Dynamic risk control by human nucleus accumbens.

Real-world decisions about reward often involve a complex counterbalance of risk and value. Although the nucleus accumbens has been implicated in the underlying neural substrate, its criticality to human behaviour remains an open question, best addressed with interventional methodology that probes the behavioural consequences of focal neural modulation. Combining a psychometric index of risky decision-making with transient electrical modulation of the nucleus accumbens, here we reveal profound, highly dynamic alteration of the relation between probability of reward and choice during therapeutic deep brain stimulation in four patients with treatment-resistant psychiatric disease. Short-lived phasic electrical stimulation of the region of the nucleus accumbens dynamically altered risk behaviour, transiently shifting the psychometric function towards more risky decisions only for the duration of stimulation. A critical, on-line role of human nucleus accumbens in dynamic risk control is thereby established.

Acute treatment of cycloid psychosis: study on a sample of naive hospitalized patients with first-episode psychosis (FEP).

INTRODUCTION: In spite of the historic, clinical and therapeutic importance of cycloid psychosis, no controlled studies have been performed as yet on its treatment. Electroconvulsive therapy has classically been the treatment of choice and the first generation antipsychotics have not been indicated. This study has aimed to analyze the acute treatment (and response to it) of cycloid psychoses. METHODOLOGY: In a sample of 75 hospitalized medication- naive patients treated for a First Psychotic Episode (FPE), possible cases of cycloid psychoses were detected using the Perris and Brockington operative diagnostic criteria. The sample was divided into “cycloids” and “non-cycloids” and both groups were compared based on clinical and therapeutic variables. RESULTS: All the patients were treated with second generation antipsychotics. No significant differences (p=0.17; t-1.39) were found in the antipsychotic dose prescribed (equivalents of chlorpromazine). However, significant differences were observed in the improvement on hospital discharge (clinical global impression severity: CGI-S), with better response in the “cycloid” group” (p=0.002; u=162). Significant differences were also observed in the dose of benzodiazepines, there being significantly greater improvement for the “cycloid” group (p>0.001; u=28). CONCLUSIONS: Without contradicting the classical idea of the treatment of cycloid psychoses, the present study contributes to the opening of a new therapeutic prospect. Thus, the use of second generation antipsychotics could have a particularly beneficial effect, especially if combined with high doses of benzodiazepines in the acute treatment of cycloid psychoses. However, controlled studies need to be carried out to confirm this.

Psychiatric morbidity and predisposing factors in a primary care population in Madrid.

OBJECTIVES: The aim of this article is to estimate the prevalence of mental disorders in patients in primary care centers in an urban area of Madrid and to study possible associated risk factors. METHODS: Cross-sectional month prevalence was evaluated in two phases in an urban area of Madrid. The sample for the first phase included 635 individuals (aged 18-65 years), and the second phase included 320 individuals. Socio-demographic variables (age, sex, educational level, living conditions and country of origin) and clinical variables (psychiatric diagnosis and level of psychosocial stress) were studied. The instruments used for screening were the General Health Questionnaire (GHQ)-28 item questionnaire and the MULTICAGE-CAD 4test. The Mini International Neuropsychiatric Interview (M.I.N.I.) was used in the second phase (in 'possible cases' and 20% of the 'non-cases'). Prevalence was calculated using weighted logistic regression with the observed sampling fractions of the patients in study phase 2 as sample weights. RESULTS AND CONCLUSIONS: The month prevalence of mental disorders was 31.3% (95% confidence interval (CI) = [27.6, 35.2]). Anxiety disorders were the most frequent diagnoses with a prevalence of 22.4% (95% CI = [17.8, 27.1]), followed by depressive disorders (16.6%; 95% CI = [12.9, 20.3]), substance abuse or dependence disorders (5.6%; 95% CI = [3.2, 6.9]) and posttraumatic stress disorder (PTSD; 4.4%; 95% CI = [2.0, 2.8]). Factors associated with mental disorders were the presence of stressful life events in the previous 12 months, Latin American region of origin, being woman aged 25 and 34 years and having a low education level.

Relationship of suicide rates to economic variables in Europe: 2000-2011.

