Mapping expectancy-based appetitive placebo effects onto the brain in women

Suggestions about hunger can generate placebo effects on hunger experiences. But, the underlying neurocognitive mechanisms are unknown. Here, we show in 255 women that hunger expectancies, induced by suggestion-based placebo interventions, determine hunger sensations and economic food choices. Functional magnetic resonance imaging in a subgroup (n = 57/255) provides evidence that the strength of expecting the placebo to decrease hunger moderates medial prefrontal cortex activation at the time of food choice and attenuates ventromedial prefrontal cortex (vmPFC) responses to food value. Dorsolateral prefrontal cortex activation linked to interference resolution formally mediates the suggestion-based placebo effects on hunger. A drift-diffusion model characterizes this effect by showing that the hunger suggestions bias participants' food choices and how much they weigh tastiness against the healthiness of food, which further moderates vmPFC-dlPFC psychophysiological interactions when participants expect decreased hunger. Thus, suggestion-induced beliefs about hunger shape hunger addressing economic choices through cognitive regulation of value computation within the prefrontal cortex.

Whole-brain gray matter maturation trajectories associated with autistic traits from adolescence to early adulthood

A growing number of evidence supports a continued distribution of autistic traits in the general population. However, brain maturation trajectories of autistic traits as well as the influence of sex on these trajectories remain largely unknown. We investigated the association of autistic traits in the general population, with longitudinal gray matter (GM) maturation trajectories during the critical period of adolescence. We assessed 709 community-based adolescents (54.7% women) at age 14 and 22. After testing the effect of sex, we used whole-brain voxel-based morphometry to measure longitudinal GM volumes changes associated with autistic traits measured by the Social Responsiveness Scale (SRS) total and sub-scores. In women, we observed that the SRS was associated with slower GM volume decrease globally and in the left parahippocampus and middle temporal gyrus. The social communication sub-score correlated with slower GM volume decrease in the left parahippocampal, superior temporal gyrus, and pallidum; and the social cognition sub-score correlated with slower GM volume decrease in the left middle temporal gyrus, the right ventromedial prefrontal and orbitofrontal cortex. No longitudinal association was found in men. Autistic traits in young women were found to be associated with specific brain trajectories in regions of the social brain and the reward circuit known to be involved in Autism Spectrum Disorder. These findings support both the hypothesis of an earlier GM maturation associated with autistic traits in adolescence and of protective mechanisms in women. They advocate for further studies on brain trajectories associated with autistic traits in women.

[Ketamine in antidepressant treatment: a revolution?]

Thirty percent of depressed patients are treatment resistant (TRD) suggesting the need of new therapeutic strategy. Recently, it has been shown that ketamine, an anesthetic agent with dissociative effects, has potent and rapid antidepressant properties. Ketamine is a ionotropic glutamatergic NMDA antagonist that inhibits gabaergic neurons. Its antidepressant effect peaks at 24 h post-treatment. Several meta-analyses of placebo randomized clinical trials emphasized its efficacy. More recently, a meta-analysis showed its efficiency in real-world population of TRD patients. Although there is no clear biological or clinical predictors of response or remission to ketamine, patients with high level of resistance were found to remit less often. Restoring both the optimism bias and the asymmetry in belief updating mediates the antidepressant ketamine's effect. Consistent with predictive bayesian model and terror management theory, this suggests that dissociation induced by ketamine may contribute to its clinical antidepressant action. Although increasing access to ketamine and esketamine is welcome, legitimate concerns have been raised with respect to long-term safety and abuse risk.

Storm on predictive brain: A neurocomputational account of ketamine antidepressant effect

For the past decade, ketamine, an N-methyl-D-aspartate receptor (NMDAr) antagonist, has been considered a promising treatment for major depressive disorder (MDD). Unlike the delayed effect of monoaminergic treatment, ketamine may produce fast-acting antidepressant effects hours after a single administration at subanesthetic dose. Along with these antidepressant effects, it may also induce transient dissociative (disturbing of the sense of self and reality) symptoms during acute administration which resolve within hours. To understand ketamine's rapid-acting antidepressant effect, several biological hypotheses have been explored, but despite these promising avenues, there is a lack of model to understand the timeframe of antidepressant and dissociative effects of ketamine. In this article, we propose a neurocomputational account of ketamine's antidepressant and dissociative effects based on the Predictive Processing (PP) theory, a framework for cognitive and sensory processing. PP theory suggests that the brain produces top-down predictions to process incoming sensory signals, and generates bottom-up prediction errors (PEs) which are then used to update predictions. This iterative dynamic neural process would relies on N-methyl-D-aspartate (NMDAr) and α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic receptors (AMPAr), two major component of the glutamatergic signaling. Furthermore, it has been suggested that MDD is characterized by over-rigid predictions which cannot be updated by the PEs, leading to miscalibration of hierarchical inference and self-reinforcing negative feedback loops. Based on former empirical studies using behavioral paradigms, neurophysiological recordings, and computational modeling, we suggest that ketamine impairs top-down predictions by blocking NMDA receptors, and enhances presynaptic glutamate release and PEs, producing transient dissociative symptoms and fast-acting antidepressant effect in hours following acute administration. Moreover, we present data showing that ketamine may enhance a delayed neural plasticity pathways through AMPAr potentiation, triggering a prolonged antidepressant effect up to seven days for unique administration. Taken together, the two sides of antidepressant effects with distinct timeframe could constitute the keystone of antidepressant properties of ketamine. These PP disturbances may also participate to a ketamine-induced time window of mental flexibility, which can be used to improve the psychotherapeutic process. Finally, these proposals could be used as a theoretical framework for future research into fast-acting antidepressants, and combination with existing antidepressant and psychotherapy.

Patients' needs in proton therapy: A survey among ten European facilities

Aims

The number of Proton Therapy (PT) facilities is still limited worldwide, and the access to treatment could be characterized by patients' logistic and economic challenges. Aim of the present survey is to assess the support provided to patients undergoing PT across Europe.

Methods

Through a personnel contact, an online questionnaire (62 multiple-choice and open-ended questions) via Microsoft Forms was administered to 10 European PT centers. The questionnaire consisted of 62 questions divided into 6 sections: i) personal data; ii) general information on clinical activity; iii) fractionation, concurrent systemic treatments and technical aspects of PT facility; iv) indication to PT and reimbursement policies; v) economic and/ or logistic support to patients vi) participants agreement on statements related to the possible limitation of access to PT. A qualitative analysis was performed and reported.

Results

From March to May 2022 all ten involved centers filled the survey. Nine centers treat from 100 to 500 patients per year. Paediatric patients accounted for 10-30%, 30-50% and 50-70% of the entire cohort for 7, 2 and 1 center, respectively. The most frequent tumours treated in adult population were brain tumours, sarcomas and head and neck carcinomas; in all centers, the mean duration of PT is longer than 3 weeks. In 80% of cases, the treatment reimbursement for PT is supplied by the respective country's Health National System (HNS). HNS also provides economic support to patients in 70% of centers, while logistic and meal support is provided in 20% and 40% of centers, respectively. PT facilities offer economic and/or logistic support in 90% of the cases. Logistic support for parents of pediatric patients is provided by HNS only in one-third of centers. Overall, 70% of respondents agree that geographic challenges could limit a patient's access to proton facilities and 60% believe that additional support should be given to patients referred for PT care.

Conclusions

Relevant differences exist among European countries in supporting patients referred to PT in their logistic and economic challenges. Further efforts should be made by HNSs and PT facilities to reduce the risk of inequities in access to cancer care with protons.

Preoperative Carbon Ion Radiotherapy (CIRT) with Chemotherapy in Resectable and Borderline Resectable Pancreatic Adenocarcinoma (PCa): A Multicenter Prospective Phase II Clinical Study (Pioppo Study NCT 03822936)

PURPOSE/OBJECTIVE(S)

Preoperative chemoradiation and surgery may improve survival for resectable (Re) or borderline resectable (BRe) PCa. However, there is a lack of evidence regarding the feasibility of combined chemotherapy (CT) and CIRT in the neoadjuvant setting for Re/BRe PCa, especially in the Caucasian population. To assess the safety and efficacy of this challenging combination, we designed a prospective multicentric single-arm phase II trial MATERIALS/METHODS: PIOPPO trial was opened in September 2014. We prospectively treated patients with Re/BRe Pca with a neoadjuvant CT (3 cycles of FOLFIRINOX) and a short-course of CIRT (38.4 GyRBE, 8 fractions, 4 fractions per week) planned with 4D-imaging and delivered with breath-gating and rescanning. Four-6 weeks after CIRT patients (pts) received surgery followed by adjuvant-CT (FOLFIRINOX for 9 or gemcitabine for 6 cycles). After each step patients underwent a re-staging. The primary endpoint was Local Progression Free Survival (LPFS).

