Repetitive transcranial magnetic stimulation in psychiatry

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive and relatively painless tool that has been used to study various cognitive functions as well as to understand the brain–behavior relationship in normal individuals as well as in those with various neuropsychiatric disorders. It has also been used as a therapeutic tool in various neuropsychiatric disorders because of its ability to specifically modulate distinct brain areas. Studies have shown that repeated stimulation at low frequency produces long-lasting inhibition, which is called as long-term depression, whereas repeated high-frequency stimulation can produce excitation through long-term potentiation. This paper reviews the current status of rTMS as an investigative and therapeutic modality in various neuropsychiatric disorders. It has been used to study the cortical and subcortical functions, neural plasticity and brain mapping in normal individuals and in various neuropsychiatric disorders. rTMS has been most promising in the treatment of depression, with an overall milder adverse effect profile compared with electroconvulsive therapy. In other neuropsychiatric disorders such as schizophrenia, mania, epilepsy and substance abuse, it has been found to be useful, although further studies are required to establish therapeutic efficacy. It appears to be ineffective in the treatment of obsessive compulsive disorder. There is a paucity of studies of efficacy and safety of rTMS in pediatric and geriatric population. Although it appears safe, further research is required to optimize its efficacy and reduce the side-effects. Magnetic seizure therapy, which involves producing seizures akin to electroconvulsive therapy, appears to be of comparable efficacy in the treatment of depression with less cognitive adverse effects.

Stage-specific gender differences in cognitive and neuropsychiatric manifestations of vascular dementia

Studies on gender differences in the clinical manifestations of vascular dementia (VaD) are still lacking. In the present study, gender comparisons of cognitive and neuropsychiatric profiles were conducted separately for mild and moderate-to-severe VaD in a total of 467 patients with VaD. There were no significant gender differences in cognitive manifestations, except that females performed better on immediate verbal recall than males in mild stage. Women were more likely to exhibit delusions (15.5% vs 7.4%), hallucinations (9.5% vs 3.4%), and depression (43.1% vs 27.3%) in mild stage. The predominance of male patients was observed in apathy at moderate-to-severe stage (50.5% vs 34.8%). To conclude, gender differences existed in neuropsychiatric symptoms of VaD and were especially pronounced in mild stage. Delusions, hallucinations, and depression were more prevalent in females in mild VaD, with the male predominance only in apathy in the later stage.

Behavioral and psychological symptoms and hippocampal atrophy in subcortical ischaemic vascular disease

Background

Neuropsychiatric symptoms are common in patients with cognitive impairments, mediated by both neurodegenerative processes and cerebrovascular disease. Previous studies have reported that Behavioral and Psychological Symptoms of Dementia (BPSD) might correlate with severity of cognitive decline. Thus far, the impact of the association between white-matter hyperintensities (WHM) and hippocampal atrophy (HA) on the incidence of these symptoms has been less studied.

Objective

This cross-sectional study aimed to describe the clinical profile of a sample with large extensions of WMH, examining the association between different degrees of HA and cognitive, functional, and behavioral status.

Methods

Fifty outpatients (mean age: 76.86±8.70 years; 58% female; mean schooling: 7.44±4.69 years) with large extensions of WMH (modified-Fazekas scale=3) on MRI and different degrees of hippocampal atrophy (according to de Leon Score) underwent cognitive, functional, and behavioral assessments.

Results

Patients with mild-moderate to severe HA had worse performance on the Mini-Mental State Examination, Cambridge Cognitive Examination, Clinical Dementia Rating and Pfeffer's Functional Activities Questionnaire, compared to the group with none or questionable HA. Appetite/Eating Behavior was the only cluster of neuropsychiatric symptoms associated with presence of HA in Vascular Cognitive Impairment patients.

Discussion

Although HA may exhibit distinct impact on cognitive performance and functional status, it appears to have little effect on behavioral symptoms in patients with high severity WMH.

