Altered top-down and bottom-up processing of fear conditioning in panic disorder with agoraphobia

BACKGROUND

Although several neurophysiological models have been proposed for panic disorder with agoraphobia (PD/AG), there is limited evidence from functional magnetic resonance imaging (fMRI) studies on key neural networks in PD/AG. Fear conditioning has been proposed to represent a central pathway for the development and maintenance of this disorder; however, its neural substrates remain elusive. The present study aimed to investigate the neural correlates of fear conditioning in PD/AG patients.

METHOD

The blood oxygen level-dependent (BOLD) response was measured using fMRI during a fear conditioning task. Indicators of differential conditioning, simple conditioning and safety signal processing were investigated in 60 PD/AG patients and 60 matched healthy controls.

RESULTS

Differential conditioning was associated with enhanced activation of the bilateral dorsal inferior frontal gyrus (IFG) whereas simple conditioning and safety signal processing were related to increased midbrain activation in PD/AG patients versus controls. Anxiety sensitivity was associated positively with the magnitude of midbrain activation.

CONCLUSIONS

The results suggest changes in top-down and bottom-up processes during fear conditioning in PD/AG that can be interpreted within a neural framework of defensive reactions mediating threat through distal (forebrain) versus proximal (midbrain) brain structures. Evidence is accumulating that this network plays a key role in the aetiopathogenesis of panic disorder.

[Repeated measurement of memory with valenced test items: verbal memory, working memory and autobiographic memory]

A large number of questions in clinical and/or experimental neuropsychology require the multiple repetition of memory tests at relatively short intervals. Studies on the impact of the associated exercise and interference effects on the validity of the test results are rare. Moreover, hardly any neuropsychological instruments exist to date to record the memory performance with several parallel versions in which the emotional valence of the test material is also taken into consideration. The aim of the present study was to test whether a working memory test (WST, a digit-span task with neutral or negative distraction stimuli) devised by our workgroup can be used with repeated measurements. This question was also examined in parallel versions of a wordlist learning paradigm and an autobiographical memory test (AMT). Both tests contained stimuli with neutral, positive and negative valence. Twenty-four participants completed the memory testing including the working memory test and three versions of a wordlist and the AMT at intervals of a week apiece (measuring points 1. - 3.). The results reveal consistent performances across the three measuring points in the working and autobiographical memory test. The valence of the stimulus material did not influence the memory performance. In the delayed recall of the wordlist an improvement in memory performance over time was seen. The tests on working memory presented and the parallel versions for the declarative and autobiographical memory constitute informal economic instruments within the scope of the measurement repeatability designs. While the WST and AMT are appropriate for study designs with repeated measurements at relatively short intervals, longer intervals might seem more favourable for the use of wordlist learning paradigms.

Who is Subjected to Coercive Measures as a Psychiatric Inpatient? A Multi-Level Analysis

Background:

For a reduction in the use of coercive interventions it will be necessary to identify patients at risk. The aim of this study was to explore the impact of basic patient characteristics at admission, history within 24 hours before admission, and living conditions on the risk of experiencing coercive measures, controlling for ward characteristics in a multi-level approach.

Methods:

Patient characteristics of 3389 patients (1920 women) who had received inpatient treatment in 2007, data relating to coercive measures, and ward characteristics were extracted from the clinical basic documentation.

Results:

Patients with aggressive behaviour in the 24 hours prior to admission had a three times higher risk of coercive measures compared to non-aggressive patients. Severity of illness increased the risk of coercion markedly. With each level of severity, the risk of coercion was doubled. Voluntariness of stay appeared to be the best protective factor against coercive measures. If a patient stayed voluntarily, this reduced the risk of coercion by more than two thirds. No impact was found for living conditions.

Conclusions:

To identify patients at risk, it is most important to intensively monitor patients with aggressive behaviour prior to admission and patients with a greater severity of psychopathological symptoms.

Controlling the orbital sequence in individual Cu-phthalocyanine molecules

We report on the controlled change of the energetic ordering of molecular orbitals. Negatively charged copper(II)phthalocyanine on NaCl/Cu(100) undergoes a Jahn-Teller distortion that lifts the degeneracy of two frontier orbitals. The energetic order of the levels can be controlled by Au and Ag atoms in the vicinity of the molecule. As only one of the states is occupied, the control of the energetic order is accompanied by bistable changes of the charge distribution inside the molecule, rendering it a bistable switch.