RESULTS

Fourteen (47%) of the foreseen 30 pts were evaluated for enrollment. There were 4 screening failures for duodenum infiltration. Ten Caucasian pts (M = 7; 70%; F = 3;30%) with a median age of 65.5 (range:46-76) started the treatment. There were four (40%) Re and 6 (60%) BRe Pca. 100% of the Re and 50% of BRe PCa completed the planned combined treatment for a total of 7 (70%) pts. Three (30%) pts developed systemic progression after CT and underwent palliative care (2 cases) or a second line of CT (1 case). With regards to toxicities, we recorded 2 (28.6%) cases of neutropenia during CT, none acute CIRT toxicity and one (14%) case of intra-operative ulceration of the gastro-enteric anastomosis. Moreover, we reported one (14%) case of fatal liver failure due to portal vein stenosis due to the combo approach (CT+CIRT+surgery). Six (86%) pts experienced Tumor Regression Grade (TRG) = 2 according to the College of American Pathologists (CAP) and 1 (14%) a TRG = 3. At the last follow-up, among pts who completed the scheme, 2 (28%) are currently alive and disease-free at 57 and 49 months, respectively. With a median follow-up of 13 months, the median LPFS was 9.4 months (range:4.9-57), with 1 case (14%) of systemic progression and 3 cases (43%) of local recurrence + systemic progression. The study was early closed due to low accrual in August 2022.

CONCLUSION

Although the small sample size limits the interpretation of the endpoints, a neoadjuvant approach combining CT and a short course of CIRT for resectable/borderline Pca seems feasible. Liver toxicity was similar to the Japanese series and needs to deepen investigation on the vascular dose constraints and surgical techniques. Considering the worse outcomes, a better selection of patients to treat also with a centralized imaging interpretation is mandatory.

[Theoretical and clinical implications of trauma]

Usually, trauma is defined as exposure to an event that threatens death or induces serious injury or sexual violence. Beyond post-traumatic stress disorder (PTSD), trauma may increase the risk for severe mental disorders including mood disorders and psychotic disorder. PTSD, following exposure to a traumatic event, is strongly linked to dissociation. However, in contrast convergent findings indicated that, despite the relationship between peri-traumatic dissociation and later PTSD, many people who develop PTSD do not display dissociative responses in the acute phase after the event. Several risk factors are described for PTSD including previous history of traumatic event, previous mental disorders, genetic factors and gender. It is now proposed to distinguish PTSD with or without dissociative symptoms with some specific neural signature for each syndrome. Dissociation may also lead to change in cultural belief and worldview. According to the terror management theory (TMT), it is suggested that cultural worldviews, self-esteem, and interpersonal relationships work together to protect individuals from death anxiety. The trauma, by disrupting this anxiety buffering system, contributes to change beliefs in victims and exposes them to a feeling of social exclusion.

Guide de prescription psychiatrique pendant la grossesse, le postpartum et l’allaitement

Perinatal psychopharmacology is an emerging specialty that is gradually developing alongside perinatal psychiatry. The management of psychiatric disorders during the perinatal period is a challenge for perinatal practitioners due to the multiple changes occurring during this crucial period. This little-known specialty still suffers from inappropriate considerations on the impact of psychotropic treatments on the mother and the infant during pregnancy and postpartum, which can promote a deficiency in perinatal psychic care. However, the risks associated with insufficient management of mental health are major, impacting both the mental and physical health of the mother and the infant. In this paper, we propose a perinatal psychopharmacology prescription guide based on available scientific evidence and international and national recommendations. We thus propose a decision-making process formalized on simple heuristics in order to help the clinician to prescribe psychotropic drugs during the perinatal period.

The dynamics of emotional behaviors in rapid eye movement sleep

Dream's emotions could exert a major role in desensitizing negative emotions. Studying emotional dynamics (how emotions fluctuate across time) during rapid eye movement (REM) sleep could provide some insight into this function. However, studies so far have been limited to dream reports. To bypass this limit, REM sleep behavior disorder (RBD), in which participants enact their dreams, enables direct access to overt emotional dream behaviors (such as facial expressions and speeches). In total, 17 participants with RBD, and 39.7 h of REM sleep video were analyzed. The frequency of emotional behaviors did not differ between REM sleep episodes of early and late night. Within individual REM sleep episodes, emotional behaviors exhibited a biphasic temporal course, including an increased frequency for the first 10 min, followed by a progressive decrease. The negative emotional behaviors occurred earlier (mean time: 11.3 ± 10 min) than positive (14.4 ± 10.7 min) and neutral behaviors (16.4 ± 11.8 min). Emotional behaviors of opposing (negative and positive) valences were observed in 31% (N = 14) of episodes containing at least one emotional behavior, and were separated by a median time of 4.2 [1.1-10.9] min. The biphasic temporal course of behaviors in REM sleep could include the generation reactivation of emotional content during the ascending phase, followed by processing and extinction during the descending phase. The earlier occurrence time of negative emotional behavior suggests that negative emotions may need to be processed first. The rapid succession of emotions of opposite valence could prevent prolonged periods of negative emotions and eventually nightmares.

ECT: An essential therapy in psychiatry

At a time when innovations in psychiatry are booming, particularly in the field of medical devices, we thought it necessary, as members of French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), to reconsider one of the oldest medical devices in psychiatry: the ECT apparatus. First, we recall the regulatory aspects of ECT. National guidelines define means of implementation and conditions of administration of ECT. Second, we remind of the indications and levels of evidence of ECT in the main psychiatric disorders, including catatonia. Then, we synthetize the place of ECT alongside other brain stimulation therapies, especially repetitive Trancranial Magnetic Stimulation (rTMS). Furthermore, we explain the general effects of ECT: increased neuronal plasticity and neurogenesis, enhancement of the stress axis, resistance to oxidative stress, improved vascular endothelial function, activation of microglia and astrocytes, decrease in inflammatory events by upregulation of neuroinflammatory cytokines, and production of mitochondrial ATP. These effects appear from the first sessions and continue during the course of ECT treatment, suggesting activation of endogenous neuroprotection. Finally, we remember that most patients perform as well or better on neuropsychological assessments after ECT, relative to pre-ECT results, and this improvement continues over the following months. Memory disorders reported post-ECT are not all attributable to ECT. They may be subjective in nature or linked to residual depressive (and possibly comorbid neurogenerative) symptoms later attributed to ECT, on the basis of preexisting negative representations. We urgently need to reemphasize the crucial role of ECT in psychiatric treatment strategies as well as the need to update ECT recommendations.

Factors Associated With Posttraumatic Stress Symptoms 3 and 6 Months After Hospitalization for COVID-19: A Longitudinal Multicenter Study

Objective: To identify factors associated with posttraumatic stress symptoms (PTSS) 3 and 6 months after the discharge of patients hospitalized for COVID-19. Methods: Patients hospitalized for COVID-19 between March 1 and July 31, 2020, were included in a longitudinal study. Clinical assessments were conducted with online auto-questionnaires. PTSS were assessed with the Posttraumatic Stress Disorder Checklist Scale (PCLS). We screened for several putative factors associated with PTSS, including socio-demographic status, hospitalization in an intensive care unit, history of psychiatric disorder, the Hospital Anxiety and Depression Scale, the Peritraumatic Dissociative Experiences Questionnaire, and the home-to-hospital distance. Bivariate and multilinear regression analyses were performed to evaluate their association with PTSS. Results: 119 patients were evaluated 3 months after hospital discharge, and a subset of 94 were evaluated 6 months after discharge. The prevalence of PTSS was 31.9% after 3 months and 30.9% after 6 months. Symptoms of anxiety and depression and history of psychiatric disorder were independently associated with PTSS. Additionally, dissociative experiences during hospitalization (β = 0.35; P < .001) and a longer home-to-hospital distance (β = 0.07; P = .017) were specifically associated with PTSS 3 and 6 months after discharge, respectively. Conclusions: Patients with COVID-19 showed persistent high scores of PTSS up to 6 months after discharge from the hospital. In this specific pandemic setting, PTSS were associated with high rates of dissociative experiences during hospitalization and a longer home-to-hospital distance due to the saturation of health care facilities. These results can foster early identification and better prevention of PTSS after hospitalization for COVID-19. Trial Registration: ClinicalTrials.gov identifier: NCT04362930.