Clinical research with transcranial direct current stimulation (tDCS): challenges and future directions

BACKGROUND

Transcranial direct current stimulation (tDCS) is a neuromodulatory technique that delivers low-intensity, direct current to cortical areas facilitating or inhibiting spontaneous neuronal activity. In the past 10 years, tDCS physiologic mechanisms of action have been intensively investigated giving support for the investigation of its applications in clinical neuropsychiatry and rehabilitation. However, new methodologic, ethical, and regulatory issues emerge when translating the findings of preclinical and phase I studies into phase II and III clinical studies. The aim of this comprehensive review is to discuss the key challenges of this process and possible methods to address them.

METHODS

We convened a workgroup of researchers in the field to review, discuss, and provide updates and key challenges of tDCS use in clinical research.

MAIN FINDINGS/DISCUSSION

We reviewed several basic and clinical studies in the field and identified potential limitations, taking into account the particularities of the technique. We review and discuss the findings into four topics: (1) mechanisms of action of tDCS, parameters of use and computer-based human brain modeling investigating electric current fields and magnitude induced by tDCS; (2) methodologic aspects related to the clinical research of tDCS as divided according to study phase (ie, preclinical, phase I, phase II, and phase III studies); (3) ethical and regulatory concerns; and (4) future directions regarding novel approaches, novel devices, and future studies involving tDCS. Finally, we propose some alternative methods to facilitate clinical research on tDCS.

[Thalamic Stroke and Associated Behavior Disorders. Possibilities for Integral Management: Case Report]

INTRODUCTION

Since ancient Greece, cerebrovascular accidents have been described with no variation. Even today, they are still a catastrophic event in the lives of patients with a high risk of disabling sequelae.

METHODOLOGY

Case report of a 56-year male patient with thalamic ischemia.

RESULTS

The intervention with integral strategies involving pharmacological management and cognitive interventions was decisive for the satisfactory evolution of the patient.

CONCLUSIONS

The management of patients with cerebrovascular accidents cannot be limited to the emergency room. Pharmacological advances in programs and cognitive intervention methods provide intervention tools from the very beginning of the stroke thus reducing the impact of long-term sequelae, and consequently enabling a better reintegration of the patient to his family.

Atypical presentation of tuberous sclerosis and obsessive compulsive disorder in an adult male

Tuberous Sclerosis (TSC) is clinically marked by a triad of adenoma sebaceum, epilepsy and mental retardation. It can however manifest as various neuropsychiatric disorders. We report a patient who presented with TSC and co-morbid Obsessive Compulsive Disorder.

CNS effects of CB2 cannabinoid receptors: beyond neuro-immuno-cannabinoid activity

There are two well characterized cannabinoid receptors (CBRs), CB1-Rs and CB2-Rs, with other candidates, such as GPR55, PPARs and vanilloid TRPV1 (VR1) receptors, which are either activated by cannabinoids and/or endocannabinoids (eCBs). The neuronal and functional expression of CB2-Rs in the brain has been much less well characterized in comparison with the expression of the ubiquitous CB1-Rs. CB2-Rs were previously thought to be predominantly expressed in immune cells in the periphery and were traditionally referred to as peripheral CB2-Rs. We and others have now demonstrated the expression of CB2-Rs in neuronal, glial and endothelial cells in the brain, and this warrants a re-evaluation of the CNS effects of CB2-Rs. In the present review we summarize our current understanding of CNR2 genomic structure, its polymorphic nature, subtype specificity, from mice to human subjects, and its variants that confer vulnerabilities to neuropsychiatric disorders beyond neuro-immuno-cannabinoid activity.

The relation between depression and parkin genotype: the CORE-PD study

BACKGROUND

Mutations in parkin are a known genetic risk factor for early onset Parkinson's disease (EOPD) but their role in non-motor manifestations is not well established. Genetic factors for depression are similarly not well characterized. We investigate the role of parkin mutations in depression among those with EOPD and their relatives.