[On the value of neuropsychological short tests in epileptology]

Cognitive deficits are common in patients with epilepsy refractive to therapy and have considerable influence on the quality of life in this group of patients. Therefore, neuropsychological investigations should play an important role in the comprehensive evaluation of patients with chronic epilepsy. The aim of this study was to examine whether a reliable screening for cognitive deficits in these patients may be reduced to the assessment of two bedside tests. In a prospective study we analyzed the results of 40 patients with epilepsy refractive to therapy subjected to a 45-min neuropsychological screening battery and compared them with the results of a short battery consisting of two bedside tests. Using the screening battery as the gold standard, the short battery had a sensitivity of 50% and a specificity of 100%. Changing the criteria for pathological results in the short battery, sensitivity could be raised to 81.25% but specificity fell to 50%. Therefore, bedside tests instead of longer neuropsychological testing cannot be recommended as a screening method for cognitive deficits in patients with chronic epilepsy.

Der Einfluss von Erkrankungsalter, Lebensalter und Krankheitsdauer auf die kognitiven Leistungen bei Patienten mit therapierefraktärer Epilepsie

This retrospective study was performed as part of the controversial discussion whether increasing cognitive deficits in patients with refractory epilepsy are mainly an effect of normal aging or caused by epilepsy related noxious events during the course of an intractable epilepsy. Neuropsychological data and information about the course of the disease from 146 patients with refractory epilepsy were available. There were significant correlations between the age at onset and premorbid intelligence, duration of disease and fluid intelligence and age and difference between premorbid intelligence and fluid intelligence as a measure of cognitive deterioration. Discussing these results we conclude that beneath a clear effect of normal aging on cognitive deterioration there is probably a small effect of the refractory course of the epilepsy, which might be mediated by the number of seizures. Additionally we would like to encourage early cognitive screening and rehabilitation programmes for patients with epilepsy to minimize the effect of the age of onset on the level of education or premorbid intelligence.

The influence of folate serum levels on depressive mood and mental processing in patients with epilepsy treated with enzyme-inducing anti-epileptic drugs

BACKGROUND

Folate deficiency is common in patients with epilepsy and also occurs in patients with depression or cognitive deficits.

OBJECTIVE

This study investigates whether low serum folate levels may contribute to depressive mood and difficulties in mental processing in patients with epilepsy treated with anti-epileptic drugs inducing the cytochrome P450.

METHODS

We analysed the serum folate levels, the score in the Self Rating Depression Scale (SDS) and the results of a bedside test in mental processing in 54 patients with epilepsy.

RESULTS

There was a significant negative correlation between the serum folate levels and the score in SDS and significant positive correlations between the score in SDS and the time needed to process an interference task or a letter-reading task.

CONCLUSIONS

Low serum folate levels may contribute to depressive mood and therefore to difficulties in mental processing. Further studies utilizing total plasma homocysteine as a sensitive measure of functional folate deficiency and more elaborate tests of mental processing are required to elucidate the impact of folate metabolism on depressive mood and cognitive function in patients with epilepsy.

Modification of slow cortical potentials in patients with refractory epilepsy: a controlled outcome study

PURPOSE

To compare self-regulation of low-frequency EEG components (slow cortical potentials, SCPs) with other methods of seizure control for patients with drug-refractory partial epilepsy and to separate the real anticonvulsive effect from placebo effects.

METHODS

Results of a treatment program of SCP self-regulation (experimental group) are compared with two groups of patients, one of which learned self-control of respiratory parameters (end-tidal CO2 and respiration rate: RES group); the other received medication with new anticonvulsive drugs (AEDs) in combination with psychosocial counseling (MED group). Clinical, cognitive, behavioral, and personality measures were assessed before and after treatment. In addition, to control for placebo responses, patients repeatedly estimated their beliefs in the efficiency of the respective treatment, their satisfaction and expectations, and the quality of the relationship with their therapists.

RESULTS

SCP and MED groups showed a significant decrease of seizure frequency, but the RES group did not. Clear positive changes in the sociopsychological adjustment were obtained in all three groups, with the maximal improvement being attained in the RES group.

CONCLUSIONS

All kinds of therapy result in considerable improvement of patients' emotional state, which may in part be due to potential placebo effects: however, this improvement is not related to the quality of the therapeutic effect proper (i.e., seizure reduction). Traditional double-blind control group designs are inappropriate for behavioral interventions or treatments with psychoactive pharmacologic drugs. Rather, specific tests can be developed to control the placebo effect and to separate it from the genuine therapeutic effects.

