Posttraumatic stress disorder and fMRI activation patterns of traumatic memory in patients with borderline personality disorder

BACKGROUND

Early traumatization and additional posttraumatic stress disorder are frequent in patients with borderline personality disorder (BPD). The purpose of this study was to investigate neural correlates of traumatic memory in BPD with and without posttraumatic stress disorder (PTSD) using functional magnetic resonance imaging (fMRI).

METHODS

We studied 12 traumatized female patients BPD, 6 of them with and 6 without PTSD. According to an autobiographical interview key words (cues) were defined for traumatic and for negative but nontraumatic episodes. In a block-designed fMRI task patients recalled these episodes. Contrasts between trauma condition and nontrauma condition were analyzed.

RESULTS

Analyses for all subjects revealed activation of orbitofrontal cortex areas in both hemispheres, anterior temporal lobes, and occipital areas. In the subgroup without PTSD, activation of orbitofrontal cortex on both sides and Broca's area predominated. In the subgroup with additional PTSD, we observed right more than left activation of anterior temporal lobes, mesiotemporal areas, amygdala, posterior cingulate gyrus, occipital areas, and cerebellum.

CONCLUSIONS

Dependent on absence or presence of additional PTSD different neural networks seem to be involved in the traumatic memory of patients with BPD.

No melancholia in poststroke depression? A phenomenologic comparison of primary and poststroke depression

The present study aimed at the phenomenologic comparison of depressive symptoms in elderly patients with poststroke depression (PSD) or primary depression (depression without a known neuropathology). We investigated 20 patients with PSD and 41 patients with primary depression. A structured clinical interview based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, self- and observer-based depression rating scales, a clinical neurologic examination, and neuroradiologic analysis based on standardized computed tomographic scan analysis were applied. The Cornell Depression Scale was used to compare mood-related signs, behavioral disturbances, physical signs, disturbances of cyclic signs, and ideational disturbances in both groups of patients. Those with PSD exhibited no melancholia and fewer cyclic and ideational disturbances but more physical signs of depression. These findings are in line with those of endocrinologic studies. Differences between both groups of patients indicate that careful considerations and further research are needed before treatment strategies developed for and evaluated in patients with primary depression are applied to patients with PSD.

[Is the borderline personality disorder a complex post-traumatic stress disorder? - The state of research]

Regarding the high prevalence of traumatic experiences in patients with borderline personality disorders (BPD), we review the available literature focussing on the hypothesis that BPD is a subtype of trauma associated disorders. The criteria of BPD, of complex post-traumatic stress disorders (PTSD), and of disorders of extreme stress not otherwise specified (DESNOS) substantially overlap. Research of the long-term course of BPD and PTSD, trauma research, and research of vulnerability in both disorders yielded converging results. Neuropsychological deficits in BPD and PTSD as well as psychoendocrinological and neuroimaging studies in BPD und PTSD also revealed common features. A pathogenetic specificity of individual etiologic factors does not appear to exist, however the assumption of a diathesis-stress model with traumatisation as a necessary but etiologically insufficient condition seems justified. Further research will have to prove BPD as a complex and early-onset post-traumatic stress disorder after multiple and/or chronic (type II) traumatic experiences during childhood and/or youth. Definitive conclusions require further research efforts.

[Relevance of neuropsychological studies of depression in the elderly]

Neuropsychological deficits are a common feature of depressive disorders. In the systems ICD 10 and DSM IV neuropsychological deficits constitute a relevant diagnostic criterion. Deficits in executive functions, attention and memory are documented. Primarily, mental flexibility seems to be impaired. The relation between neuropsychological deficits and depression is moderated by the patient's age. In the elderly, depression is more often accompanied by neuropsychological deficits. Clinically, the relevance of neuropsychological testing in depression has different aspects. Neuropsychological testing is the prerequisite for neuropsychological therapy when patients exhibit residual cognitive symptoms, and for professional and social rehabilitation. The neuropsychological outcome provides important information for the therapy process, and for predicting therapy success. In addition, neuropsychological testing can influence the choice of medication and psychotherapy. Neuropsychological data can also help to differ depression from dementia, an important problem in elder psychiatric and neurological patients. For this purpose a comprehensive neuropsychological test-battery that covers different neuropsychological domains needs to be employed. Furthermore, the analysis of the patients behavior and errors during testing provides essential information. However, in many cases a neuropsychological re-test and the analysis of the course of neuropsychological deficits is needed to differ depression from dementia.