METHODS

We collected psychiatric information using the Patient Health Questionnaire and Beck Depression Inventory II on 328 genotyped individuals including 88 probands with early onset PD (41 with parkin mutations, 47 without) and 240 first and second-degree relatives without PD.

RESULTS

Genotype was not associated with depression risk among probands. Among unaffected relatives of EOPD cases, only compound heterozygotes (n = 4), and not heterozygotes, had significantly increased risk of depressed mood (OR = 14.1; 95% CI 1.2-163.4), moderate to severe depression (OR = 17.8; 95% CI 1.0-332.0), depression (score ≥ 15) on the Beck Depression Inventory II (BDI-II) (OR = 51.9; 95% CI 4.1-657.4), and BDI-II total depression score (β = 8.4; 95% CI 2.4-11.3) compared to those without parkin mutations.

CONCLUSIONS

Relatives of EOPD cases with compound heterozygous mutations and without diagnosed PD may have a higher risk of depression compared to relatives without parkin mutations. These findings support evidence of a genetic contribution to depression and may extend the phenotypic spectrum of parkin mutations to include non-motor manifestations that precede the development of PD.

Behavioral variant frontotemporal dementia with corticobasal degeneration pathology: phenotypic comparison to bvFTD with Pick's disease

Patients with corticobasal degeneration (CBD) pathology present with diverse clinical syndromes also associated with other neuropathologies, including corticobasal syndrome, progressive nonfluent aphasia, and an Alzheimer's-type dementia. Some present with behavioral variant frontotemporal dementia (bvFTD), though this subtype still requires more detailed clinical characterization. All patients with CBD pathology and clinical assessment were reviewed (N = 17) and selected if they initially met criteria for bvFTD [bvFTD(CBD), N = 5]. Available bvFTD patients with Pick's [bvFTD(Pick's), N = 5] were selected as controls. Patients were also compared to healthy older controls [N = 53] on neuropsychological and neuroimaging measures. At initial presentation, bvFTD(CBD) showed few neuropsychological or motor differences from bvFTD(Pick's). Neuropsychiatrically, they were predominantly apathetic with less florid social disinhibition and eating disturbances, and were more anxious than bvFTD(Pick's) patients. Voxel-based morphometry revealed similar patterns of predominantly frontal atrophy between bvFTD groups, though overall degree of atrophy was less severe in bvFTD(CBD), who also showed comparative preservation of the frontoinsular rim, with dorsal > ventral frontal atrophy, and sparing of temporal and parietal structures relative to bvFTD(Pick's) patients. Despite a remarkable overlap between the two patient types, bvFTD patients with underlying CBD pathology show subtle clinical features that may distinguish them from patients with Pick's disease neuropathology.

The neuropsychiatric aspects of influenza/swine flu: A selective review

The world witnessed the influenza virus during the seasonal epidemics and pandemics. The current strain of H1N1 (swine flu) pandemic is believed to be the legacy of the influenza pandemic (1918-19). The influenza virus has been implicated in many neuropsychiatric disorders. In view of the recent pandemic, it would be interesting to review the neuropsychiatric aspects of influenza, specifically swine flu. Author used popular search engine 'PUBMED' to search for published articles with different MeSH terms using Boolean operator (AND). Among these, a selective review of the published literature was done. Acute manifestations of swine flu varied from behavioral changes, fear of misdiagnosis during outbreak, neurological features like seizures, encephalopathy, encephalitis, transverse myelitis, aseptic meningitis, multiple sclerosis, and Guillian-Barre Syndrome. Among the chronic manifestations, schizophrenia, Parkinson's disease, mood disorder, dementia, and mental retardation have been hypothesized. Further research is required to understand the etiological hypothesis of the chronic manifestations of influenza. The author urges neuroscientists around the world to make use of the current swine flu pandemic as an opportunity for further research.

Psychiatric disorders in primary focal dystonia and in Parkinson's disease

BACKGROUND

Primary focal dystonia and Parkinson's disease are movement disorders that have contrasting motor phenotypes. The aim of this study was to compare the frequency and the severity of psychiatric disorders in primary focal dystonia and Parkinson's disease.

