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November 1996, Vol 53, No. 11 >
Article | November 1996

Effects of Tryptophan Depletion in Drug-Free Adults With Autistic Disorder

Christopher McDougle, MD; Susan T. Naylor, RN, MSN; Donald J. Cohen, MD; George K. Aghajanian, MD; George R. Heninger, MD; Lawrence H. Price, MD
Arch Gen Psychiatry. 1996;53(11):993-1000. doi:10.1001/archpsyc.1996.01830110029004
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Background:  The primary objective of this study was to investigate the behavioral and biochemical responses to acute tryptophan depletion in drug-free adult patients with autistic disorder.

Methods:  Twenty drug-free adults with autistic disorder (16 men and 4 women) (mean [±SD] age, 30.5±8.5 years) underwent short-term tryptophan depletion in a double-blind, placebo-controlled, randomized cross over design. Patients received a 24-hour, lowtryptophan diet followed the next morning by an amino acid drink. Behavioral ratings were obtained on the morning of the amino acid drink (baseline) and 180, 300, and 420 minutes after the drink. Plasma free and total tryptophan levels were obtained at baseline and 5 hours after the drink. The active and sham testing sessions were separated by 7 days.

Results:  Eleven (65%) of the 17 patients who completed both test days showed a significant global worsening of behavioral symptoms with short-term tryptophan depletion, but none of the 17 patients showed any significant change in clinical status from baseline after sham depletion (P=.001). Tryptophan depletion led to a significant increase in behaviors such as whirling, flapping, pacing, banging and hitting self, rocking, and toe walking (P<.05). In addition, patients were significantly less calm and happy and more anxious. No significant change was observed in social relatedness or repetitive thoughts and behavior. Plasma total and free tryptophan levels were reduced 86% and 69%, respectively, 5 hours after the tryptophan-deficient amino acid drink. Patients who had a significant global exacerbation of symptoms had significantly higher baseline plasma total tryptophan levels (P<.001) and Autism Behavior Checklist scores (P= .005) than did patients who showedno significant change in symptoms after tryptophan depletion.

Conclusions:  The results of this study are consistent with previous research that has implicated a dysregulation in serotonin function in some patients with autism. These data suggest that the short-term reduction of serotonin precursor availability may exacerbate some symptoms characteristic of autism in some patients. Continued investigation into the role of serotonin in the pathogenesis and treatment of autistic disorder is warranted.

REFERENCES

1 +
Schain RJ, Freedman DX.  Studies on 5-hydroxyindole metabolism in autistic and other mentally retarded children . J Pediatr . 1961;;58:315-320.
2 +
Anderson GM, Freedman DX, Cohen DJ, Volkmar FR, Hoder EL, McPhedran P, Minderaa RB, Hansen CR, Young JG.  Whole blood serotonin in autistic and normal subjects . J Child Psychol Psychiatry . 1987;;28:885-900.
3 +
Hanley HG, Stahl SM, Freedman DX.  Hyperserotonemia and amine metabolites in autistic and retarded children . Arch Gen Psychiatry . 1977;;34:521-531.
4 +
Cohen DJ, Shaywitz BA, Johnson WT, Bowers MB.  Biogenic amines in autistic and atypical children: cerebrospinal fluid measures of homovanillic acid and 5-hydroxyindoleacetic acid . Arch Gen Psychiatry . 1974;;31:845-853.
5 +
Narayan M, Srinath S, Anderson GM, Meundi OB.  Cerebrospinal fluid levels of homovanillic acid and 5-hydroxyindoleacetic acid in autism . Biol Psychiatry . 1993;;33:630-635.
6 +
Geller E, Ritvo ER, Freeman BJ, Yuwiler A.  Preliminary observations on the effect of fenfluramine on blood serotonin and symptoms in three autistic boys . N Engl J Med . 1982;;307:165-169.
7 +
Campbell M.  Fenfluramine treatment of autism . J Child Psychol Psychiatry . 1988;;29:1-10.