Evaluation of Early Ketamine Effects on Belief-Updating Biases in Patients With Treatment-Resistant Depression

IMPORTANCE

Clinical research has shown that persistent negative beliefs maintain depression and that subanesthetic ketamine infusions induce rapid antidepressant responses.

OBJECTIVE

To evaluate whether ketamine alters belief updating and how such cognitive effects are associated with the clinical effects of ketamine.

DESIGN, SETTING, AND PARTICIPANTS

This study used an observational case-control protocol with a mixed-effects design that nested 2 groups by 2 testing time points. Observers were not blinded. Patients with treatment-resistant depression (TRD) and healthy volunteer participants aged 34 to 68 years were included. Patients with TRD were diagnosed with major depressive disorder or bipolar depression, had a Montgomery-Åsberg Depression Rating Scale score greater than 20, a Maudsley Staging Method score greater than 7, and failed to respond to at least 2 prior antidepressant trials. Exclusion criteria were any other psychiatric, neurological, or neurosurgical comorbidities, substance use or addictive disorders, and recreational ketamine consumption. Data were collected from January to February 2019 and from May to December 2019, and data were analyzed from January 2020 to July 2021.

EXPOSURES

Patients with TRD were observed 24 hours before single ketamine infusion, 4 hours after the infusion, and 4 hours after the third infusion, which was 1 week after the first infusion. Healthy control participants were observed twice 1 week apart without ketamine exposure.

MAIN OUTCOMES AND MEASURES

Montgomery-Åsberg Depression Rating Scale score and belief updating after belief updating when patients received good news and bad news measured by a cognitive belief-updating task and mathematically formalized by a computational reinforcement learning model.

RESULTS

Of 56 included participants, 29 (52%) were male, and the mean (SEM) age was 52.3 (1.2) years. A total of 26 patients with TRD and 30 control participants were included. A significant group × testing time point × news valence interaction showed that patients with TRD updated their beliefs more after good than bad news following a single ketamine infusion (controlled for age and education: β = -0.91; 95% CI, -1.58 to -0.24; t216 = -2.67; P = .008) than controls. Computational modeling showed that this effect was associated with asymmetrical learning rates (LRs) after ketamine treatment (good news LRs after ketamine, 0.51 [SEM, 0.04]; bad news LRs after ketamine 0.36 [SEM, 0.03], t25 = 3.8; P < .001) and partially mediated early antidepressant responses (path a*b: β = -1.00 [SEM, 0.66]; t26 = -1.53; z = -1.98; P = .04).

CONCLUSIONS AND RELEVANCE

These findings provide novel insights into the cognitive mechanisms of the action of ketamine in patients with TRD, with promising perspectives for augmented psychotherapy for individuals with mood disorders.

JS09.6.A Low incidence of radiation-induced brain lesions and stable QoL following proton irradiation for CNS and Skull Base tumors- results from the prospective MedAustron register REGI-MA-002015

Background

Irradiation of intracranial tumors may induce endothelial damage in the surrounding normal brain tissues, resulting in an increase of capillary permeability. These changes can be depicted on magnetic resonance imaging (MRI) as a new contrast medium uptake - not associated with tumor. Radiation-induced brain lesions (RIBL) occur after photon as well as proton irradiation. This study evaluated the incidence of RIBL after proton irradiation and their impact on Quality of Life (QoL).

Material and Methods

421 patients treated between 01/2017 and 06/2021 were included. All patients participated in a prospective registry study (ClinicalTrials.gov Identifier: NCT03049072). Follow-up evaluations including MRIs were at 3,6,12 months after treatment completion and annually thereafter. QoL parameters were assessed by EORTC-CTC30 and BN20 questionnaires.

Results

48.9% (n=206) patients received therapy for intracranial non-CNS tumors (meningioma, pituitary adenoma, and other), 26.8% (n=113) for head and neck cancer with skull base involvement, 14.5% (n=61) for primary CNS tumors and 9.7% (n=41) for skull base tumor. Median follow-up was 24 months (range 6-54 ), 352 (86%) patients had proton therapy as primary treatment, 59 (14%) had salvage treatment with proton re-irradiation (ReRT). Median prescribed dose was 58.5 Gy (RBE) (range 40-78 Gy (RBE)), median D1% of brain tissue was 54.3 Gy (RBE) (range 30-76 Gy RBE). Local control and overall survival were 91% and 95% at 2 years. The cumulative RIBL incidence was 15.0% (n=63), with significantly lower occurrence in the primary RT group vs. the ReRT group (12.9% vs. 27.1%; p&lt;0.001). According to Grade, the distribution was 10.5% (n=44) Grade I (asymptomatic, MRT finding only), Grade II RIBL, 13 (3.1%) (moderate symptoms) (grade 2) and 1,4% (n=6) developed Grade 3 toxicity. Actuarial 2-year RIBL incidence was 18.2% (95%CI: 14.1-23.2) for the all Grades and the entire, 15.7% (95%CI: 11.6-21) following primary radiation and 34.2% (95%CI: 21.9-50.9) after ReRT. All RIBL developed outside the residual tumor, but inside the Planning Target Volume (PTV), median D1% was 60.3Gy (RBE) (range 46.1- 122.3 Gy(RBE)), median time to development was 11.8 months (range 2.7-37 months) in the total cohort, for primary RT 14.2mo (4.3mo -37.1mo) and 6.0mo (2.7mo -19.3mo) following ReRT. At the time of analysis 26 of the 63 RIBL had resolved (41.3%). General QoL was not compromised. In a matched-pair analysis of 54/50 patients with/without RIBL, only at the 12 month a significant difference in the global health score in favour of non-RIBL patients was observed. At 24 months the score for RIBL patients improved without difference between the groups.

Conclusion

Overall incidence of RIBL after proton radiotherapy is very low - even for skull base tumors requiring high total doses and it had no significant negative impact on long term QoL.

P03.06.B Proton irradiation (PT) for benign meningiomas, Grade I clinical experience of the first 100 patients from REGI-MA-002015

Background

Meningiomas are the most common CNS tumors and the majority is regarded as benign. However, a subset of patients presents with complex tumors involving several anatomic compartments of the skull base - eluding any concepts of gross total resection. Proton therapy (PT) is applied as definitive treatment for primary or recurrent disease or postoperatively following subtotal resection. We report on the first 100 adult patients treated with PT at MedAustron.

Material and Methods

All patients were enrolled in a prospective registry trial (ClinicalTrials.gov Identifier: NCT03049072). Target volume definition was based on CT, MR and DOTA-PET/CT. PT treatment plans were generated by applying a Simultaneous Integrated Boost (SIB) concept with the Single Field-optimisation method and utilizing 2-4 beams per plan with a beam spacing of &gt;30°. Prescribed doses to PTV1 were 50.49Gy_RBE at 1.87Gy_RBE/fr and 54.0Gy_RBE at 2.0Gy_RBE/fr to PTV2 in overall 27 fractions. Follow up status was assessed by MRI at 6, 12 months and annually thereafter, side effects were assessed using CTCAE v4.0. and quality of life (QoL) using EORTC-CTC30 and BN20 questionnaires. The scores entered by the patients were added and normalized to 0-100 scale according to previously described protocols.

Results

Between 08/2017 and 04/2021, 100 patients were treated, 22% (n=22) male and 78% (n=78) female patients. Median age at therapy was 54a (25a-82a). In 57% (n=57) PT was the definitive treatment (no resection or surgery &gt;12 mo prior to PT). 43% (n=43) underwent postoperative PT with at least one surgery (range 1-3), and median time from last resection to start of PT of 6mo (3mo-11mo). 89% (n=89) meningiomas were located in the skull base with involvement of multiple anatomic compartments. The median GTV size was 24cc (1cc-226cc) and the median CTV 41cc (2cc-352cc), respectively. At median follow-up of 31.1 months (range 6.6-51.6), 2 local in-field failures were observed (both patients treated postoperatively) resulting in disease-specific survival of 100% and local control of 98% at 3 years, respectively. No &gt; Grade 2 acute toxicity was observed. During follow-up two Grade 3 toxicities occurred: One patient developed symptomatic radiation induced brain lesion (RIBL) which resolved within 12 month; one patient was hospitalized for new onset of epilepsy without corresponding radiographic findings. 9% (n=9) developed G1/G2 RIBL, which resolved spontaneously. The general QoL including the global health status and all functioning domains remained stable and did not decrease significantly following PT.

Conclusion

First clinical data demonstrate that PT based on a SIB concept is a safe and efficient treatment of anatomically complex, low grade meningiomas. Acute and late toxicity incidences in our series were low with excellent, prospectively assessed preservation of QoL.