METHODS

Two groups of 30 patients matched by gender and age underwent a neurological and psychiatric assessment.

RESULTS

Parkinson's disease patients were diagnosed with higher rates of major depression (P = 0.02) and generalized anxiety disorder (P = 0.02), and greater severity of depressive symptoms (P = 0.04), while patients with primary focal dystonia exhibited increased severity of obsessive-compulsive symptoms (P = 0.02).

DISCUSSION

The difference in pathophysiology of primary focal dystonia and Parkinson's disease may explain the different psychiatric profiles of these two diseases. The increased frequency of affective symptoms in Parkinson's disease may be related to the fact that Parkinson's disease is a neurodegenerative disease marked by the loss of monoaminergic neurons which does not happen in primary focal dystonia.

CONCLUSION

The psychiatric profile differs in movement disorders with distinct neurobiological bases.

Did you rule out neurosyphilis?

Neurosyphilis, formerly a frequent cause of dementia, is now a rare condition in developed countries. However, syphilis remains common in many developing countries, where adequate diagnosis and treatment of early syphilis may be lacking, increasing the chances of neurosyphilis and prevalence of syphilitic dementia.

Multi-modal hallucinations and cognitive function in Parkinson's disease

BACKGROUND/AIMS

Hallucinations have been linked to a constellation of cognitive deficits in Parkinson's disease (PD), but it is not known whether multi-modal hallucinations are associated with greater neuropsychological dysfunction.

METHODS

152 idiopathic PD patients were categorized based on the presence or absence of hallucinations and then were further subdivided into visual-only (VHonly; n = 35) or multi-modal (VHplus; n = 12) hallucination groups. All participants underwent detailed neuropsychological assessment.

RESULTS

Participants with hallucinations performed more poorly on select neuropsychological measures and exhibited more mood symptoms. There were no differences between VHonly and VHplus groups.

CONCLUSIONS

PD patients with multi-modal hallucinations are not at greater risk for neuropsychological impairment than those with single-modal hallucinations.

Recurrent schizophrenia-like psychosis as first manifestation of epilepsy: a diagnostic challenge in neuropsychiatry

Since the 1950s, several studies have been carried out to investigate the occurrence of schizophrenia-like psychoses in epilepsy. The psychopathological profile comprises symptoms from the affective, schizophrenic, and cognitive domains and the prevalence varies between 2% to 20%. Classification of such conditions is performed according to their temporal relationship with the seizure itself. Although it is well known that epilepsy may be associated with psychotic disorders, it is less widely recognized that relapsing psychotic phenomena may be the first and only symptom of epilepsy. In this research, two patients are described who were initially referred for recurrent episodes of bipolar affective disorder and schizophrenic psychosis, respectively. In both patients, a diagnosis of relapsing postictal psychotic states due to previously undiagnosed epilepsy was made and consequently, treatment with antiepileptics was started. During follow up over several months, they remained free of both epileptic and psychotic symptoms. Given the kaleidoscopic nature of the postictal psychosis and full recovery from this, such psychoses best meet the criteria for a cycloid psychosis. These observations illustrate diagnostic and therapeutic pitfalls due to the conceptual disintegration emerging from the inadequate separation between psychiatry and neurology. Therefore, the importance of a neuropsychiatric viewpoint should be promoted.

The blood brain barrier and the role of cytokines in neuropsychiatry

Cytokines have emerged in the past two decades as some of the most extensively studied peptide molecules contributing to the pathophysiology of many diseases. As a result of these translational efforts, discovery of drugs aimed at reducing damage caused by cytokines has been accomplished for some conditions. The characterization of the role of cytokines in the pathophysiology of neuropsychiatric disorders is still in its infancy. This article highlights the growing correlation of brain cytokine levels with corresponding psychiatric symptoms, known as cytokine-induced sickness behavior, comprising increased sleep, decreased appetite, decreased sexual drive, and overwhelming fatigue frequently combined with fever.

