The research landscape of bipolar disorder in Germany: productive, but underfunded.

BACKGROUND: The recurrent mental illness bipolar disorder is a major burden on the healthcare system, which underlines the importance of research into this disease. Germany is one of the most productive countries in this research activity. This bibliometric analysis aims to outline the social and conceptual structure of the German research landscape on bipolar disorder over the last decade. Furthermore, we provide a short overview over current public funding. RESULTS: Concerning the social structure, most of the German publications were collaboration projects, both with a national but also international orientation, in the latter case predominantly with countries of the global North. Analysis of the conceptual structure of German research activity identified psychiatric genetics, early recognition of bipolar disorder, neuroimaging, and pharmacological interventions as important topics within the field. In the context of a survey, only few publicly funded research projects were reported, many of which did not exclusively investigate bipolar disorder but followed a transdiagnostic approach. CONCLUSIONS: Our bibliometric analysis revealed internationally well-networked German research activities on bipolar disorder. In stark contrast to its high prevalence and correspondingly high financial burden to the healthcare system, current grant support for research on this illness is strikingly low, particularly concerning the development of novel treatments.

Individual differences in resilience to stress are associated with affective flexibility.

Cognitive flexibility is frequently linked to resilience because of its important contribution to stress regulation. In this context, particularly affective flexibility, defined as the ability to flexibly attend and disengage from affective information, may play a significant role. In the present study, the relationship of cognitive and affective flexibility and resilience was examined in 100 healthy participants. Resilience was measured with three self-report questionnaires, two defining resilience as a personality trait and one focusing on resilience as an outcome in the sense of stress coping abilities. Cognitive and affective flexibility were assessed in two experimental task switching paradigms with non-affective and affective materials and tasks, respectively. The cognitive flexibility paradigm additionally included measures of cognitive stability and spontaneous switching in ambiguous situations. In the affective flexibility paradigm, we explicitly considered the affective valence of the stimuli. Response time switch costs in the affective flexibility paradigm were significantly correlated to all three measures of resilience. The correlation was not specific for particular valences of the stimuli before or during switching. For cognitive (non-affective) flexibility, a significant correlation of response time switch costs was found with only one resilience measure. A regression analysis including both affective and cognitive switch costs as predictors of resilience indicated that only affective, but not cognitive switch costs, explained unique variance components. Furthermore, the experimental measures of cognitive stability and the rate of spontaneous switching in ambiguous situations did not correlate with resilience scores. These findings suggest that specifically the efficiency of flexibly switching between affective and non-affective information is related to resilience.

Neural correlates of affective task switching and asymmetric affective task switching costs.

The control of emotions is of potentially great clinical relevance. Accordingly, there has been increasing interest in understanding the cognitive mechanisms underlying the ability to switch efficiently between the processing of affective and non-affective information. Reports of asymmetrically increased switch costs when switching toward the more salient emotion task indicate specific demands in the flexible control of emotion. The neural mechanisms underlying affective task switching, however, are so far not fully understood. Using functional Magnetic Resonance Imaging (MRI) (N = 57), we observed that affective task switching was accompanied by increased activity in domain-general fronto-parietal control systems. Blood-oxygen-level-dependent (BOLD) activity in the posterior medial frontal and anterolateral prefrontal cortex was directly related to affective switch costs, indicating that these regions play a particular role in individual differences in (affective) task-switching ability. Asymmetric switch costs were associated with increased activity in the right inferior frontal and dorsal anterior medial prefrontal cortex, two brain regions critical for response inhibition. This suggests that asymmetric switch costs might-to a great extent-reflect higher demands on inhibitory control of the dominant emotion task. These results contribute to a refined understanding of brain systems for the flexible control of emotions and thereby identify valuable target systems for future clinical research.

Internal consistency and test-retest reliability of an affective task-switching paradigm.