[Multidimensional and computational theory of mood]

What is mood? Despite its crucial place in psychiatric nosography and cognitive science, it is still difficult to delimit its conceptual ground. The distinction between emotion and mood is ambiguous: mood is often presented as an affective state that is more prolonged and less intense than emotion, or as an affective polarity distinguishing high and low mood swinging around a baseline. However, these definitions do not match the clinical reality of mood disorders such as unipolar depression and bipolar disorder, and do not allow us to understand the effect of mood on behaviour, perception and cognition. In this paper, we propose a multidimensional and computational theory of mood inspired by contemporary hypotheses in theoretical neuroscience and philosophy of emotion. After suggesting an operational distinction between emotion and mood, we show how a succession of emotions can cumulatively generate congruent mood over time, making mood an emerging state from emotion. We then present how mood determines mental and behavioral states when interacting with the environment, constituting a dispositional state of emotion, perception, belief, and action. Using this theoretical framework, we propose a computational representation of the emerging and dispositional dimensions of mood by formalizing mood as a layer of third-order Bayesian beliefs encoding the precision of emotion, and regulated by prediction errors associated with interoceptive predictions. Finally, we show how this theoretical framework sheds light on the processes involved in mood disorders, the emergence of mood congruent beliefs, or the mechanisms of antidepressant treatments in clinical psychiatry.

Glutamatergic and N-Acetylaspartate Metabolites in Bipolar Disorder: A Systematic Review and Meta-Analysis of Proton Magnetic Resonance Spectroscopy Studies

The exact neurobiological mechanisms of bipolar disorder (BD) remain unknown. However, some neurometabolites could be implicated, including Glutamate (Glu), Glutamine (Gln), Glx, and N-acetylaspartate (NAA). Proton Magnetic Resonance Spectroscopy (¹H-MRS) allows one to quantify these metabolites in the human brain. Thus, we conducted a systematic review and meta-analysis of the literature to compare their levels between BD patients and healthy controls (HC). The main inclusion criteria for inclusion were ¹H-MRS studies comparing levels of Glu, Gln, Glx, and NAA in the prefrontal cortex (PFC), anterior cingulate cortex (ACC), and hippocampi between patients with BD in clinical remission or a major depressive episode and HC. Thirty-three studies were included. NAA levels were significantly lower in the left white matter PFC (wmPFC) of depressive and remitted BD patients compared to controls and were also significantly higher in the left dorsolateral PFC (dlPFC) of depressive BD patients compared to HC. Gln levels were significantly higher in the ACC of remitted BD patients compared to in HC. The decreased levels of NAA of BD patients may be related to the alterations in neuroplasticity and synaptic plasticity found in BD patients and may explain the deep white matter hyperintensities frequently observed via magnetic resonance imagery.

Memory reconsolidation impairment using the β-adrenergic receptor blocker propranolol reduces nightmare severity in patients with post-traumatic stress disorder: a preliminary study

STUDY OBJECTIVES

Post-traumatic nightmares may exacerbate and perpetuate the daytime symptoms of post-traumatic stress disorder (PTSD) and might represent a therapeutic target. The therapeutic strategy of memory reconsolidation using the β-adrenergic receptor blocker propranolol associated with re-exposure psychotherapy is a promising treatment in PTSD patients. Previous studies have established this therapy is effective in reducing overall clinician-assessed PTSD symptoms but to date no previous study has specifically focused on posttraumatic nightmares in this therapy. This study provides a preliminary assessment of the evolution of nightmares severity during this therapy protocol, compared with the decrease of the other PTSD symptoms. It evaluates the incidence of side effects and examines the relative effects on posttraumatic nightmares.

METHODS

Patients were recruited as part of the Paris Mémoire Vive study. Data were collected using a prospective longitudinal design including one baseline visit, six therapeutic visits, and two follow-up visits. During the six therapeutic visits, propranolol was administered orally 60 to 75 minutes prior to the psychotherapeutic session.

RESULTS

On average, nightmare severity decreased from "severe" to "mild" during the protocol and remained stable two months after the last session. Whereas 85% of patients reported nightmares at baseline, only 50% still had them after the protocol. The protocol was generally well tolerated and, did not increase nightmare severity for any patient in the study.

CONCLUSIONS

Memory reconsolidation therapy with propranolol seems promising in reducing nightmare severity, up to and including remission. However, research using a randomized controlled design, and assessing maintenance of nightmare extinction, is warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Using Reconsolidation Blockade to Treat Trauma Related Disorders After Paris Attacks: An Effectiveness Study (PARIS-MEM); Identifier: NCT02789982; URL: https://www.clinicaltrials.gov/ct2/show/NCT02789982.

[Belief updating and mood congruence in depressive disorder]

Depressive disorder is characterized by a polymorphic symptomatology associating emotional, cognitive and behavioral disturbances. One of the most specific symptoms is negative beliefs, called congruent to mood. Despite the importance of these beliefs in the development, the maintenance, and the recurrence of depressive episodes, little is known about the processes underlying the generation of depressive beliefs. In this paper, we detail the link between belief updating mechanisms and the genesis of depressive beliefs. We show how depression alters information processing, generating cognitive immunization when processing positive information, affective updating bias related to the valence of belief and prediction error, and difficultie to disengage from negative information. We suggest that disruption of belief-updating mechanisms forms the basis of belief-mood congruence in depression.

[Anticholinergic scales: Use in psychiatry and update of the anticholinergic impregnation scale]

Anticholinergic properties are well known to prescribers, notably in mental health, as a therapeutic strategy for i.e. extrapyramidal syndrome but also as a source of numerous adverse side effects. Herein, we propose a narrative literature review describing: (i) cholinergic pharmacology and anticholinergic properties; (ii) the importance of anticholinergic therapeutic properties in psychiatry; (iii) the existing anticholinergic drug scales and their usage limitations in Psychiatry and; last (iv) an update to the anticholinergic drug impregnation scale, designed for the French psychiatry practice. The anticholinergic side effects can appear both in the peripheral level (dry mouth, constipation, etc.) and in the central level (especially as cognitive deficits). Many of the so called « anticholinergic » drugs are in fact entirely or mostly antimuscarinic and act essentially as parasympathetic system antagonists. Overall, anticholinergic/antimuscarinic side effects are usually attributed to psychotropic medications: to certain antipsychotics, notably classical neuroleptics such as phenothiazine and also to tricyclic antidepressants. In practice, the impact of anticholinergic toxicity treatments is often highlighted due to their excessively prolonged use in patients on antipsychotics. Interestingly, these antipsychotic treatments are better known for their anticholinergic side effects, especially cognitive ones, with an early onset specially in elder patients and/or in the case of polymedication. In order to evaluate anticholinergic side effects, metrics known as anticholinergic burden scales were created in the last few decades. Nowadays, 13 different scales are documented and accepted by the international academic community, but only three of them are commonly used: the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB). All of them are based on a similar principle, consisting of grading treatments individually, and they are normally scored from 0 - no presence of side effects - to 3 - anticholinergic effects considered to be strong or very strong. Using these scales enables the calculation of the so-called "anticholinergic burden", which corresponds to the cumulative effect of using multiple medications with anticholinergic properties simultaneously. The application of anticholinergic scales to patients with psychiatric disorders has revealed that schizophrenic patients seem to be especially sensitive to anticholinergic cognitive side effects, while elder and depressed patients were more likely to show symptoms of dementia when exposed to higher anticholinergic burden. Unfortunately, these tools appear to have a low parallel reliability, and so they might induce large differences when assessing side effects predictability. In addition, the capacity of these scales to predict central adverse effects is limited due to the fact they poorly or do not differentiate, the ability of treatments to cross the blood-brain barrier. Finally, one last limitation on the validity of these scales is prescription posology is not accounted for side effects considered to be dose dependent. Recently, the MARANTE (Muscarinic Acetylcholine Receptor ANTagonist Exposure) scale has incorporated an anticholinergic burden weighting by posology. Nevertheless, this new model can be criticized, due to the limited number of medications included and due to testing a limited number of potency ranges and dosages for each treatment. Herein, we propose an update to the Anticholinergic Impregnation Scale, developed specifically for the French Psychiatry practice. The scale validation was based on an evaluation of the prescriptions correcting anticholinergic peripheral side effects (constipation, xerostomia and xeropthalmia). This indirect evaluation allowed us to show patients with an anticholinergic impregnation score higher than 5 received significantly more treatments for constipation and xerostomia. This strategy bypasses the bias of a cognitive evaluation in patients with severe mental health disorders. Moreover, the relevance of a tool developed specifically for French psychiatry is justified by the fact that some highly prescribed treatments for mental illness in France (cyamemazine and tropatemine) are strong anticholinergics, and also by the fact they are rarely included in the existing anticholinergic scales. This update of the original scale, published in 2017, includes information whether prescribed drugs cross the blood-brain barrier and thus makes possible a more accurate assessment when evaluating anticholinergic central side effects. Finally, the anticholinergic impregnation scale will soon be integrated into a prescription help software, which is currently being developed to take into consideration dose dependent adverse effects.