8 +
Ekman G, Miranda-Linné F, Gillberg C, Garle M, Wetterberg L.  Fenfluramine treatment of twenty children with autism . J Autism Dev Disord . 1989;:19:511-532.
9 +
Sherman J, Factor DC, Swinson R, Darjes RW.  The effects of fenfluramine (hydrochloride) on the behaviors of fifteen autistic children . J Autism Dev Disord . 1989;;19:533-543.
10 +
Duker PC, Welles K, Seys D, Rensen H, Vis A.  Brief report: effects of fenfluramine on communicative, Stereotypie, and inappropriate behaviors of autistictype mentally handicapped individuals . J Autism Dev Disord . 1991;:21:355-363.
11 +
Chase TM, Shoulson I.  Behavioral and biochemical effects of fenfluramine in patients with neurologic disease . Postgrad Med J . 1975;;51:105-109.
12 +
Schuster CR, Lewis M, Seiden LS.  Fenfluramine: neurotoxicity . Psychopharmacol Bul 1986;;22:148-151.
13 +
Volkmar FR, Paul R, Cohen DJ, Shaywitz BA.  Irritability in autistic children treated with fenfluramine . Engl J Med . 1983;;309:187.
14 +
Hoshino Y, Tachibana JR, Watanabe M, Murata S, Yokoyama F, Kaneko M, Yashima Y, Kumoshiro H.  Serotonin metabolism and hypothalamic-pltuitary function in children with infantile autism and minimal brain dysfunction . Jpn J Psychiatry Neurol . 1984;;26:937-945.
15 +
McBride PA, Anderson GM, Hertzig ME, Sweeney JA, Kream J, Cohen DJ, Mann JJ.  Serotonergic responsivity in male young adults with autistic disorder: results of a pilot study . Arch Gen Psychiatry . 1989;;46:213-221.
16 +
McDougle CJ, Price LH, Volkmar FR, Goodman WK, Ward-O'Brien D, Nielsen J, Bregman J, Cohen DJ.  Clomipramine in autism: preliminary evidence of efficacy . J Am Acad Child Adolesc Psychiatry . 1992;;31:746-750.
17 +
Gordon CT, State RC, Nelson JE, Hamburger SD, Rapoport JL.  A double-blind comparison of clomipramine, desipramine, and placebo in the treatment of autistic disorder . Arch Gen Psychiatry . 1993;;50:441-447.
18 +
Cook EH, Rowlett R, Jaselskis C, Leventhal BL.  Fluoxetine treatment of children and adults with autistic disorder and mental retardation . J Am Acad Child Adolesc Psychiatry . 1992;;31:739-745.
19 +
Mehlinger R, Scheftner WA, Poznanski E.  Fluoxetine and autism . J Am Acad Child Adolesc Psychiatry . 1990;;29:985.
20 +
Hamdan-Allen G.  Brief report: trichotillomania in an autistic male . J Autism Dev Disord . 1991;;21:79-82.
21 +
Todd RD.  Fluoxetine in autism . Am J Psychiatry . 1991;;148:1089.
22 +
Ghaziuddin M, Tsai L, Ghaziuddin N.  Fluoxetine in autism with depression . J Am Acad Child Adolesc Psychiatry . 1991;;30:3.
23 +
McDougle CJ, Price LH, Goodman WK.  Fluvoxamine treatment of coincident autistic disorder and obsessive-compulsive disorder: a case report . J Autism Dev Disord . 1990;;20:537-543.
24 +
McDougle CJ, Naylor ST, Cohen DJ, Volkmar FR, Heninger GR, Price LH.  A double-blind, placebo-controlled study of fluvoxamine in adults with autistic disorder . Arch Gen Psychiatry . 1996;;53:1001-1008.
25 +
Rose WC, Haines WJ, Warner DT.  The amino acid requirements of man . J Biol Chem . 1954;;206:421-430.