Pathophysiologische und neuropsychologische Aspekte depressiver Störungen

Zusammenfassung: Bei depressiven Störungen sind zahlreiche neurobiologische Auffälligkeiten dokumentiert. Aufschluß darüber geben Untersuchungen bei primärer Depression sowie Untersuchungen bei depressiven Störungen, die sich im Zusammenhang mit Hirnschädigungen, wie etwa Schlaganfällen, manifestieren. Ebenfalls lassen neuropsychologische Befunde Rückschlüsse auf pathophysiologische Mechanismen zu. Vieles deutet darauf hin, daß es bei depressiven Störungen zu einer Störung eines komplexen neuronalen Netzwerkes kommt, insbesondere unter Beteiligung präfrontaler cortikaler Strukturen, der Amygdala und der Basalganglien sowie ihrer monoaminergen Afferenzen aus Hirnstamm und pontinem Tegmentum. Der Befund eines reduzierten Hippokampusvolumens bei Subtypen der Depression geht möglicherweise auf einen Hypercortisolismus zurück. Neurobiologische Auffälligkeiten stellen einen wichtigen Anknüpfungspunkt für antidepressive Therapien dar. Insgesamt ist die Depression als eine psychobiologische Störung konzeptualisierbar, bei der biologische und psychologische Faktoren eng miteinander verzahnt sind.

Neuropsychologische Befunde bei der Diagnostik hirnorganischer Erkrankungen mit Demenz

Zusammenfassung: Auf der Basis einer retrospektiven Untersuchung von 175 Patienten, die im Laufe der letzten 4 Jahre mit der klinischen Verdachtsdiagnose einer Demenz in unserer Abteilung vorgestellt wurden, werden die neuropsychologischen Defizite verschiedener Patientengruppen mit Morbus Parkinson, Chorea Huntington (HD), Multisystematrophien, vaskulärer subcorticaler Encephalopathie, Normaldruck-Hydrocephalus und wahrscheinlicher Alzheimerscher Erkrankung (AD) verglichen. Die Ergebnisse zeigen bei allen Patientengruppen schwere Beeinträchtigungen in den Bereichen Aufmerksamkeit und exekutive Funktionen ohne signifikante Unterschiede zwischen den einzelnen Diagnosegruppen. Eine deutliche Clusterbildung in bezug auf stärkere Beeinträchtigungen zeigt sich hingegen bezüglich längerfristigen Gedächtnisleistungen (HD und AD) sowie bei aphasischen, sprachassoziierten und apraktischen Störungen (AD). Auf Basis dieser Befunde werden die möglichen Implikationen der neuropsychologischen Diagnostik für die Differentialdiagnostik der Demenz diskutiert.

[Neuropsychological deficits in depressive disorders]

Neuropsychological deficits are considered a significant feature of depression both for their differential value in the diagnostics and the underlying pathophysiology of depressive disorders. The studies reviewed in the present paper predominantly focus on memory disorders as well as frontal-lobe associated dysfunctions such as deficits of attentional performance and executive functions. Despite heterogeneous results in the literature, there is emerging evidence that executive functions and anterograde memory performance are those domains predominantly affected in depressive disorders. The fact that not all depressive patients display neuropsychological deficits rather indicates a dominant role of moderating variables. We discuss the following variables possibly intervening with type and degree of neuropsychological dysfunction: [1] severity and remission of depressive disorders, [2] age of patients and age at the first manifestation of a depressive disorder, [3] psychological factors such as motivation and coping with failure, [4] type and efficacy of antidepressive drug treatment, [5] duration of the stay as inpatients, [6] number of depressive episodes, and [7] gender. Furthermore, we discuss the theory of a dysfunction of fronto-striatal circuits as an underlying mechanism of depressive disorders. The majority of neuropsychological findings seem to support this theory.

The crucial role of frontostriatal circuits for depressive disorders in the postacute stage after stroke

OBJECTIVE

This study analyzes lesion configuration in patients in the post-acute stage after first single unilateral stroke who suffered from depressive disorders.

BACKGROUND

Recent studies indicate a biological origin of poststroke depressive disorders. Due to differences in times of investigation, methods applied, and patient selection, most data are not comparable. Furthermore, only a few studies of poststroke depression report detailed neuropsychologic assessments.

METHODS

We investigated 20 consecutive patients who were diagnosed as depressive according to DSM-III-R criteria and exhibited no other severe illness, had no history of neurologic or psychiatric disease, and who were either not aphasic, or only mildly aphasic. A structured clinical interview, self-based and observer-based depression rating scales, a comprehensive neuropsychologic and neurologic examination and ADL-measurement were applied. Neuroradiologic analysis was based on standardized computed tomography scans.

RESULTS

Nine of 10 subjects with left hemisphere strokes exhibited a major depression and 7 of 10 subjects with right hemisphere infarcts a minor depression. The most prominent neuropsychologic deficits were found in frontal lobe associated tasks. Type and severity of depression were not related to the severity of neurologic symptoms or impairment in activities of daily living. For both major and minor depression the maximal overlap of lesions was found in subcortical areas, including parts of the caudate nucleus, posterior parts of the putamen, and the deep white matter.

CONCLUSIONS

The findings support the theory that poststroke depression is related to the dysfunction of (cortico-) striato-pallido-thalamic-cortical projections that modulate cortico-thalamo-cortical loop systems.