Affective flexibility refers to the flexible adaptation of behavior or thought given emotionally relevant stimuli, tasks, or contexts, and has been associated with the efficiency of emotion regulation and dealing with stress and adversity. Experimentally, individual differences in affective flexibility have been measured as behavioral costs (response times, errors rates) of switching between affective and neutral tasks. However, behavioral task measures can only be treated as trait-like characteristics if they have sufficient psychometric quality. We report an analysis of the test-retest reliability (interval 2 weeks) as well as internal consistencies of behavioral switch costs measured in an affective task-switching paradigm. This paradigm elicits strong response time switch costs for both tasks, but higher when switching to the emotion than to the gender task. These "asymmetric switch costs" suggest dominance of the emotional task rule. Reliability analyses indicated excellent internal consistency estimates (Spearman-Brown corrected r = .92 for both switch directions) and good test-retest reliabilities (ICC(2,1) of .78 and .82, respectively) for response time-based switch costs. Effect sizes and reliability estimates were substantially lower for switch costs calculated from error rates, which is consistent with previous literature discussing the psychometric properties of task-based cognitive measures. Reliability measures were lower but still acceptable for valence-specific response time-based switch costs, potentially due to lower trial numbers per cell when increasing granularity of the analysis. In conclusion, our results indicate that response time-based affective switch costs are well-suited as individual differences measure, and thus may be a valuable proxy for assessing affective flexibility. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cognitive, Affective, and Feedback-Based Flexibility - Disentangling Shared and Different Aspects of Three Facets of Psychological Flexibility.

Cognitive flexibility - the ability to adjust one ´s behavior to changing environmental demands - is crucial for controlled behavior. However, the term 'cognitive flexibility' is used heterogeneously, and associations between cognitive flexibility and other facets of flexible behavior have only rarely been studied systematically. To resolve some of these conceptual uncertainties, we directly compared cognitive flexibility (cue-instructed switching between two affectively neutral tasks), affective flexibility (switching between a neutral and an affective task using emotional stimuli), and feedback-based flexibility (non-cued, feedback-dependent switching between two neutral tasks). Three experimental paradigms were established that share as many procedural features (in terms of stimuli and/or task rules) as possible and administered in a pre-registered study plan (N = 100). Correlation analyses revealed significant associations between the efficiency of cognitive and affective task switching (response time switch costs). Feedback-based flexibility (measured as mean number of errors after rule reversals) did not correlate with task switching efficiency in the other paradigms, but selectively with the effectiveness of affective switching (error rate costs when switching from neutral to emotion task). While preregistered confirmatory factor analysis (CFA) provided no clear evidence for a shared factor underlying the efficiency of switching in all three domains of flexibility, an exploratory CFA suggested commonalities regarding switching effectiveness (accuracy-based switch costs). We propose shared mechanisms controlling the efficiency of cue-dependent task switching across domains, while the relationship to feedback-based flexibility may depend on mechanisms controlling switching effectiveness. Our results call for a more stringent conceptual differentiation between different variants of psychological flexibility.

Acetylcholine modulates human working memory and subsequent familiarity based recognition via alpha oscillations.

Working memory (WM) can be defined as the ability to maintain and process physically absent information for a short period of time. This vital cognitive function has been related to cholinergic neuromodulation and, in independent work, to theta (4-8Hz) and alpha (9-14Hz) band oscillations. However, the relationship between both aspects remains unclear. To fill this apparent gap, we used electroencephalography (EEG) and a within-subject design in healthy humans who either received the acetylcholinesterase inhibitor galantamine (8mg) or a placebo before they performed a Sternberg WM paradigm. Here, sequences of sample images were memorized for a delay of 5s in three different load conditions (two, four or six items). On the next day, long-term memory (LTM) for the images was tested according to a remember/know paradigm. As a main finding, we can show that both theta and alpha oscillations scale during WM maintenance as a function of WM load; this resembles the typical performance decrease. Importantly, cholinergic stimulation via galantamine administration slowed down retrieval speed during WM and reduced associated alpha but not theta power, suggesting a functional relationship between alpha oscillations and WM performance. At LTM, this pattern was accompanied by impaired familiarity based recognition. These findings show that stimulating the healthy cholinergic system impairs WM and subsequent recognition, which is in line with the notion of a quadratic relationship between acetylcholine levels and cognitive functions. Moreover, our data provide empirical evidence for a specific role of alpha oscillations in acetylcholine dependent WM and associated LTM formation.

Structural and functional hallmarks of amyotrophic lateral sclerosis progression in motor- and memory-related brain regions.