Psychotropics and COVID-19: An analysis of safety and prophylaxis

The use of psychotropics during the COVID-19 pandemic has raised two questions, in order of importance: first, what changes should be made to pharmacological treatments prescribed to mental health patients? Secondly, are there any positive side effects of these substances against SARS-CoV-2? Our aim was to analyze usage safety of psychotropics during COVID-19; therefore, herein, we have studied: (i) the risk of symptomatic complications of COVID-19 associated with the use of these drugs, notably central nervous system activity depression, QTc interval enlargement and infectious and thromboembolic complications; (ii) the risk of mistaking the iatrogenic impact of psychotropics with COVID-19 symptoms, causing diagnostic error. Moreover, we provided a summary of the different information available today for these risks, categorized by mental health disorder, for the following: schizophrenia, bipolar disorder, anxiety disorder, ADHD, sleep disorders and suicidal risk. The matter of psychoactive substance use during the pandemic is also analyzed in this paper, and guideline websites and publications for psychotropic treatments in the context of COVID-19 are referenced during the text, so that changes on those guidelines and eventual interaction between psychotropics and COVID-19 treatment medication can be reported and studied. Finally, we also provide a literature review of the latest known antiviral properties of psychotropics against SARS-CoV-2 as complementary information.

Inflexibly sustained negative affect and rumination independently link default mode network efficiency to subclinical depressive symptoms

Aberrant DMN connectivity and activity have been robustly linked to Major Depressive Disorder (MDD) and risk for depression. This link has mostly been explained in terms of rumination, a form of negative, repetitive cognitive processing. Yet, accumulating findings are indicating altered DMN dynamics during emotional processing in MDD, pointing at a potential emotion-related DMN pathology in depression linked to inflexibly sustained emotional responses. Such a link might be especially important in understanding risk of depression. However, whether inflexible emotional processing (i.e. emotional inertia) is connecting aberrant DMN organization to risk of depression as well as how this might relate to rumination remains unclear. Addressing this gap, 34 participants underwent a resting-state fMRI and a 7-day Experience Sampling phase. Using regression and multiple mediation analysis we investigated the relations between negative emotional inertia, rumination, DMN organization and risk of depression as indicated by high subclinical depressive symptoms. The findings indicated that DMN efficiency at rest was positively associated with depressive symptoms and risk of depression. Both negative emotional inertia in daily life and rumination were independently mediating this relationship. While negative emotional inertia was connected to a broad increase in the coupling of DMN regions, rumination was only related to an increase in node strength of the dorsomedial Prefrontal Cortex. These findings are pointing towards an emotional-related DMN pathology contributing to risk of depression. Furthermore the findings are indicating that this relationship is independent from the rumination-related link between the DMN and depression - representing different aspects of DMN organization.

Alpha activity neuromodulation induced by individual alpha-based neurofeedback learning in ecological context: a double-blind randomized study

The neuromodulation induced by neurofeedback training (NFT) remains a matter of debate. Investigating the modulation of brain activity specifically associated with NF requires controlling for multiple factors, such as reward, performance, congruency between task and targeted brain activity. This can be achieved using sham feedback (FB) control condition, equating all aspects of the experiment but the link between brain activity and FB. We aimed at investigating the modulation of individual alpha EEG activity induced by NFT in a double-blind, randomized, sham-controlled study. Forty-eight healthy participants were assigned to either NF (n = 25) or control (n = 23) group and performed alpha upregulation training (over 12 weeks) with a wearable EEG device. Participants of the NF group received FB based on their individual alpha activity. The control group received the auditory FB of participants of the NF group. An increase of alpha activity across training sessions was observed in the NF group only (p < 0.001). This neuromodulation was selective in that there was no evidence for similar effects in the theta (4-8 Hz) and low beta (13-18 Hz) bands. While alpha upregulation was found in the NF group only, psychological outcome variables showed overall increased feeling of control, decreased anxiety level and increased relaxation feeling, without any significant difference between the NF and the control groups. This is interpreted in terms of learning context and placebo effects. Our results pave the way to self-learnt, NF-based neuromodulation with light-weighted, wearable EEG systems.

Prevalence and impact of patient suicide in psychiatrists: Results from a national French web-based survey

BACKGROUND

Patient suicide (PS) is known to be a frequent and challenging occupational hazard for mental health professionals. No study previously explored the prevalence and impact of PS in a large sample of French psychiatrists.

METHOD

A national web-based survey was performed between September and December 2019 to assess (a) the prevalence of the exposure to PS, (b) the emotional, traumatic and professional impacts of PS, and (c) the perceived support in the aftermath of PS in French psychiatrists. Participants were contacted through email to answer the online 62-item questionnaire, including a measure of traumatic impact through the Impact of Event Scale-Revised. Emotional and professional impacts and perceived support were assessed through dedicated items.

RESULTS

A total of 764 psychiatrists fully completed the survey. Of them, 87.3% reported an exposure to PS and 13.7% reported PTSD symptoms afterward. Guilt, sadness and shock were the most frequent emotions. Among the exposed psychiatrists, 15.1% have temporarily considered changing their career path. The most emotionally distressing PS occurred during their ten first years of practice or during residency. A total of 37.1% of respondents felt unsupported and 50.4% reported that no team meeting had been organized in the aftermath. The feeling of responsibility for the death was strongly associated with negative impacts.

CONCLUSION

Our results entail considerations to prevent negative mental health outcomes in psychiatrists after PS. Notably, our results advocate for the implementation of educational programs during psychiatric residency and postvention programs in healthcare settings to effectively help psychiatrists in dealing with PS.

[Psychopharmacotherapeutic guidelines : a challenge during health crisis]

The construction of pharmacological guidelines is a complex endeavor, and this is all the truer amidst a health crisis such as the current SARS-CoV-2 pandemic. In psychiatric settings, guidelines have to consider the handling of other drugs (i.e., psychotropic medications), that have been suggested as potentially prophylactic for COVID-19. These dialectics are discussed here, and the methodological foundations used for the elaboration of guidelines are put forward.

[Ketamine, psilocybin, and rapid acting antidepressant: new promise for psychiatry?]

The hypothesis of monoaminergic deficiency has long dominated the conceptual framework for the development of new antidepressant strategies, but the limits of conventional antidepressant treatments targeting monoaminergic signaling have motivated the search for new antidepressant pathways. The success of ketamine in the management of depressive disorders has provoked a renewed interest in hallucinogenic substances such as psilocybin targeting the serotonergic signaling 5HT^2A and neurosteroid allosteric modulator of γ-aminobutyric acid (GABAA) receptors such as brexanolone. Unlike conventional treatments, these modulators of glutamatergic, serotonergic and GABAergic systems exert a rapid antidepressant effect ranging from 24hours to a week. Apart from their clinical interest and the fantasized search for a "miracle" molecule that jointly meets the expectations of patients and clinicians, these new targets could lead to the identification of potential new biomarkers for the development of rapid-acting antidepressants and redefine therapeutic strategies in mood disorders.

COVID-19-related encephalopathy: a case series with brain FDG-positron-emission tomography/computed tomography findings

Aim

The aim of this paper is to describe the clinical features of COVID‐19‐related encephalopathy and their metabolic correlates using brain 2‐desoxy‐2‐fluoro‐D‐glucose (FDG)‐positron‐emission tomography (PET)/computed tomography (CT) imaging.

Background and purpose

A variety of neurological manifestations have been reported in association with COVID‐19. COVID‐19‐related encephalopathy has seldom been reported and studied.

Methods

We report four cases of COVID‐19‐related encephalopathy. The diagnosis was made in patients with confirmed COVID‐19 who presented with new‐onset cognitive disturbances, central focal neurological signs, or seizures. All patients underwent cognitive screening, brain magnetic resonance imaging (MRI), lumbar puncture, and brain 2‐desoxy‐2‐fluoro‐D‐glucose (FDG)‐positron‐emission tomography (PET)/computed tomography (CT) (FDG‐PET/CT).