Cranial nerve I: olfaction

Olfactory (smell) testing is one of the most interesting and revealing individual neurologic tests in psychiatric research. It is also one of the most neglected tests in the clinical practice of psychiatry. There are several diagnostic applications of smell testing in clinical psychiatry. This review covers reasons for the psychiatrist to test olfaction, ways of testing olfaction, and how to interpret test results.

Clinical presentation of anxiety among patients with epilepsy

Different factors have been related with interictal anxiety, reported in 10%-25% of patients with epilepsy. We determined the frequency of interictal anxiety in 196 patients with active epilepsy in a cross-sectional survey to know which symptoms of anxiety were most frequently reported in patients with epilepsy and to analyze the factors associated with their presence. Patients were assessed with the Beck Depression Inventory (BDI), Montgomery-Asberg Depression Rating Scale (MADRS), and the Hamilton Anxiety Scale (HAMA). Data were analyzed with a logistic regression model. The HAMA ratings revealed that 38.8% experienced significant anxiety symptoms, as defined by a rating above 18 points. Use of primidone, depression, cryptogenic, and posttraumatic etiologies significantly predicted anxiety after logistic regression. Symptoms related to higher scores on HAMA were anxious mood, tension, insomnia, intellectual function, depressed mood, cardiovascular and genitourinary symptoms. Further studies should be performed to define the role of psychosocial factors in the development and evolution of anxiety among these patients.

Psychiatric disorders and traumatic brain injury

Psychiatric disorders after traumatic brain injury (TBI) are frequent. Researches in this area are important for the patients' care and they may provide hints for the comprehension of primary psychiatric disorders. Here we approach epidemiology, diagnosis, associated factors and treatment of the main psychiatric disorders after TBI. Finally, the present situation of the knowledge in this field is discussed.

"Getting physical": the management of neuropsychiatric disorders using novel physical treatments

OBJECTIVE

To summarize and review the utility of physical interventions in the treatment of psychiatric disorders.

METHODS

A systematic review of the literature pertaining to novel physical interventions, namely, transcranial magnetic stimulation, deep brain stimulation, vagus nerve stimulation, and neurosurgery, was conducted using MEDLINE, EMBASE, and PSYCHLIT. Bibliographies of papers were scrutinized for further relevant references along with literature known to the authors.

RESULTS

Currently available physical interventions worldwide are reviewed with respect to efficacy, applications, and putative indications. Physical interventions have experienced a resurgence of interest for both the investigation of brain function and the treatment of neuropsychiatric disorders. The widespread availability of neuroimaging technology has advanced our understanding of brain function and allowed closer examination of the effects of physical treatments. Clinically, transcranial magnetic stimulation seems likely to have a role in the management of depression, and its use in other neuropsychiatric disorders appears promising. Following on from its success in the management of intractable epilepsy, vagus nerve stimulation is undergoing evaluation in the treatment of depression with some success in refractory cases. Deep brain stimulation has improved mood in patients with Parkinson's disease and may also relieve symptoms of obsessive-compulsive disorder. Neurosurgery has re-invented itself by way of increased technical sophistication, and although further assessment of its efficacy and clinical utility is still needed, its widespread practice reflects its increasing acceptance as a viable treatment of last resort.

CONCLUSION

It is clear that physical treatments are here to stay and "getting physical" offers a useful addition to the neuropsychiatrist's therapeutic armamentarium. However, like all new treatments these interventions need to remain under rigorous scientific scrutiny to determine accurately their immediate and long-term effects.

Neuroscience of decision making and informed consent: an investigation in neuroethics

Progress in neuroscience will allow us to reveal the neuronal correlates of psychological processes involved in ethically relevant notions such as informed consent. Informed consent involves decision making, the psychological and neural processes of which have been investigated extensively in neuroscience. The neuroscience of decision making may be able to contribute to an ethics of informed consent by providing empirical and thus descriptive criteria. Since, however, descriptive criteria must be distinguished from normative criteria, the neuroscience of decision making cannot replace the ethics of informed consent. Instead, the neuroscience of decision making could complement the current ethics, resulting in what can be called neuroethics of informed consent. It is concluded that current progress in the neurosciences could complement and change the way in which we approach ethical problems in neuropsychiatry.