Previous studies have shown that in amyotrophic lateral sclerosis (ALS) multiple motor and extra-motor regions display structural and functional alterations. However, their temporal dynamics during disease-progression are unknown. To address this question we employed a longitudinal design assessing motor- and novelty-related brain activity in two fMRI sessions separated by a 3-month interval. In each session, patients and controls executed a Go/NoGo-task, in which additional presentation of novel stimuli served to elicit hippocampal activity. We observed a decline in the patients' movement-related activity during the 3-month interval. Importantly, in comparison to controls, the patients' motor activations were higher during the initial measurement. Thus, the relative decrease seems to reflect a breakdown of compensatory mechanisms due to progressive neural loss within the motor-system. In contrast, the patients' novelty-evoked hippocampal activity increased across 3 months, most likely reflecting the build-up of compensatory processes typically observed at the beginning of lesions. Consistent with a stage-dependent emergence of hippocampal and motor-system lesions, we observed a positive correlation between the ALSFRS-R or MRC-Megascores and the decline in motor activity, but a negative one with the hippocampal activation-increase. Finally, to determine whether the observed functional changes co-occur with structural alterations, we performed voxel-based volumetric analyses on magnetization transfer images in a separate patient cohort studied cross-sectionally at another scanning site. Therein, we observed a close overlap between the structural changes in this cohort, and the functional alterations in the other. Thus, our results provide important insights into the temporal dynamics of functional alterations during disease-progression, and provide support for an anatomical relationship between functional and structural cerebral changes in ALS.

Dopaminergic stimulation facilitates working memory and differentially affects prefrontal low theta oscillations.

We used electroencephalography (EEG) together with psychopharmacological stimulation to investigate the role of dopamine in neural oscillations during working memory (WM). Following a within-subjects design, healthy humans either received the dopamine precursor L-Dopa (150 mg) or a placebo before they performed a Sternberg WM paradigm. Here, sequences of sample images had to be memorized for a delay of 5 s in three different load conditions (two, four or six items). On the next day, long-term memory (LTM) for the images was tested. Behaviorally, L-Dopa improved WM and LTM performance as a function of WM load. More precisely, there was a specific drug effect in the four-load condition with faster reaction times to the probe in the WM task and higher corrected hit-rates in the LTM task. During the maintenance period, there was a linear and quadratic effect of WM load on power in the high theta (5-8 Hz) and alpha (9-14 Hz) frequency range at frontal sensors. Importantly, a drug by load interaction--mimicking the behavioral results--was found only in low theta power (2-4 Hz). As such, our results indicate a specific link between prefrontal low theta oscillations, dopaminergic neuromodulation during WM and subsequent LTM performance.

Motor phenotype and magnetic resonance measures of basal ganglia iron levels in Parkinson's disease.

BACKGROUND: In Parkinson's disease the degree of motor impairment can be classified with respect to tremor dominant and akinetic rigid features. While tremor dominance and akinetic rigidity might represent two ends of a continuum rather than discrete entities, it would be important to have non-invasive markers of any biological differences between them in vivo, to assess disease trajectories and response to treatment, as well as providing insights into the underlying mechanisms contributing to heterogeneity within the Parkinson's disease population. METHODS: Here, we used magnetic resonance imaging to examine whether Parkinson's disease patients exhibit structural changes within the basal ganglia that might relate to motor phenotype. Specifically, we examined volumes of basal ganglia regions, as well as transverse relaxation rate (a putative marker of iron load) and magnetization transfer saturation (considered to index structural integrity) within these regions in 40 individuals. RESULTS: We found decreased volume and reduced magnetization transfer within the substantia nigra in Parkinson's disease patients compared to healthy controls. Importantly, there was a positive correlation between tremulous motor phenotype and transverse relaxation rate (reflecting iron load) within the putamen, caudate and thalamus. CONCLUSIONS: Our findings suggest that akinetic rigid and tremor dominant symptoms of Parkinson's disease might be differentiated on the basis of the transverse relaxation rate within specific basal ganglia structures. Moreover, they suggest that iron load within the basal ganglia makes an important contribution to motor phenotype, a key prognostic indicator of disease progression in Parkinson's disease.

Dopamine modulates processing speed in the human mesolimbic system.