26 +
Gal EM, Dreses PA.  Studies on the metabolism of 5-hydroxytryptamine (serotonin). II: effect of tryptophan deficiency in rats . Proc Soc Exp Biol Med . 1962;;110:368-371.
27 +
Fernstrom JD.  Effects of the diet on brain neurotransmitters . Metabolism . 1977;;26:207-223.
28 +
Curzon G.  Influence of plasma tryptophan on brain 5HT synthesis and serotonergic activity . In: Haber G, Gabay S, eds. Serotonin: Current Aspects of Neurochemistry and Function . New York, NY: Plenum Publishing Corp; 1981;:207-219.
29 +
Young SN, Ervin FR, Phil RO, Finn P.  Biochemical aspects of tryptophan depletion in primates . Psychopharmacology (Beri) . 1989;;95:508-511.
30 +
Moja EA, Cipollo P, Castoldi D, Tofanetti 0.  Dose-response decrease in plasma tryptophan and in brain tryptophan and serotonin after tryptophan-free amino acid mixtures in rats . Life Sci . 1989;;44:971-976.
31 +
Moir ATB, Eccleston D.  The effects of precursor loading in the cerebral metabolism of 5-hydroxyindoles . J Neurochem . 1968;;15:1093-1108.
32 +
Fernstrom JD, Hirsch MJ.  Rapid repletion of brain serotonin in malnourished corn-fed rats following L-tryptophan injection . Life Sci . 1975;;17:455-464.
33 +
Lytle LD, Messing RB, Fisher L, Phebus L.  Effects of long-term corn consumption on brain serotonin and the response to electric shock . Science . 1975;;190:692-694.
34 +
Messing RB, Fisher LA, Phebus L, Lytle LD.  Interaction of diet and drugs in the regulation of brain 5-hydroxyindoles and the response to painful electric shock . Life Sci . 1976;;18:707-714.
35 +
Walters JK, Davis M, Sheard MH.  Tryptophan-free diet: effects on the acoustic startle reflex in rats . Psychopharmacology . 1979;;62:103-109.
36 +
Gibbons JL, Barr GA, Bridger WH, Leibowitz SF.  Manipulations of dietary tryptophan: effects on mouse killing and brain serotonin in the rat . Brain Res . 1979;;169:139-153.
37 +
Harper AE, Benevenga NJ, Wohlhueter RM.  Effects of ingestion of disproportionate amounts of amino acids . Physiol Rev . 1970;;50:428-548.
38 +
Delgado PL, Charney DS, Price LH, Aghajanian GK, Landis H, Heninger GR.  Serotonin function and the mechanism of antidepressant action: reversal of antidepressant induced remission by rapid depletion of plasma tryptophan . Arch Gen Psychiatry . 1990;;47:411-418.
39 +
Barr LC, Goodman WK, McDougle CJ, Delgado PL, Heninger GR, Charney DS, Price LH.  Tryptophan depletion in patients with obsessive-compulsive disorder who respond to serotonin reuptake inhibitors . Arch Gen Psychiatry . 1994;;51:309-317.
40 +
Young SN, Smith SE, Pihl RD, Ervin FR.  Tryptophan depletion causes a rapid lowering of mood in normal males . Psychopharmacology (Beri) . 1985;;87:173-177.
41 +
Smith SE, Pihl RO, Young SW, Ervin FR.  A test of possible cognitive and environmental influences on the mood-lowering effect of tryptophan depletion in normal males . Psychopharmacology . 1987;;91:451-457.
42 +
Delgado PL, Price LH, Miller HL, Salomon RM, Aghajanian GK, Heninger GR, Charney DS.  Serotonin and the neurobiology of depression: effects of tryptophan depletion in drug-free depressed patients . Arch Gen Psychiatry . 1994;;51:865-874.
43 +
Barr LC, Goodman WK, Delgado PL, McDougle CJ, Price LH.  Effects of tryptophan depletion in drug-free obsessive compulsive disorder patients . Biol Psychiatry . In press.