BACKGROUND: It is unclear whether there is a direct link between economic crises and changes in suicide rates. AIMS: The Lopez-Ibor Foundation launched an initiative to study the possible impact of the economic crisis on European suicide rates. METHOD: Data was gathered and analysed from 29 European countries and included the number of deaths by suicide in men and women, the unemployment rate, the gross domestic product (GDP) per capita, the annual economic growth rate and inflation. RESULTS: There was a strong correlation between suicide rates and all economic indices except GPD per capita in men but only a correlation with unemployment in women. However, the increase in suicide rates occurred several months before the economic crisis emerged. CONCLUSIONS: Overall, this study confirms a general relationship between the economic environment and suicide rates; however, it does not support there being a clear causal relationship between the current economic crisis and an increase in the suicide rate.

Romanticism and schizophrenia. Second part: The intimacy hypothesis.

In the first part of this article we have analyzed the evidence supporting the recency hypothesis of schizophrenia and also what we can call the intimate nature of the disease. In this part we highlight the role of certain cultural aspects that have been ignored up to now, aspects that are associated with deep changes in the Weltanschauung and systems of beliefs on human nature brought up by the late Modernism, specifically by Romanticism. The description of the main characteristics of Romanticism, starting with the “discovery of intimacy”, leads to the conclusion that the characteristic alteration of subjectivity and ipseity of the disease appears to be a vulnerability factor when somebody has to face the new challenges raise Romanticism. The consideration of Hölderlin’s literary achievements and the deep psychological drama prevailing in them, makes explicit how the late modern human being finds in Romanticism the source of creativity and personal development but also the threat of his or her own destruction. Finally we link our hypothesis with recent genetic perspectives that consider sets of diseases associated to the same gene or genes (diseasome). In any case the process of associating the traits of Late Modernism and Romanticism with the core features of schizophrenia allows to consider the amalgamation of insanity with society, both at a general level an in what concerns individual patients, paving the way for novel therapeutic strategies.

Romanticism and schizophrenia. First part: The recency hypothesis and the core Gestalt of the disease.

Descriptions of irrational, incomprehensible, or unconstrained behavior such as is common nowadays in patients suffering from severe mental disorders can be found in the Bible, in Mesopotamian scripts, in classical Greek and Roman literature, and in the writings of many non-Western cultures. However, the presence of full-blown features of schizophrenia as seen today in psychiatric settings is controversial. Typical symptoms, the expected onset, duration and outcome, the impact of the disease on psychic functioning and the associated disability of the disease are mostly absent in those texts. Torrey (1980) and Hare (1988) have claimed that the disease did not exist before the year 1800 (this is known as the recency hypothesis). This would be the consequence of biological factors such as viruses, genetic or dietary factors or environmental contaminants associated to civilization. Others have put the emphasis on industrialization and its repercussions on social conditions such as family structure and migration. After analyzing the many manifestations of insanity in literary characters, in medical texts and in key historical figures, the arguments presented in this paper tend to support the recency hypothesis. A review of the core characteristics of schizophrenia and its impact on selfhood, intersubjetivity and ipseity, topics relatively neglected in recent psychiatric literature, opens the doors to consider in a second part the relationship between the features of Romanticism, starting by the "discovery of intimacy", and its articulation with the disturbance of ipseity and selfhood characteristic of the disease.

Deep brain stimulation for obsessive-compulsive disorder: is the side relevant?

BACKGROUND: Deep brain stimulation for obsessive-compulsive disorder (OCD) has targeted several subcortical nuclei, including the subthalamic nucleus (STN) and the nucleus accumbens. While the most appropriate target is still being looked for, little attention has been given to the side of the stimulated hemisphere in relationship to outcome. METHODS: We report 2 patients diagnosed with OCD, one having symmetry obsessions and the other one with sexual-religious obsessive thoughts. They were implanted bilaterally with deep electrodes located at both STN and nuclei accumbens. The effectiveness of the stimulation was tested for every possible paired combination of electrodes guided by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score reduction. RESULTS: In both cases, the combination of electrodes which best relieved the OCD symptoms was both the left STN and left accumbens. In case 1, the preoperative Y-BOCS score was 33, and 1 month after stimulation it was 16. In case 2, the Y-BOCS scores were 33 and 3, respectively, with the patient being free of obsessions. CONCLUSION: Some reports suggest that lesion stimulation or stimulation of only the right side relieves OCD symptoms. However, anatomical and functional studies are not conclusive as to which side is most affected in OCD. Possibly, each OCD patient has an individualized optimal side to stimulate.