Biofeedback treatment in patients with refractory epilepsy: changes in depression and control orientation

Depression is a common and serious interictal problem in patients with epilepsy. The genesis of depressive disorders is multifactorial. One aetiological aspect focuses on psychosocial factors. It was hypothesized that uncontrollable, unpredictable chronic aversive events (i.e. epileptic seizures) result in cognitive deficits of external control orientation. If this is true, biofeedback training could represent a possible treatment strategy to lower depression, because biofeedback is known to mediate success experiences and control. Measures of depression and locus of control were administered to 20 patients with refractory partial epilepsy before and after biofeedback treatment. The biofeedback consisted of slow cortical potentials or breathing parameters in 10 patients each. A clear relationship occurred between depression and locus of control in the subjects. After biofeedback training control orientation moved towards a more internal locus of control. Also, depression scores were significantly reduced six months after training. Results show that in patients with refractory epilepsy depression is highly correlated with locus of control, in a way that external control orientation relates to high depression scores. Biofeedback is able to improve internal control orientation through personal success mediation.

Beyond habituation: long-term repetition effects on visual event-related potentials in epileptic patients

Sixteen patients with partial epilepsy learned to produce positive or negative slow cortical potential shifts in a biofeedback condition during 20 consecutive training sessions. Visual ERPs to the presentation of the feedback and the discriminative stimulus were recorded at vertex. Regardless of the subjects' task (positivity versus negativity), amplitudes of the P2 (mean peak latency about 225 ms) and P3a (322 ms) components decreased across sessions, resulting in appearance and subsequent enhancement of a negative wave N2 (298 ms) between P2 and P3a. As N2 grew the P2 latency decreased and the P3a latency increased. Additionally, the P3b (472 ms) decreased with repetition, however, it did so slower than P2 and P3a. A comparison between the present data, on the one hand, and those obtained in the ERP habituation paradigm within one session, on the other hand, indicates that some repetition effects cannot be explained by habituation.

Self-regulation of slow cortical potentials in epilepsy: a retrial with analysis of influencing factors

Twenty sessions of biofeedback training were carried out with 12 drug-resistant patients with focal epilepsy who learned to produce either negative or positive shifts of their slow cortical potentials (SCPs) at vertex. Feedback trials were interspersed with transfer trials in which only a discriminative stimulus (signalizing whether positivity or negativity was required) was presented, without feedback signal. Patients were able to differentiate significantly between the conditions of cortical positivity and cortical negativity, with larger differentiation scores being obtained in feedback trials than in transfer trials. The amplitude of positivity generated in the positivity condition increased linearly across sessions both in feedback and in transfer trials. The largest negativity was produced in the 5th session; after this, more transient negativities were generated, whose amplitude decreased towards the end of trial. The mean severity of seizures, estimated as the frequency of seizures weighted by their subjective 'strength', decreased significantly after training as compared to the pre-training phase. The data suggest that (1) patients could learn to achieve a state of cortical disfacilitation and (2) with progressed learning, they became less motivated for (or afraid of) producing considerable negative shifts, since extensive negativity may reflect cortical over-excitation and therefore be associated with early signs of seizures. The inability of producing cortical negativity is however not necessarily a bad predictor.

The body's response to processing emotional trauma: linking verbal text with autonomic activity

When individuals talk or think about upsetting experiences, different coping and defensive processes are invoked from one minute to the next. Further, some coping strategies are thought to be more effortful and to be associated with greater biological activity than others. The present research sought to identify how the expression of emotions and the use of different psychological defenses were reflected in momentary changes in autonomic nervous system activity while subjects wrote about emotional topics. A new methodology is introduced that links the production of natural written language with autonomic activity on a word-by-word or phrase-by-phrase basis. Using this technique with a sample of 24 subjects who wrote about traumatic experiences, it was found that certain text dimensions are highly related to skin conductance level (SCL) but not heart rate. In general, subjects' SCLs increased when expressing negative emotions and when using denial and the passive voice. SCLs were more likely to drop when subjects used positive emotion words and self-references and at the conclusion of sentences or thought units. Implications for this methodology for understanding psychological defense and physical health are discussed.