44 +
Goddard AW, Sholomskas DE, Augeri FM, Walton KE, Charney DS, Heninger GR, Goodman WK, Price LH.  Effects of tryptophan depletion in panic disorder . Biol Psychiatry . 1994;;36:775-777.
45 +
McDougle CJ, Naylor ST, Goodman WK, Volkmar FR, Cohen DJ, Price LH.  Acute tryptophan depletion in autistic disorder: a controlled case study . Biol Psychiatry . 1993;;33:547-550.
46 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition , Revised. Washington, DC: American Psychiatric Association; 1987;.
47 +
World Health Organization. International Statistical Classification of Diseases, 10th Revision (ICD-10) . Geneva, Switzerland: World Health Organization; 1992;.
48 +
Guy W. ECDEU Assessment Manual for Psychopharmacology. Washington, DC: US Dept of Health, Education, and Welfare; 1976. Publication 76-338.
49 +
Le Couteur A, Rutter M, Lord C, Rios P, Robertson S, Holdgrafer M, McLennan J.  Autism Diagnostic Interview: a standardized investigator-based instrument . J Autism Dev Disord . 1989;;19:363-387.
50 +
Lord C, Rutter M, Goode S, Heemsbergen J, Jordan H, Mawhood L, Schopler E.  Autism Diagnostic Observation Schedule: a standardized observation of communicative and social behavior . J Autism Dev Disord . 1989;;19:185-212.
51 +
Krug DA, Arick JR, Almond PJ. Autism Screening Instrument for Education Planning . Portland, Ore: ASIEP Educational Co; 1980;.
52 +
Wechsler D. Manual for the Wechsler Adult Intelligence Scale-Revised . San Antonio, Tex: The Psychological Corp; 1981;.
53 +
Leiter RG. Leiter International Performance Scale . Chicago, Ill: Stoelting Co; 1948;.
54 +
Freeman BJ, Ritvo ER, Yokota A, Ritvo A.  A scale for rating symptoms of patients with the syndrome of autism in real life settings . J Am Acad Child Adolesc Psychiatry . 1986;;25:130-136.
55 +
Anderson GM, Young JG, Cohen DJ, Schlicht KR, Patel N.  Liquid-chromatographic determination of serotonin and tryptophan in whole blood and plasma . Clin Chem . 1981;;27:775-776.
56 +
Kruesi MJ, Rapoport JL, Hamburger S, Hibbs E, Potter WZ, Lenane M, Brown GL.  Cerebrospinal fluid monoamine metabolites, aggression, and impulsivlty in disruptive behavior disorders of children and adolescents . Arch Gen Psychiatry . 1990;;47:419-426.
57 +
Kruesi MJ, Hibbs ED, Zahn TP, Keysor CS, Hamburger SD, Bartko JJ, Rapoport JL.  A 2-year prospective follow-up study of children and adolescents with disruptive behavior disorders: prediction by cerebrospinal fluid 5-hydroxyindoleacetic acid, homovanillic acid, and autonomie measures? Arch Gen Psychiatry . 1992;;49:429-435.
58 +
Markowitz PI.  Effect of fluoxetine on self-injurious behavior in the developmentally disabled: a preliminary study . J Clin Psychopharmaco! 1992;;12:27-31.
59 +
Kelley LA, Hellings JA, Gabrielli WF, Kilgore E. Sertraline response in mentally retarded adults. Presented at the American Psychiatric Association 146th Annual Meeting; May 22-27, 1993; San Francisco, Calif.
60 +
Garber HJ, McGonigle JJ, Slomka GT, Monteverde E.  Clomipramine treatment of Stereotypie behaviors and self-injury in patients with developmental disabilities . J Am Acad Child Adolesc Psychiatry . 1992;;31:1157-1160.
61 +
Raleigh MJ, Brammer GL, Yuwiler A, Flannery JW, McGuire MT, Geller E.  Serotonergic influences on the social behavior of vervet monkeys (Cercopithecus aethiops sabaeus) . Exp Neurol . 1980;;68:322-324.