A new time limited psychotherapy for BPD: preliminary results of a randomized and controlled trial.

INTRODUCTION: Psychic Representation focused Psychotherapy (PRFP) is a new time limited dynamic psychotherapy for the treatment of Borderline Personality Disorder. It is a psychodynamic technique based on brief psychoanalytic psychotherapy principles. It is manualized and designed to be applied in the framework of public health care services. A randomized and controlled study with a sample of 53 patients was conducted to assess PRFP efficacy. This work presents the results for the first 44 trial completers at termination of treatment. METHODS: Both groups, the experimental (n= 18) and control group (n= 26), received treatment as usual. The experimental group received an additional 20 (PRFP) sessions, conducted by four therapists with homogenous characteristics specifically trained in this technique. The main outcome variables measures were: Severity global index of SCL-90-R, Barrat Impulsivity Scale scores and Social Adaptation (SASS score). Baseline and final condition at termination was compared. CONCLUSIONS: Preliminary results showed significantly better outcomes for the experimental group in all the main variables measured and in most of the secondary ones. PRFP may represent an important contribution for the treatment of BPD patients. Follow-up assessment at 6 and 12 months is planned.

The media and intellectuals' response to medical publications: the antidepressants' case.

During the last decade, there was a debate concerning the true efficacy of antidepressants. Several papers were published in scientific journals, but many articles were also published in the lay press and the internet both by medical scientists and academics from other disciplines or representatives of societies or initiatives. The current paper analyzes the articles authored by three representative opinion makers: one academic in medicine, one academic in philosophical studies, and a representative of an activists' group against the use of antidepressants. All three articles share similar gaps in knowledge and understanding of the scientific data and also are driven by an 'existential-like' ideology. In our opinion, these articles have misinterpreted the scientific data, and they as such may misinform or mislead the general public and policy makers, which could have a potential impact upon public health. It seems that this line of thought represents another aspect of the stigma attached to people suffering from mental illness.

Paving the way for new research strategies in mental disorders. Second part: the light at the end of the tunnel.

Following we consider strategies to overcome the situation described in a previous article (López-Ibor JJ, López-Ibor MI. Paving the Way for New Research Strategies in Mental Disorders. First part: the recurring crisis of psychiatry. Actas Esp Psiquiat. 2013;41(1):33-43), by putting emphasis on psychopathology instead than in classification, in functions rather than in diagnostic criteria, to be aware in the progress in neuroscientific monistic perspectives and by importing the methods of the emerging connectomics. Medicine is undergoing deep changes. Networking is becoming the new paradigm and we consider that it should be the turning point of the future psychiatry, both in research and in practice.

Paving the way for new research strategies in mental disorders. First part: the recurring crisis of psychiatry.

Psychiatry is going through a deep crisis, both as a scientific discipline as a medical speciality. In the present paper we consider in length what we consider to be the three aspects that could explain the situation: the recurring disappointment in classification; the persistence of dualistic perspectives in research; and third, the continuing of a localizacionism inadequate to explain normal and pathological behaviour. Psychiatry lacks a definition of mental disorder that covers all situations, there are difficulties in drawing a precise distinction between normality and psychopathology, and the majority of these “diagnostic” categories are not validated by biological criteria. Furthermore, there is still a debate on the nature of the symptoms of mental disorders, a confusion classification and diagnosis and a preoccupation with the growing inflation of diagnostic categories. Dualism is at the core of psychopathology, simply because Cartesian dualism led to the development of modern science, but the price paid includes the split-up of mental and physical phenomena and illnesses and of psychiatry and the rest of medicine. Localizationism, that is, the approach to brain function considering that particular pychological functions are carried out by particular brain areas or centers, helps to understand many clinical and psychological phenomena, but have largely fild in explaining the nature of most mental disorders. In a second part of this article we provide some strategies that could help to go beyond the present impasse.