Neural activity in mesolimbic brain regions scales with stimulus novelty but the mechanistic role of neurotransmitters in this process remains unclear. Here, we used magnetoencephalography together with psychopharmacological stimulation in healthy humans to demonstrate that the neuronal dynamics of novelty processing are temporally adaptive and flexible. In particular, enhanced dopaminergic (150mg levodopa) - but not cholinergic (8mg galantamine) - neurotransmission accelerated the onset of novelty signals within the medial temporal lobe (MTL) from ~300 to <100ms. Cholinergic stimulation, on the other hand, led to a shift in underlying neural substrates from medial temporal to prefrontal brain regions. Our findings indicate a causal role of dopamine in regulating the processing speed of novelty sensitive MTL neurons. Moreover, they suggest that the influence of MTL and prefrontal brain regions in novelty processing is mediated by the balance of dopamine and acetylcholine levels.

Magnetic resonance volumetry and spectroscopy of hippocampus and insula in relation to severe exposure of traumatic stress.

Severe and chronic stress affects the hippocampus, especially during development. However, studies concerning structural alterations of the hippocampus yielded a rather inconsistent picture. Moreover, further anxiety-relevant brain regions, such as the insula, might be implicated in the pathophysiology of posttraumatic stress disorder (PTSD). We combined magnetic resonance (MR) volumetric and spectroscopic analyses of hippocampus and insula in highly traumatized refugees without a history of alcohol/substance abuse or other comorbid diseases. No PTSD-related difference was apparent in the volumes or neurometabolite levels of bilateral hippocampus or insula. However, an association between left hippocampal N-acetyl-aspartate (NAA) and adverse childhood experiences indicated a potential detrimental effect of the early environment on hippocampal integrity. Our results add to increasing evidence that PTSD-related, morphological alterations in the hippocampus are a consequence of early adversity or may result from other factors, such as extensive use of alcohol.

Structural alterations in lateral prefrontal, parietal and posterior midline regions of men with chronic posttraumatic stress disorder.

BACKGROUND: So far, the neural network associated with posttraumatic stress disorder (PTSD) has been suggested to mainly involve the amygdala, hippocampus and medial prefrontal cortex. However, increasing evidence indicates that cortical regions extending beyond this network might also be implicated in the pathophysiology of PTSD. We aimed to investigate PTSD-related structural alterations in some of these regions. METHODS: We enrolled highly traumatized refugees with and without (traumatized controls) PTSD and nontraumatized controls in the study. To increase the validity of our results, we combined an automatic cortical parcellation technique and voxel-based morphometry. RESULTS: In all, 39 refugees (20 with and 19 without PTSD) and 13 controls participated in the study. Participants were middle-aged men who were free of psychoactive substances and consumed little to no alcohol. Patients with PTSD (and to a lesser extent traumatized controls) showed reduced volumes in the right inferior parietal cortex, the left rostral middle frontal cortex, the bilateral lateral orbitofrontal cortex and the bilateral isthmus of the cingulate. An influence of cumulative traumatic stress on the isthmus of the cingulate and the lateral orbitofrontal cortex indicated that, at least in these regions, structural alterations might be associated with repeated stress experiences. Voxel-based morphometry analyses produced largely consistent results, but because of a poorer signal-to-noise ratio, conventional statistics did not reach significance. LIMITATIONS: Although we controlled for several important confounding variables (e.g., sex, alcohol abuse) with our particular sample, this might limit the generalizibility of our data. Moreover, high comorbidity of PTSD and major depression hinders a definite separation of these conditions in our findings. Finally, the results concerning the lateral orbito frontal cortex should be interpreted with caution, as magnetic resonance imaging acquisition in this region is affected by a general signal loss. CONCLUSION: Our results indicate that lateral prefrontal, parietal and posterior midline structures are implicated in the pathophysiology of PTSD. As these regions are particularly involved in episodic memory, emotional processing and executive control, this might have important implications for the understanding of PTSD symptoms.

Association study of trauma load and SLC6A4 promoter polymorphism in posttraumatic stress disorder: evidence from survivors of the Rwandan genocide.