62 +
Mehlman PT, Higley JD, Faucher I, Lilly AA, Taub DM, Vickers J, Suomi SJ, Linnoila M.  Correlation of CSF 5-HIAA concentration with sociality and the timing of emigration in free-ranging primates . Am J Psychiatry . 1995;;152:907-913.
63 +
Goodman WK, Price LH, Rasmussen SA, Delgado PL, Heninger GR, Charney DS.  Efficacy of fluvoxamine in obsessive-compulsive disorder: a double-blind comparison with placebo . Arch Gen Psychiatry . 1989;;46:36-43.
64 +
Insel TR, Mueller EA, Alterman A, Linnoila M, Murphy DL.  Obsessivecompulsive disorder and serotonin: is there a connection? Biol Psychiatry . 1985;;20:1174-1188.
65 +
McDougle CJ, Kresch L, Goodman WK, Naylor ST, Volkmar FR, Cohen DJ, Price LH.  Repetitive thoughts and behaviors in adults with autistic disorder and obsessive compulsive disorder: a case-controlled study . Am J Psychiatry . 1995;;152:772-777

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Schain RJ, Freedman DX.  Studies on 5-hydroxyindole metabolism in autistic and other mentally retarded children . J Pediatr . 1961;;58:315-320.
2 +
Anderson GM, Freedman DX, Cohen DJ, Volkmar FR, Hoder EL, McPhedran P, Minderaa RB, Hansen CR, Young JG.  Whole blood serotonin in autistic and normal subjects . J Child Psychol Psychiatry . 1987;;28:885-900.
3 +
Hanley HG, Stahl SM, Freedman DX.  Hyperserotonemia and amine metabolites in autistic and retarded children . Arch Gen Psychiatry . 1977;;34:521-531.
4 +
Cohen DJ, Shaywitz BA, Johnson WT, Bowers MB.  Biogenic amines in autistic and atypical children: cerebrospinal fluid measures of homovanillic acid and 5-hydroxyindoleacetic acid . Arch Gen Psychiatry . 1974;;31:845-853.
5 +
Narayan M, Srinath S, Anderson GM, Meundi OB.  Cerebrospinal fluid levels of homovanillic acid and 5-hydroxyindoleacetic acid in autism . Biol Psychiatry . 1993;;33:630-635.
6 +
Geller E, Ritvo ER, Freeman BJ, Yuwiler A.  Preliminary observations on the effect of fenfluramine on blood serotonin and symptoms in three autistic boys . N Engl J Med . 1982;;307:165-169.
7 +
Campbell M.  Fenfluramine treatment of autism . J Child Psychol Psychiatry . 1988;;29:1-10.
8 +
Ekman G, Miranda-Linné F, Gillberg C, Garle M, Wetterberg L.  Fenfluramine treatment of twenty children with autism . J Autism Dev Disord . 1989;:19:511-532.
9 +
Sherman J, Factor DC, Swinson R, Darjes RW.  The effects of fenfluramine (hydrochloride) on the behaviors of fifteen autistic children . J Autism Dev Disord . 1989;;19:533-543.
10 +
Duker PC, Welles K, Seys D, Rensen H, Vis A.  Brief report: effects of fenfluramine on communicative, Stereotypie, and inappropriate behaviors of autistictype mentally handicapped individuals . J Autism Dev Disord . 1991;:21:355-363.
11 +
Chase TM, Shoulson I.  Behavioral and biochemical effects of fenfluramine in patients with neurologic disease . Postgrad Med J . 1975;;51:105-109.
12 +
Schuster CR, Lewis M, Seiden LS.  Fenfluramine: neurotoxicity . Psychopharmacol Bul 1986;;22:148-151.
13 +
Volkmar FR, Paul R, Cohen DJ, Shaywitz BA.  Irritability in autistic children treated with fenfluramine . Engl J Med . 1983;;309:187.