Functional neuroimaging and presenting psychiatric features in frontotemporal dementia

BACKGROUND

Frontotemporal dementia (FTD) is a behavioural syndrome caused by degeneration of the frontal and anterior temporal lobes. Behavioural disturbances include psychiatric features. Whether patients with FTD present with psychiatric features varies with the initial neuroanatomical variability of FTD.

OBJECTIVE

To identify presenting psychiatric changes not part of diagnostic criteria of FTD and contrast them with the degree of hemispheric asymmetry and frontal and temporal hypoperfusion on single photon emission computed tomography (SPECT) imaging.

METHODS

74 patients who met consensus criteria for FTD were evaluated at a two year follow up. All had brain SPECT on initial presentation. Results of an FTD psychiatric checklist were contrasted with ratings of regional hypoperfusion.

RESULTS

The regions of predominant hypoperfusion did not correlate with differences on FTD demographic variables but were associated with presenting psychiatric features. Dysthymia and anxiety were associated with right temporal hypoperfusion. "Moria" or frivolous behaviour also occurred with temporal lobe changes, especially on the right. The only significant frontal lobe feature was the presence of a peculiar physical bearing in association with right frontal hypoperfusion.

CONCLUSIONS

Patients with FTD may present with psychiatric changes distinct from the behavioural diagnostic criteria for this disorder. Early temporal involvement is associated with frivolous behaviour and right temporal involvement is associated with emotional disturbances. In contrast, those with right frontal disease may present with alterations in non-verbal behaviour.

Pharmacologic management of anxiety and affective lability during recovery from Guillain-Barré syndrome: some preliminary observations

Psychiatric symptoms in Guillain-Barré syndrome (GBS) can include anxiety and affective lability, which require treatment to improve functional outcomes. Three cases in which modest doses of selective serotonin reuptake inhibitors (SSRIs), alone or in combination with anticonvulsants, reduced symptoms of anxiety and affective lability during acute rehabilitation of GBS are presented. These agents were both more effective and better tolerated than benzodiazepines and appeared to facilitate engagement in rehabilitation therapies, including psychotherapy. Further investigation of the pharmacotherapy of neuropsychiatric disturbances in this population using prospective, blinded, placebo-controlled methods is recommended.

Frontotemporal dementia classification and neuropsychiatry

BACKGROUND

Frontotemporal dementia (FTD) is a syndrome encompassing the clinical expression of frontal or temporal lobe degeneration. The many clinical phenotypes of FTD include primary progressive aphasias and a more common frontotemporal degeneration with less marked language alteration but significant behavioral changes.

SUMMARY

This paper describes the clinical progression of neuropsychiatric symptoms among 62 predominantly behavioral presentations and 30 language presentations of FTD. Disinhibition and depression became common for both subject groups over the course of illness. Significantly more cases presenting with behavioral changes had apathy and disinhibition.

CONCLUSIONS

Language presentations of FTD had longer latency to onset of distinct neuropsychiatric changes but eventually converge with the phenotype initially affected with behavioral change. Clinicians should anticipate such neuropsychiatric changes, prepare families for the course of illness in patients with either clinical presentation,treat symptomatically with psychotropic medications to help families cope with behaviorally disturbed patients.

AIDS and psychiatry, revisited

The psychiatry of HW and AIDS is a subject that now receives little attention but is still relevant to clinical practice. The mechanism of the HW assault on the brain is still not clearly understood, although early detection of central nervous system involvement is becoming easier with neuropsychological assessment. It has been suggested that HN has brain specificity, with patients presenting with cerebral problems without other physical signs. It is possible that AIDS may present with psychiatric symptoms. The mechanism of the damage to the CNS remains unclear.