OBJECTIVE: As exposure to different types of traumatic stressors increases, the occurrence of posttraumatic stress disorder (PTSD) increases. However, because some people exhibit either surprising resilience or high vulnerability, further influencing factors have been conjectured, such as gene-environment interactions. The SLC6A4 gene, which encodes serotonin transporter, has been identified as predisposing toward differential emotional processing between genotypes of its promoter polymorphism. METHOD: We investigated 408 refugees from the Rwandan genocide and assessed lifetime exposure to traumatic events, PTSD (according to DSM-IV) status, and genotype of the SLC6A4 promoter polymorphism. The study was conducted from March 2006 to February 2007. RESULTS: The prevalence of PTSD approached 100% when traumatic exposure reached extreme levels. However, persons homozygous for the short allele of the SLC6A4 promoter polymorphism showed no dose-response relationship but were at high risk for developing PTSD after very few traumatic events. This genotype influence vanished with increasing exposure to traumatic stressors. CONCLUSION: We find evidence for a gene-environment interplay for PTSD and show that genetic influences lose importance when environmental factors cause an extremely high trauma burden to an individual. In the future, it may be important to determine whether the effectiveness of therapeutic interventions in PTSD is also modulated by the SLC6A4 genotype.

No PTSD-related differences in diurnal cortisol profiles of genocide survivors.

Posttraumatic stress disorder (PTSD) has been associated with reduced cortisol levels. Opposing results have been interpreted as resulting from methodological differences between studies. We investigated the diurnal profile of salivary cortisol in a population of highly traumatized adult males from Rwanda with and without PTSD, who spent the whole day of examination together under a maximally standardized schedule. Besides the detection of PTSD-related alterations in cortisol release we aimed at determining physiologically relevant effects of cumulative trauma exposure on HPA functioning in interaction with or independent of diagnosis. There were no differences in the diurnal pattern of cortisol release between subjects with and without PTSD. We observed an increasing prevalence of PTSD with increasing number of different traumatic event types experienced, replicating earlier results on a "building-block effect" of multiple traumatization. However, size of cumulative exposure was not related to any of the cortisol measures. The results suggest that besides methodological constraints also confounding factors not previously controlled for, e.g., sex differences or current life stress, might contribute to the diverging results of lowered, unchanged or enhanced cortisol secretion in PTSD. Future research should therefore closely monitor these possible confounds to optimize models for cortisol in research on stress-dependent illnesses.

Lack of cortisol response in patients with posttraumatic stress disorder (PTSD) undergoing a diagnostic interview.

BACKGROUND: According to DSM-IV, the diagnosis of posttraumatic stress disorder (PTSD) requires the experience of a traumatic event during which the person's response involved intense fear, helplessness, or horror. In order to diagnose PTSD, clinicians must interview the person in depth about his/her previous experiences and determine whether the individual has been traumatized by a specific event or events. However, asking questions about traumatic experiences can be stressful for the traumatized individual and it has been cautioned that subsequent "re-traumatization" could occur. This study investigated the cortisol response in traumatized refugees with PTSD during a detailed and standardized interview about their personal war and torture experiences. METHODS: Participants were male refugees with severe PTSD who solicited an expert opinion in the Psychological Research Clinic for Refugees of the University of Konstanz. 17 patients were administered the Vivo Checklist of War, Detention, and Torture Events, a standardized interview about traumatic experiences, and 16 subjects were interviewed about absorption behavior. Self-reported measures of affect and arousal, as well as saliva cortisol were collected at four points. Before and after the experimental intervention, subjects performed a Delayed Matching-to-Sample (DMS) task for distraction. They also rated the severity of selected PTSD symptoms, as well as the level of intrusiveness of traumatic memories at that time. RESULTS: Cortisol excretion diminished in the course of the interview and showed the same pattern for both groups. No specific response was detectable after the supposed stressor. Correspondingly, ratings of subjective well-being, memories of the most traumatic event(s) and PTSD symptoms did not show any significant difference between groups. Those in the presumed stress condition did not perform worse than persons in the control condition after the stressor. However, both groups performed poorly in the DMS task, which is consistent with memory and concentration problems demonstrated in patients with PTSD. CONCLUSION: A comprehensive diagnostic interview including questions about traumatic events does not trigger an HPA-axis based alarm response or changes in psychological measures, even for persons with severe PTSD, such as survivors of torture. Thus, addressing traumatic experiences within a safe and empathic environment appears to impose no unacceptable additional load to the patient.