14 +
Hoshino Y, Tachibana JR, Watanabe M, Murata S, Yokoyama F, Kaneko M, Yashima Y, Kumoshiro H.  Serotonin metabolism and hypothalamic-pltuitary function in children with infantile autism and minimal brain dysfunction . Jpn J Psychiatry Neurol . 1984;;26:937-945.
15 +
McBride PA, Anderson GM, Hertzig ME, Sweeney JA, Kream J, Cohen DJ, Mann JJ.  Serotonergic responsivity in male young adults with autistic disorder: results of a pilot study . Arch Gen Psychiatry . 1989;;46:213-221.
16 +
McDougle CJ, Price LH, Volkmar FR, Goodman WK, Ward-O'Brien D, Nielsen J, Bregman J, Cohen DJ.  Clomipramine in autism: preliminary evidence of efficacy . J Am Acad Child Adolesc Psychiatry . 1992;;31:746-750.
17 +
Gordon CT, State RC, Nelson JE, Hamburger SD, Rapoport JL.  A double-blind comparison of clomipramine, desipramine, and placebo in the treatment of autistic disorder . Arch Gen Psychiatry . 1993;;50:441-447.
18 +
Cook EH, Rowlett R, Jaselskis C, Leventhal BL.  Fluoxetine treatment of children and adults with autistic disorder and mental retardation . J Am Acad Child Adolesc Psychiatry . 1992;;31:739-745.
19 +
Mehlinger R, Scheftner WA, Poznanski E.  Fluoxetine and autism . J Am Acad Child Adolesc Psychiatry . 1990;;29:985.
20 +
Hamdan-Allen G.  Brief report: trichotillomania in an autistic male . J Autism Dev Disord . 1991;;21:79-82.
21 +
Todd RD.  Fluoxetine in autism . Am J Psychiatry . 1991;;148:1089.
22 +
Ghaziuddin M, Tsai L, Ghaziuddin N.  Fluoxetine in autism with depression . J Am Acad Child Adolesc Psychiatry . 1991;;30:3.
23 +
McDougle CJ, Price LH, Goodman WK.  Fluvoxamine treatment of coincident autistic disorder and obsessive-compulsive disorder: a case report . J Autism Dev Disord . 1990;;20:537-543.
24 +
McDougle CJ, Naylor ST, Cohen DJ, Volkmar FR, Heninger GR, Price LH.  A double-blind, placebo-controlled study of fluvoxamine in adults with autistic disorder . Arch Gen Psychiatry . 1996;;53:1001-1008.
25 +
Rose WC, Haines WJ, Warner DT.  The amino acid requirements of man . J Biol Chem . 1954;;206:421-430.
26 +
Gal EM, Dreses PA.  Studies on the metabolism of 5-hydroxytryptamine (serotonin). II: effect of tryptophan deficiency in rats . Proc Soc Exp Biol Med . 1962;;110:368-371.
27 +
Fernstrom JD.  Effects of the diet on brain neurotransmitters . Metabolism . 1977;;26:207-223.
28 +
Curzon G.  Influence of plasma tryptophan on brain 5HT synthesis and serotonergic activity . In: Haber G, Gabay S, eds. Serotonin: Current Aspects of Neurochemistry and Function . New York, NY: Plenum Publishing Corp; 1981;:207-219.
29 +
Young SN, Ervin FR, Phil RO, Finn P.  Biochemical aspects of tryptophan depletion in primates . Psychopharmacology (Beri) . 1989;;95:508-511.
30 +
Moja EA, Cipollo P, Castoldi D, Tofanetti 0.  Dose-response decrease in plasma tryptophan and in brain tryptophan and serotonin after tryptophan-free amino acid mixtures in rats . Life Sci . 1989;;44:971-976.
31 +
Moir ATB, Eccleston D.  The effects of precursor loading in the cerebral metabolism of 5-hydroxyindoles . J Neurochem . 1968;;15:1093-1108.