Results

The four patients were aged 60 years or older, and presented with various degrees of cognitive impairment, with predominant frontal lobe impairment. Two patients presented with cerebellar syndrome, one patient had myoclonus, one had psychiatric manifestations, and one had status epilepticus. The delay between first COVID‐19 symptoms and onset of neurological symptoms was between 0 and 12 days. None of the patients had MRI features of encephalitis nor significant cerebrospinal fluid (CSF) abnormalities. SARS‐CoV‐2 RT‐PCR in the CSF was negative for all patients. All patients presented with a consistent brain FDG‐PET/CT pattern of abnormalities, namely frontal hypometabolism and cerebellar hypermetabolism. All patients improved after immunotherapy.

Conclusions

Despite varied clinical presentations, all patients presented with a consistent FDG‐PET pattern, which may reflect an immune mechanism.

[Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review]

OBJECTIVE

The lack of ressources and coordination to face the epidemic of coronavirus raises concerns for the health of patients with mental disorders in a country where we keep in memory the dramatic experience of famine in psychiatric hospitals during the Second World War. This article aims at proposing guidance to ensure mental health care during the SARS-CoV epidemy in France.

METHODS

Authors performed a narrative review identifying relevant results in the scientific and medical literature and local initiatives in France.

RESULTS

We identified four types of major vulnerabilities in patients suffering from mental disorders during this pandemic: (1) medical comorbidities that are more frequently found in patients suffering from mental disorders (cardiovascular and pulmonary pathologies, diabetes, obesity, etc.) which represent risk factors for severe infections with Covid-19; (2) age (the elderly constituting the population most vulnerable to coronavirus); (3) cognitive and behavioral troubles which can hamper compliance with confinement and hygiene measures and finally and (4) psychosocial vulnerability due to stigmatization and/or socio-economic difficulties. Furthermore, the mental health healthcare system is more vulnerable than other healthcare systems. Current government plans are poorly adapted to psychiatric establishments in a context of major shortage of organizational, material and human resources. In addition, a certain number of structural aspects make the psychiatric institution particularly vulnerable: many beds are closed, wards have a high density of patients, mental health community facilities are closed, medical teams are understaffed and poorly trained to face infectious diseases. We could also face major issues in referring patients with acute mental disorders to intensive care units. To maintain continuity of psychiatric care in this pandemic situation, several directions can be considered, in particular with the creation of Covid+ units. These units are under the dual supervision of a psychiatrist and of an internist/infectious disease specialist; all new entrants should be placed in quarantine for 14 days; the nurse staff should benefit from specific training, from daily medical check-ups and from close psychological support. Family visits would be prohibited and replaced by videoconference. At the end of hospitalization, in particular for the population of patients in compulsory ambulatory care situations, specific case-management should be organized with the possibility of home visits, in order to support them when they get back home and to help them to cope with the experience of confinement, which is at risk to induce recurrences of mental disorders. The total or partial closure of mental health community facilities is particularly disturbing for patients but a regular follow-up is possible with telemedicine and should include the monitoring of the suicide risk and psychoeducation strategies; developing support platforms could also be very helpful in this context. Private psychiatrists have also a crucial role of information with their patients on confinement and barrier measures, but also on measures to prevent the psychological risks inherent to confinement: maintenance of sleep regularity, physical exercise, social interactions, stress management and coping strategies, prevention of addictions, etc. They should also be trained to prevent, detect and treat early warning symptoms of post-traumatic stress disorder, because their prevalence was high in the regions of China most affected by the pandemic.

DISCUSSION

French mental healthcare is now in a great and urgent need for reorganization and must also prepare in the coming days and weeks to face an epidemic of emotional disorders due to the containment of the general population.

Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review

OBJECTIVE

The lack of resources and coordination to face the coronavirus epidemic raises concerns for the health of patients with mental disorders in a country where we still have memories of the dramatic experience of famine in psychiatric hospitals during the Second World War. This article aims to propose guidance to ensure mental health care during the SARS-CoV epidemic in France.

METHODS

The authors performed a narrative review identifying relevant results in the scientific and medical literature and in local initiatives in France.

RESULTS

We identified four types of major vulnerabilities among patients with mental disorders during this pandemic: (1) medical comorbidities that are more frequently found among patients with mental disorders (cardiovascular and pulmonary pathologies, diabetes, obesity, etc.) which are risk factors for severe covid-19 infection; (2) age (the elderly form the population most vulnerable to the coronavirus); (3) cognitive and behavioural disorders, which can hamper compliance with confinement and hygiene measures and finally and (4) psychosocial vulnerability as a result of stigmatization and/or socio-economic difficulties. Furthermore, the mental health healthcare system is more vulnerable than other healthcare systems. Current government plans are poorly suited to psychiatric establishments in a context of major shortages of organizational, material and human resources. In addition, a certain number of structural aspects make the psychiatric institution particularly vulnerable: many beds have been closed, wards have high densities of patients, mental health community facilities are closed, and medical teams are understaffed and poorly trained to face infectious diseases. There are also major issues when referring patients with acute mental disorders to intensive care units. To maintain the continuity of psychiatric care in this pandemic situation, several directions can be considered, in particular with the creation of "COVID+ units". These units are under the dual supervision of a psychiatrist and an internist/infectious disease specialist; all new entrants are placed in quarantine for 14 days; the nursing staff receives specific training, daily medical check-ups and close psychological support. Family visits are prohibited and replaced by videoconference. At the end of hospitalization, in particular for the population of patients in compulsory ambulatory care situations, specific case-management are organized with the possibility of home visits, in order to support patients when they get back home and to help them cope with the experience of confinement, which is liable to induce recurrences of mental disorders. The total or partial closure of community mental health facilities is particularly disturbing for patients, but a regular follow-up is possible with telemedicine and should include the monitoring of suicide risk and psycho-education strategies; developing support platforms could also be very helpful in this context. Private practice psychiatrists also have a crucial role of information towards their patients on confinement and barrier measures, and also on measures to prevent the psychological risks inherent in confinement: maintenance of regular sleep r, physical exercise, social interactions, stress management and coping strategies, prevention of addictions, etc. They should also be trained to prevent, detect and treat early warning symptoms of post-traumatic stress disorder, because their prevalence was high in the regions of China most affected by the pandemic.

DISCUSSION

French mental healthcare is now facing a great and urgent need for reorganization and must also prepare in the coming days and weeks to face an epidemic of emotional disorders due to the confinement of the general population.

[Challenges for psychotropics in the context of the SARS-Cov-2 pandemic]

French recommendations have been proposed for psychotropics use and possible adaptations during the SARS-CoV-2 epidemic. Between uncertainties linked to the lack of data and speculations about possible benefits of psychotropics against the coronavirus, we propose here elements allowing to base the pharmacotherapeutic decisions potentially useful in Covid+ patients with psychiatric disorders.

[Coronavirus: Predictive brain and terror management]

Emerging infectious diseases like Covid-19 cause a major threat to global health. When confronted with new pathogens, individuals generate several beliefs about the epidemic phenomenon. Many studies have shown that individual protective behaviors largely depend on these beliefs. Due to the absence of treatment and vaccine against these emerging pathogens, the relation between these beliefs and these behaviors represents a crucial issue for public health policies. In the premises of the Covid-19 pandemic, several preliminary studies have highlighted a delay in the perception of risk by individuals, which potentially holds back the implementing of the necessary precautionary measures: people underestimated the risks associated with the virus, and therefore also the importance of complying with sanitary guidelines. During the peak of the pandemic, the salience of the threat and of the risk of mortality could then have transformed the way people generate their beliefs. This potentially leads to upheavals in the way they understand the world. Here, we propose to explore the evolution of beliefs and behaviors during the Covid-19 crisis, using the theory of predictive coding and the theory of terror management, two influential frameworks in cognitive science and in social psychology.

