck his mother's breast twice daily. This act was no secret and was not considered a reason for seeking psychiatric help, a symptom of a disorder, or a source of distress for the son, mother, or any other family member. A phenomenon like this has never been reported in the literature before. We discuss this phenomenon through the dynamic formulation of the case using data from his psychiatric and developmental history as well as direct observation and psychological tests.
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PMID:[Forty-six year old baby]. 1456 74

Adapting to psychosocial and physical changes can trigger nonspecific somatic complaints and depression. Somatization has been noted in all societies and cultures; however, it is more frequently observed in Asian populations. This study used the Geriatric Depression Scale (GDS) to screen 100 Taiwanese American older adults for depressive symptoms and found that seven participants (7%) experienced depressive symptoms (GDS >/= 14). Although the mean number of illnesses reported was significantly higher (t = -16.8, P <.001) in the depressive group, the seven individuals did not focus on physical symptoms during interview. They reported guilt, sadness, anger, resentment, loneliness, helplessness, hopelessness, inability to enjoy activities, and anhedonia. If older adults are given the time to express themselves, they are able to reveal their emotional pain and distress rather than remain preoccupied with somatic complaints. A simple depression screening tool, such as the GDS, can help detect depression.
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PMID:Is somatization a significant depressive symptom in older Taiwanese Americans? 1519 75

Although their disease processes and treatments are different, patients with motor neurone disease (MND) and those with late-stage cancer share a common situation--one in which the quality of life, rather than a cure, becomes the focus of care. We report here a comparison of 126 patients with MND and 125 with metastatic cancer on a range of physical and psychosocial measures. Compared to cancer patients, MND patients were younger, had greater social contacts, but were more physically impaired. Cancer patients had more pain and were on more medication (opioids, steroids, and analgesics). Although the Beck depression scores were similar in both groups, MND patients had significantly higher scores for demoralization, hopelessness, and suicidal ideation. Cancer patients, on the other hand, scored significantly higher on anhedonia. We suggest this difference in the quality of depression represents a difference in illness experience of the two groups and has relevance for the ways we treat depression in the medically ill.
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PMID:A comparison of psychosocial and physical functioning in patients with motor neurone disease and metastatic cancer. 1633 72

Pleasant and unpleasant flavors and odors can modulate pain perception, and the efficacy of sweet flavors in reducing pain seems to be related to its hedonic value. Chronic variate stress paradigm is a model of depression, and is suggested to induce anhedonia. We observed previously that lithium may prevent behavioral and neurochemical alterations induced by chronic stress; so we hypothesized that chronically stressed animals may present different nociceptive response to pleasant and unpleasant tastes that could be prevented by lithium treatment. Adult male Wistar rats were divided into four groups, control and stressed, treated or not with lithium. A Chronic Variate Stress paradigm was used, and lithium was added to the chow. After 40 days of treatment, the tail flick latency of the animals was evaluated, and rats were immediately placed in a box with access to a 5% acetic acid solution (acid flavor). After 5 min, tail flick latency was measured again. On the following day, animals were submitted to the same procedure, with the substitution of acetic acid by condensed sweet milk (sweet flavor). The stressed group was the only group who did not present analgesia after sweet taste exposition. All groups, except the control group, presented increased tail flick latency after exposition to the acid flavor. These results indicate that pleasant and unpleasant flavors present different relevance for the induction of antinociception in stressed animals, and the absence of sweet flavor-induced analgesia may represent an anhedonic effect of the chronic variate stress paradigm. On the other hand, perception of different flavors may be more prominent in animals treated with lithium.
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PMID:The nociceptive response of stressed and lithium-treated rats is differently modulated by different flavors. 1680 30

Deep brain stimulation (DBS) to different sites allows interfering with dysfunctional network function implicated in major depression. Because a prominent clinical feature of depression is anhedonia--the inability to experience pleasure from previously pleasurable activities--and because there is clear evidence of dysfunctions of the reward system in depression, DBS to the nucleus accumbens might offer a new possibility to target depressive symptomatology in otherwise treatment-resistant depression. Three patients suffering from extremely resistant forms of depression, who did not respond to pharmacotherapy, psychotherapy, and electroconvulsive therapy, were implanted with bilateral DBS electrodes in the nucleus accumbens. Stimulation parameters were modified in a double-blind manner, and clinical ratings were assessed at each modification. Additionally, brain metabolism was assessed 1 week before and 1 week after stimulation onset. Clinical ratings improved in all three patients when the stimulator was on, and worsened in all three patients when the stimulator was turned off. Effects were observable immediately, and no side effects occurred in any of the patients. Using FDG-PET, significant changes in brain metabolism as a function of the stimulation in fronto-striatal networks were observed. No unwanted effects of DBS other than those directly related to the surgical procedure (eg pain at sites of implantation) were observed. Dysfunctions of the reward system--in which the nucleus accumbens is a key structure--are implicated in the neurobiology of major depression and might be responsible for impaired reward processing, as evidenced by the symptom of anhedonia. These preliminary findings suggest that DBS to the nucleus accumbens might be a hypothesis-guided approach for refractory major depression.
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PMID:Deep brain stimulation to reward circuitry alleviates anhedonia in refractory major depression. 2654 64

Although still considered a paradigmatic movement disorder, Parkinson's disease (PD) is associated with a broad spectrum of non-motor symptoms. These include disorders of mood and affect with apathy, anhedonia and depression, cognitive dysfunction and hallucinosis, as well as complex behavioural disorders. Sensory dysfunction with hyposmia or pain is almost universal, as are disturbances of sleep-wake cycle regulation. Autonomic dysfunction including orthostatic hypotension, urogenital dysfunction and constipation is also present to some degree in a majority of patients. Whilst overall non-motor symptoms become increasingly prevalent with advancing disease, many of them can also antedate the first occurrence of motor signs - most notably depression, hyposmia or rapid eye movement sleep behaviour disorder (RBD). Although exact clinicopathological correlations for most of these non-motor features are still poorly understood, the occurrence of constipation, RBD or hyposmia prior to the onset of clinically overt motor dysfunction would appear consistent with the ascending hypothesis of PD pathology proposed by Braak and colleagues. Screening these early non-motor features might, therefore, be one approach towards early 'preclinical' diagnosis of PD. This review article provides an overview of the clinical spectrum of non-motor symptoms in PD together with a brief review of treatment options.
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PMID:Non-motor symptoms in Parkinson's disease. 1835 32


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