32 +
Fernstrom JD, Hirsch MJ.  Rapid repletion of brain serotonin in malnourished corn-fed rats following L-tryptophan injection . Life Sci . 1975;;17:455-464.
33 +
Lytle LD, Messing RB, Fisher L, Phebus L.  Effects of long-term corn consumption on brain serotonin and the response to electric shock . Science . 1975;;190:692-694.
34 +
Messing RB, Fisher LA, Phebus L, Lytle LD.  Interaction of diet and drugs in the regulation of brain 5-hydroxyindoles and the response to painful electric shock . Life Sci . 1976;;18:707-714.
35 +
Walters JK, Davis M, Sheard MH.  Tryptophan-free diet: effects on the acoustic startle reflex in rats . Psychopharmacology . 1979;;62:103-109.
36 +
Gibbons JL, Barr GA, Bridger WH, Leibowitz SF.  Manipulations of dietary tryptophan: effects on mouse killing and brain serotonin in the rat . Brain Res . 1979;;169:139-153.
37 +
Harper AE, Benevenga NJ, Wohlhueter RM.  Effects of ingestion of disproportionate amounts of amino acids . Physiol Rev . 1970;;50:428-548.
38 +
Delgado PL, Charney DS, Price LH, Aghajanian GK, Landis H, Heninger GR.  Serotonin function and the mechanism of antidepressant action: reversal of antidepressant induced remission by rapid depletion of plasma tryptophan . Arch Gen Psychiatry . 1990;;47:411-418.
39 +
Barr LC, Goodman WK, McDougle CJ, Delgado PL, Heninger GR, Charney DS, Price LH.  Tryptophan depletion in patients with obsessive-compulsive disorder who respond to serotonin reuptake inhibitors . Arch Gen Psychiatry . 1994;;51:309-317.
40 +
Young SN, Smith SE, Pihl RD, Ervin FR.  Tryptophan depletion causes a rapid lowering of mood in normal males . Psychopharmacology (Beri) . 1985;;87:173-177.
41 +
Smith SE, Pihl RO, Young SW, Ervin FR.  A test of possible cognitive and environmental influences on the mood-lowering effect of tryptophan depletion in normal males . Psychopharmacology . 1987;;91:451-457.
42 +
Delgado PL, Price LH, Miller HL, Salomon RM, Aghajanian GK, Heninger GR, Charney DS.  Serotonin and the neurobiology of depression: effects of tryptophan depletion in drug-free depressed patients . Arch Gen Psychiatry . 1994;;51:865-874.
43 +
Barr LC, Goodman WK, Delgado PL, McDougle CJ, Price LH.  Effects of tryptophan depletion in drug-free obsessive compulsive disorder patients . Biol Psychiatry . In press.
44 +
Goddard AW, Sholomskas DE, Augeri FM, Walton KE, Charney DS, Heninger GR, Goodman WK, Price LH.  Effects of tryptophan depletion in panic disorder . Biol Psychiatry . 1994;;36:775-777.
45 +
McDougle CJ, Naylor ST, Goodman WK, Volkmar FR, Cohen DJ, Price LH.  Acute tryptophan depletion in autistic disorder: a controlled case study . Biol Psychiatry . 1993;;33:547-550.
46 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition , Revised. Washington, DC: American Psychiatric Association; 1987;.
47 +
World Health Organization. International Statistical Classification of Diseases, 10th Revision (ICD-10) . Geneva, Switzerland: World Health Organization; 1992;.
48 +
Guy W. ECDEU Assessment Manual for Psychopharmacology. Washington, DC: US Dept of Health, Education, and Welfare; 1976. Publication 76-338.
49 +
Le Couteur A, Rutter M, Lord C, Rios P, Robertson S, Holdgrafer M, McLennan J.  Autism Diagnostic Interview: a standardized investigator-based instrument . J Autism Dev Disord . 1989;;19:363-387.