[Informations on psychotropics and their adaptations for patients suffering from mental disorders in France during the SARS-CoV-2 epidemic]

The 2019-20 coronavirus pandemic (SARS-CoV-2; severe acute respiratory syndrome coronavirus 2) has dramatic consequences on populations in terms of morbidity and mortality and in social terms, the general confinement of almost half of the world's population being a situation unprecedented in history, which is difficult today to measure the impact at the individual and collective levels. More specifically, it affects people with various risk factors, which are more frequent in patients suffering from psychiatric disorders. Psychiatrists need to know: (i) how to identify, the risks associated with the prescription of psychotropic drugs and which can prove to be counterproductive in their association with COVID-19 (coronavirus disease 2019), (ii) how to assess in terms of benefit/risk ratio, the implication of any hasty and brutal modification on psychotropic drugs that can induce confusion for a differential diagnosis with the evolution of COVID-19. We carried out a review of the literature aimed at assessing the specific benefit/risk ratio of psychotropic treatments in patients suffering from COVID-19. Clinically, symptoms suggestive of COVID-19 (fever, cough, dyspnea, digestive signs) can be caused by various psychotropic drugs and require vigilance to avoid false negatives and false positives. In infected patients, psychotropic drugs should be used with caution, especially in the elderly, considering the pulmonary risk. Lithium and Clozapine, which are the reference drugs in bipolar disorder and resistant schizophrenia, warrant specific attention. For these two treatments the possibility of a reduction in the dosage - in case of minimal infectious signs and in a situation, which does not allow rapid control - should ideally be considered taking into account the clinical response (even biological; plasma concentrations) observed in the face of previous dose reductions. Tobacco is well identified for its effects as an inducer of CYP1A2 enzyme. In a COVID+ patient, the consequences of an abrupt cessation of smoking, particularly related with the appearance of respiratory symptoms (cough, dyspnea), must therefore be anticipated for patients receiving psychotropics metabolized by CYP1A2. Plasma concentrations of these drugs are expected to decrease and can be related to an increase risk of relapse. The symptomatic treatments used in COVID-19 have frequent interactions with the most used psychotropics. If there is no curative treatment for infection to SARS-CoV-2, the interactions of the various molecules currently tested with several classes of psychotropic drugs (antidepressants, antipsychotics) are important to consider because of the risk of changes in cardiac conduction. Specific knowledge on COVID-19 remains poor today, but we must recommend rigor in this context in the use of psychotropic drugs, to avoid adding, in patients suffering from psychiatric disorders, potentially vulnerable in the epidemic context, an iatrogenic risk or loss of efficiency.

Mood congruency effects are mediated by shifts in salience and central executive network efficiency

Emotions are not confined to short momentary states but carry on over time, facilitating the perception and interpretation of the environment in mood-congruent ways. Yet, the (neural) mechanism linking affective stimulation at a certain time-point to such altered, mood-congruent processing of stimuli presented at a subsequent time-point remains unknown. Recent research suggests that such a link could be explained by transient effects of affective stimulation on the organization of intrinsic macro-scale neural networks. It remains, however, unclear whether these changes in network organization are influencing subsequent perception in a mood-congruent way. Addressing this gap the current study investigated whether changes in network organization, measured in terms of network efficiency, mediate the relation between mood induction and mood-congruent processing as measured by reaction times during an emotional Stroop task. The results demonstrated that negative mood induction increased the efficiency of the salience network and decreased the efficiency of the central executive network. This modulation of network efficiency fully mediated the effects of mood induction on reaction times to negative words. These findings indicate that transient shifts in the organization of macro-scale neural networks are an essential part of the emotional response and can help to explain how affect shapes our interaction with the environment.

Late-Onset OCD as a Potential Harbinger of Dementia With Lewy Bodies: A Report of Two Cases

OBJECTIVES

Obsessive-compulsive disorder usually begins in adolescence or young adulthood. OCD cases appearing after the age of 50 years are rare, most often associated with inflammatory, brain lesions, or neurodegenerative comorbidities. We describe two cases of late-onset obsessive compulsive disorder followed by the development of Dementia with Lewy Bodies and review the links between these two disorders.

METHODS AND RESULTS

We describe the clinical history of two patients that first showed OCD symptoms at an atypical age (>60 years). After several failed treatment attempts, they were hospitalized in our unit. Both presented severe sensitivity to antipsychotic agents that led to a diagnosis of Dementia with Lewy Bodies. Administration of cholinesterase inhibitors was associated with decrease of psychiatric symptoms in both cases. In addition to those clinical observations, a systematic review of the literature suggests that, beyond prefrontal cortex, temporal lobe and putamen have important roles in OCD pathophysiology. Based on these findings, we discuss four hypotheses to explain the sequential appearance of OCD and DLB symptoms. First, we considered the possibility that comorbidity of OCD with DLB was coincidental. Second, we propose to interpret OCD symptoms as motor stereotypies. Third, we hypothesize that late-onset OCD might be a symptom of late-onset depression. Four, we hypothesize that through early deterioration of basal ganglia, DLB caused the onset of OCD.

CONCLUSION

In conclusion, we recommend that cases of late-onset treatment-resistant OCD should be carefully tested for possible organic etiologies, and for DLB in particular.

Factors Associated With a Higher Score of Burnout in a Population of 860 French Psychiatrists

Burnout rates are estimated to be twice as high among healthcare professionals as in the general working population, and studies indicate rising incidence. The present study aimed to identify the contextual factors associated with self-reported burnout rates among French psychiatrists. A total of 860 French or French-speaking psychiatrists completed an online questionnaire when they registered for a major psychiatric conference. The Copenhagen Burnout Inventory, a validated scale that independently appraises personal, work- and patient-related dimensions, was used to assess the degree of perceived burnout. Respondents were divided into lower risk and higher risk groups. The latter contained the 25% of individuals who scored the highest on each of the three dimensions of the CBI scale. Univariate analysis showed that private practice was associated with lower levels of risk on the personal and work-related dimensions. Working for the public sector and long hours were both associated with a higher score on the work-related dimension. Interestingly, none of the variables we investigated, except from poor atmosphere at work, correlated with the patient-related dimension. Among public-sector psychiatrists, female gender, longer hours, and more consultations per week were associated with a higher score on the work-related dimension. Working four or more night shifts per month was significantly associated with a higher score of burnout risk on all three dimensions. Private- and public-sector practitioners who mainly treated patients with schizophrenia had a higher score of burnout risk. Multivariate analysis showed that a poor atmosphere at work, longer hours, and working four or more night shifts were significantly associated with higher score of burnout risk. A nonreassuring working environment and more stressors while treating patients each had a possibly negative impact. Although this study only examined the factors that distinguish between clinicians with the lowest versus highest CBI burnout risk scores, it opens up important avenues for research and development of programs to reduce burnout risk within the French healthcare system.

Mind-Wandering Changes in Dysphoria

Changes in mind-wandering (MW) and involuntary autobiographical memory (IAM) in dysphoria have been explored with conflicting results. The aim of this study was to evaluate both MW and IAM in a group of 23 stable dysphoric participants compared to 37 controls and to compare their thoughts characteristics (i.e., specificity, visual perspective, time orientation, and emotional valence). To make this study comparable with previous research, we used two different monotonous vigilance tasks (with and without verbal interference stimuli). Our results showed a significantly greater focus on MW thoughts in dysphoria. The characteristics of spontaneous thoughts content did not differ significantly between our dysphoric participants and controls, which is not in favor of strong emotional dysfunction. Our results suggest a difficulty to regulate the occurrence of self-generated thoughts rather than their content, that may confer to dysphoric subjects increased cognitive risk to develop a major depressive episode.

Use of 3,5-dichloro-2-hydroxybenzenesulfonic acid/4-aminophenazone chromogenic system in direct enzymic assay of uric acid in serum and urine

A new direct colorimetric procedure for uric acid assay in serum or urine is described, utilizing a 3,5-dichloro-2-hydroxybenzene sulfonic acid/4-aminophenazone chromogenic system in the presence of horseradish peroxidase and uricase from Aspergillus flavus. This chromogen system has a high absorptivity, affording useful results with sample/reagent volume ratios as low as 0.025. The procedure is applicable to serum, plasma, or diluted urine. A single working reagent is used; the reaction is complete in less than 15 min at room temperature. The red dye formed is measured at 520 nm; a blank sample measurement is not needed. The standard curve for the method is linear for uric acid concentrations up to 1500 mumol/L. Average analytical recovery of uric acid in human sera and urine exceeded 99%; within-run and between-run precision studies showed CV's of less than or equal to 1.2 and less than or equal to 2.2%, respectively. The new procedure correlated well with the uricase/catalase and uricase/ultraviolet methods. The method is suitable for automation.