Nasopharyngeal and adjacent neoplasms: a clinico-pathologic and immunologic study

Thirteen cases of nasopharyngeal carcinoma (NPC) and 16 cases of non-NPC tumors in the nasopharynx or in adjacent locations were investigated clinically, immunologically, and pathologically. All tumors were classified according to the TNM classification, and the stage and course of the disease was correlated with the histological tumor type, the T- and B-cell distribution in tumor tissue and in the peripheral blood, as well as with antibody titers against Epstein-Barr virus (EBV). The results showed a positive correlation of decreased T- and B-cells in tumor tissue and of decreased T-cells in the peripheral blood with the extend of the tumor in both NPC and non-NPC cases, with some exceptions of lymphocyte rich neoplasms (lymphoepithelial carcinoma and malignant lymphoma). Antibodies against EBV (early antigen and capsid antigen) became progressively elevated with increasing tumor stage in NPC-cases but not in non-NPC cases. The latter, however, was observed only in two histological types of NPC's: anaplastic carcinoma and lymphoepithelial carcinoma; titers in the remaining tumor types stayed insignificant.

Percent distribution of T- and B-cells in tonsils of children, juveniles and adults

The percent distribution of T- and B-lymphocytes in tonsilar tissue of 122 patients from 2--68 years and both sexes was investigated. T-cells were determined by the E-rosetting technique and B-cells by immunofluorescence. We found 50.3% B-cells and 30.6% T-cells in tonsilar tissue. There was a significant decrease of IgM-receptor carrying cells with increasing age and with a converse behavior of the sum of IgA-, IgD-, IgE-receptor B-cells. In tonsils with acute inflammation and with hyperplasia IgM cells were also increased significantly when compared to cell counts in chronic tonsillitis. The results are discussed and compared to data from the literature.

[Percent distribution of B-Lymphocytes in human tonsils at various ages]

B-Lymphocytes of the classes G, M and A were determined by use of heavy-chain-specific fluorescent antisera from 67 children between 2 and 14 years of age and from 15 adults up to 60 years of age. Tonsils from which viable cell suspensions were investigated for B-Cells were classified histologically, according to their degree of lymphatic hyperplasia and inflammation. With increasing age, a statiscally significant decrease in percent G- and M-cells was observed while A-cells remained unchanged. With increasing severity and extent of inflammation and lymphatic hyperplasia, there occured a mild increase in percent M-cells. G-cells did not exhibit major changes under such conditions. It is suggested, that the tonsil may represent an early and fast reaching immunocompetent organ primarily determined for the production of large molecular IgM and IgA of less specificity.

[The distribution of B-lymphocytes in lymphoepithelial tissues as well as in tumors of the neck-, nose-, and throat region derived from lymphoreticular and lymphoepithelial tissues (author's transl)]

B-Lymphocytes carrying IgG-, IgM,- and IgA-surface receptors were estimated by fluorescence microscopy in the palatine tonsil of 50 patients aged 3 to 18 years as well as in 44 patients with various types of malignant lymphoms and lymphoepithelial carcinomas. Hyperplastic tonsillartissue contains large numbers of B-cells with a marked variability in concentration (4-30% IgG-cells, medium 12,9%;6-36 IgM-cells, medium 23.4%;3-38% IgA cells, medium 20.8%). There appears to exist an age-dependent increase in IgM-cells and an increase in IgG-and IgA-cells in patients with numerous recurrent infections of the upper respiratory tract. Malignant lymphomas can be grouped into three main categories: Such with a predominance of one B-cell line (above 75-80% of one immunological cell type); these include primarily malignant lymphomas of the well differentiated lymphocytic type (IgM and IgA receptors). Secondly, such with a significant decrease in B-cells (below 10%) which include primarily malignant lymphomas of the poorly differentiated lymphocytic type. Thirdly, such with an increased B-cell content but with more than one cell line participating in cell proliferation. The latter ones comprise certain cases of Hodkin's lymphomas. Lymphoepithial carcinomas are charactersized by a significant decrease in total B-cell content, except for IgE- and IgD-cells which were not investigated. The results show that the immunologic classification of malignant lymphomas correlates only to a certain degree with the morphologic classification; i.e. the same morphologic type of tumor may possess different immunologic characteristics. Since the immunologic characteristics may reflect a certain functional potential of these tumors as well as probably a certain kind of immunologic incompetence prior to tumor development, it is suggested, that future morphologic investigations of malignant lymphomas and lymphoepithelial carcinomas are combined with immunologic classifications.