50 +
Lord C, Rutter M, Goode S, Heemsbergen J, Jordan H, Mawhood L, Schopler E.  Autism Diagnostic Observation Schedule: a standardized observation of communicative and social behavior . J Autism Dev Disord . 1989;;19:185-212.
51 +
Krug DA, Arick JR, Almond PJ. Autism Screening Instrument for Education Planning . Portland, Ore: ASIEP Educational Co; 1980;.
52 +
Wechsler D. Manual for the Wechsler Adult Intelligence Scale-Revised . San Antonio, Tex: The Psychological Corp; 1981;.
53 +
Leiter RG. Leiter International Performance Scale . Chicago, Ill: Stoelting Co; 1948;.
54 +
Freeman BJ, Ritvo ER, Yokota A, Ritvo A.  A scale for rating symptoms of patients with the syndrome of autism in real life settings . J Am Acad Child Adolesc Psychiatry . 1986;;25:130-136.
55 +
Anderson GM, Young JG, Cohen DJ, Schlicht KR, Patel N.  Liquid-chromatographic determination of serotonin and tryptophan in whole blood and plasma . Clin Chem . 1981;;27:775-776.
56 +
Kruesi MJ, Rapoport JL, Hamburger S, Hibbs E, Potter WZ, Lenane M, Brown GL.  Cerebrospinal fluid monoamine metabolites, aggression, and impulsivlty in disruptive behavior disorders of children and adolescents . Arch Gen Psychiatry . 1990;;47:419-426.
57 +
Kruesi MJ, Hibbs ED, Zahn TP, Keysor CS, Hamburger SD, Bartko JJ, Rapoport JL.  A 2-year prospective follow-up study of children and adolescents with disruptive behavior disorders: prediction by cerebrospinal fluid 5-hydroxyindoleacetic acid, homovanillic acid, and autonomie measures? Arch Gen Psychiatry . 1992;;49:429-435.
58 +
Markowitz PI.  Effect of fluoxetine on self-injurious behavior in the developmentally disabled: a preliminary study . J Clin Psychopharmaco! 1992;;12:27-31.
59 +
Kelley LA, Hellings JA, Gabrielli WF, Kilgore E. Sertraline response in mentally retarded adults. Presented at the American Psychiatric Association 146th Annual Meeting; May 22-27, 1993; San Francisco, Calif.
60 +
Garber HJ, McGonigle JJ, Slomka GT, Monteverde E.  Clomipramine treatment of Stereotypie behaviors and self-injury in patients with developmental disabilities . J Am Acad Child Adolesc Psychiatry . 1992;;31:1157-1160.
61 +
Raleigh MJ, Brammer GL, Yuwiler A, Flannery JW, McGuire MT, Geller E.  Serotonergic influences on the social behavior of vervet monkeys (Cercopithecus aethiops sabaeus) . Exp Neurol . 1980;;68:322-324.
62 +
Mehlman PT, Higley JD, Faucher I, Lilly AA, Taub DM, Vickers J, Suomi SJ, Linnoila M.  Correlation of CSF 5-HIAA concentration with sociality and the timing of emigration in free-ranging primates . Am J Psychiatry . 1995;;152:907-913.
63 +
Goodman WK, Price LH, Rasmussen SA, Delgado PL, Heninger GR, Charney DS.  Efficacy of fluvoxamine in obsessive-compulsive disorder: a double-blind comparison with placebo . Arch Gen Psychiatry . 1989;;46:36-43.
64 +
Insel TR, Mueller EA, Alterman A, Linnoila M, Murphy DL.  Obsessivecompulsive disorder and serotonin: is there a connection? Biol Psychiatry . 1985;;20:1174-1188.
65 +
McDougle CJ, Kresch L, Goodman WK, Naylor ST, Volkmar FR, Cohen DJ, Price LH.  Repetitive thoughts and behaviors in adults with autistic disorder and obsessive compulsive disorder: a case-controlled study . Am J Psychiatry . 1995;;152:772-777

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To understand the clinical management of acute heart failure syndromes.
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Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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