Personality and Neuropsychological Profiles in Friedreich Ataxia

Friedreich ataxia, an autosomal recessive mitochondrial disease, is the most frequent inherited ataxia. Many studies have attempted to identify cognitive and affective changes associated with the disease, but conflicting results have been obtained, depending on the tests used and because many of the samples studied were very small. We investigated personality and neuropsychological characteristics in a cohort of 47 patients with genetically confirmed disease. The neuropsychological battery assessed multiple cognition domains: processing speed, attention, working memory, executive functions, verbal memory, vocabulary, visual reasoning, emotional recognition, and social cognition. Personality was assessed with the Temperament and Character Inventory, and depressive symptoms were assessed with the Beck Depression Inventory. We found deficits of sustained attention, processing speed, semantic capacities, and verbal fluency only partly attributable to motor deficit or depressed mood. Visual reasoning, memory, and learning were preserved. Emotional processes and social cognition were unimpaired. We also detected a change in automatic processes, such as reading. Personality traits were characterized by high persistence and low self-transcendence. The mild cognitive impairment observed may be a developmental rather than degenerative problem, due to early cerebellum dysfunction, with the impairment of cognitive and emotional processing. Disease manifestations at crucial times for personality development may also have an important impact on personality traits.

Relevance of TSH evaluation in elderly in-patients with non-thyroidal illness

BACKGROUND

Non-thyroidal illness (NTI) is frequent in hospitalized patients. Its recovery is characterized by a raise in TSH levels. However, the clinical significance of high TSH levels at admission in hospitalized elderly patients with NTI remains uncertain.

AIM

To explore the relevance of baseline TSH evaluation in hospitalized elderly patients with NTI.

METHODS

We examined the participants with NTI (n = 123) from our previous study (Sforza, 2017). NTI was defined as: low T3 (< 80 ng/dL) and normal or low total T4 in the presence of TSH values between 0.1 and 6.0 mU/L. Thyroid function tests were performed on day 1 and day 8 of the hospital stay. Positive TSH changes (+ ΔTSH) were considered when the day-8 TSH value increased more than the reference change value for TSH (+ 78%). Multiple logistic regression was used to evaluate the independent association of baseline TSH, sex, clinical comorbidities (by ACE-27) and medications with + ΔTSH.

RESULTS

Out of 123 patients (77 ± 8 years, 52% female), 34 showed a + ΔTSH. These patients had a lower TSH at admission (p < 0.001) and intra-hospital mortality (p = 0.003) than the others. In multiple logistic regression, TSH > 2.11 mU/L at baseline was associated with reduced odds to show + ΔTSH [odds ratio (95 CI) 0.29 (0.11-0.75); p = 0.011] in a model adjusted by age, sex and ACE-27.

DISCUSSION

Inappropriately higher TSH levels at admission in hospitalized elderly patients were associated with a reduced ability to raise their TSH levels later on. The present results confront the idea that TSH levels at admission are irrelevant in this clinical context.

A step towards international prospective trials in carbon ion radiotherapy: investigation of factors influencing dose distribution in the facilities in operation based on a case of skull base chordoma

Background

Carbon ion radiotherapy (CIRT) has been delivered to more than 20,000 patients worldwide. International trials have been recommended in order to emphasize the actual benefits. The ULICE program (Union of Light Ion Centers in Europe) addressed the need for harmonization of CIRT practices. A comparative knowledge of the sources and magnitudes of uncertainties altering dose distribution and clinical effects during the whole CIRT procedure is required in that aim.

Methods

As part of ULICE WP2 task group, we sent a centrally reviewed questionnaire exploring candidate sources of uncertainties in dose deposition to the ten CIRT facilities in operation by February 2017. We aimed to explore native beam characterization, immobilization, anatomic data acquisition, target volumes and organs at risks delineation, treatment planning, dose delivery, quality assurance prior and during treatment. The responders had to consider the clinical case of a clival chordoma eligible for postoperative CIRT according to their clinical practice. With the results, our task group discussed ways to harmonize CIRT practices.

Results

We received 5 surveys from facilities that have treated 77% of the patients worldwide per November 2017. We pointed out the singularity of the facilities and beam delivery systems, a divergent definition of target volumes, the multiplicity of TPS and equieffective dose calculation approximations.

Conclusion

Multiple uncertainties affect equieffective dose definition, deposition and calculation in CIRT. Although it is not possible to harmonize all the steps of the CIRT planning between the centers, our working group proposed counter-measures addressing the improvable limitations.

Different Aspects of the Neural Response to Socio-Emotional Events Are Related to Instability and Inertia of Emotional Experience in Daily Life: An fMRI-ESM Study

Emotions are fundamentally temporal processes that dynamically change over time. This temporal nature is inherently involved in making emotions adaptive by guiding interactions with our environment. Both the size of emotional changes across time (i.e., emotional instability) and the tendency of emotions to persist across time (i.e., autocorrelation of emotional experience, emotional inertia) are key features of a person’s emotion dynamics, and have been found central to maladaptive functioning and psychopathology as well as linked to social functioning. However, whether different (neural) mechanisms are underlying these dynamics as well as how they are related to the processing of (socio-) emotional information is to date widely unknown. Using a combination of Experience Sampling methods (ESMs) and fMRI (involving a social feedback paradigm), we examine how emotional instability and inertia in everyday life are associated with different aspects of the neural response to socio-emotional events. The findings indicate that while emotional instability is connected to the response of the core salience network (SN), emotional inertia is associated to responses in the parahippocampal gyrus (PHG) and lateral orbitofrontal cortex (lOFC). This is the first study showing that different aspects of the neural response to socio-emotional events are associated with different aspects of the temporal dynamics of emotion in real life.

Depression, Cognitive Functions, and Impaired Functioning in Middle-Aged Adults From the CONSTANCES Cohort

OBJECTIVE

This large-scale population-based prospective study examined the association between depressive symptoms and cognitive performance at baseline with later functioning in middle-aged adults.

METHODS

The Center for Epidemiologic Studies Depression Scale, the Digit Symbol Substitution Test (DSST), the Trail Making Test B (TMT-B), and the Semantic Verbal Fluency test (SVF) were completed at baseline by 7,426 participants aged ≥ 45 years from February 2012 to December 2013. Role limitations and social functioning were later assessed with the second version of the 12-Item Short Form Health Survey. The association between depressive symptoms and cognitive performance at baseline with functioning at follow-up was examined using general linear models and mediation analyses including sex, age, education, alcohol intake, and cannabis use as covariates.

RESULTS

Altered functioning at follow-up was predicted by depressive symptoms (β per standard deviation [95% confidence intervals]: -1.10 [-1.16 to -1.03] and -1.02 [-1.08, -0.96] for role limitations and social functioning, respectively) and DSST, TMT-B, and SVF performance (for role limitations: 0.11 [0.09 to 0.14], -0.11 [-0.13 to -0.08], and 0.03 [0.01 to 0.06], respectively; for social functioning: 0.10 [0.07 to 0.12], -0.08 [-0.11 to -0.06], and 0.04 [0.01 to 0.05], respectively) at baseline. Depressive symptoms were associated with poorer cognitive performance at baseline (-0.19 [-0.25 to -0.13], 0.15 [0.08 to 0.21], and -0.11 [-0.17 to -0.04], respectively). Cognitive performance accounted for only 0.3%-1.4% of the relationship between depressive symptoms and functioning. In contrast, depressive symptoms accounted for 19.5%-43.7% of the association between cognitive performance and functioning.

CONCLUSIONS

In middle-aged adults from the general population, cognitive impairment is unlikely to substantially explain the association between depressive symptoms and later role limitations and social functioning.

The impact of self-distancing on emotion explosiveness and accumulation: An fMRI study

Emotions unfold over time with episodes differing in explosiveness (i.e., profiles having a steep vs. a gentle start) and accumulation (i.e., profiles increasing over time vs. going back to baseline). In the present fMRI study, we wanted to replicate and extend previous findings on the psychological and neural mechanisms underlying emotion explosiveness and accumulation. Specifically, we aimed to: (a) replicate the finding that different neural mechanisms are associated with emotion explosiveness and accumulation, (b) replicate the finding that adopting a self-distanced (vs. self-immersed) perspective decreases emotion explosiveness and accumulation at the level of self-report, and (c) examine whether adopting a self-distanced (vs. self-immersed) perspective similarly modulates activity in the brain regions associated with emotion explosiveness and accumulation. Participants in an fMRI scanner were asked to adopt a self-immersed or self-distanced perspective while reading and thinking about negative social feedback, and to report on felt changes in negative affect during that period using an emotion intensity profile tracking approach. We replicated previous findings showing that emotion explosiveness and accumulation were related to activity in regions involved in self-referential processing (such as the medial prefrontal cortex) and sustained visceral arousal (such as the posterior insula), respectively. The finding that adopting a self-distanced (vs. self-immersed) perspective lowers emotion explosiveness and accumulation was also replicated at a self-report level. However, perspective taking did not impact activity in the neural correlates of emotion explosiveness and accumulation.