Changes in the MEG background activity in patients with positive symptoms of schizophrenia: spectral analysis and impact of age.

The frequency spectrum of the magnetoencephalogram (MEG) background activity was analysed in 15 schizophrenia (SCH) patients with predominant positive symptoms and 17 age-matched healthy control subjects using the following variables: median frequency (MF), spectral entropy (SpecEn) and relative power in delta (RPδ), theta (RPθ), lower alpha (RPα1), upper alpha (RPα2), beta (RPß) and gamma (RPγ) bands. We found significant differences between the two subject groups in the average level of MF and RPγ in some regions of the scalp. Additionally, the MF, SpecEn, RPß and RPγ values of SCH patients with positive symptoms had a different dependence on age as compared with the results of control subjects, suggesting that SCH affects the way in which the brain activity evolves with age. Moreover, we also classified the MEG signals by means of a cross-validated feature selection process followed by a logistic regression. The subjects were classified with 71.3% accuracy and an area under the ROC curve of 0.741. Thus, the spectral and classification analysis of the MEG in SCH may provide insights into how this condition affects the brain activity and may help in its early detection.

Complexity and schizophrenia.

Complexity estimators have been broadly utilized in schizophrenia investigation. Early studies reported increased complexity in schizophrenia patients, associated with a higher variability or "irregularity" of their brain signals. However, further investigations showed reduced complexities, thus introducing a clear divergence. Nowadays, both increased and reduced complexity values are reported. The explanation of such divergence is a critical issue to understand the role of complexity measures in schizophrenia research. Considering previous arguments a complementary hypothesis is advanced: if the increased irregularity of schizophrenia patients' neurophysiological activity is assumed, a "natural" tendency to increased complexity in EEG and MEG scans should be expected, probably reflecting an abnormal neuronal firing pattern in some critical regions such as the frontal lobes. This "natural" tendency to increased complexity might be modulated by the interaction of three main factors: medication effects, symptomatology, and age effects. Therefore, young, medication-naïve, and highly symptomatic (positive symptoms) patients are expected to exhibit increased complexities. More importantly, the investigation of these interacting factors by means of complexity estimators might help to elucidate some of the neuropathological processes involved in schizophrenia.

No effect of polymorphisms in the non-duplicated region of the CHRNA7 gene on sensory gating P50 ratios in patients with schizophrenia and bipolar disorder.

Previous research has reported that bipolar disorder and schizophrenic patients evidence sensory gating deficits. The use of intermediate phenotypes may facilitate genetic studies. Four single nucleotide polymorphisms (SNPs) located on the non-duplicated region of the alpha-7 nicotinic receptor gene (CHRNA7) were genotyped in 95 healthy subjects, 127 bipolar disorder and 153 schizophrenic patients. We evaluated the association of these polymorphisms with P50 evoked potential measures. Our results do not support a role for the candidate gene in this neurophysiological disturbance.

Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey.

BACKGROUND: Depression is the third leading contributor to the worldwide burden of disease. We assessed the nature and severity of experienced and anticipated discrimination reported by adults with major depressive disorder worldwide. Moreover, we investigated whether experienced discrimination is related to clinical history, provision of health care, and disclosure of diagnosis and whether anticipated discrimination is associated with disclosure and previous experiences of discrimination. METHODS: In a cross-sectional survey, people with a diagnosis of major depressive disorder were interviewed in 39 sites (35 countries) worldwide with the discrimination and stigma scale (version 12; DISC-12). Other inclusion criteria were ability to understand and speak the main local language and age 18 years or older. The DISC-12 subscores assessed were reported discrimination and anticipated discrimination. Multivariable regression was used to analyse the data. FINDINGS: 1082 people with depression completed the DISC-12. Of these, 855 (79%) reported experiencing discrimination in at least one life domain. 405 (37%) participants had stopped themselves from initiating a close personal relationship, 271 (25%) from applying for work, and 218 (20%) from applying for education or training. We noted that higher levels of experienced discrimination were associated with several lifetime depressive episodes (negative binomial regression coefficient 0·20 [95% CI 0·09-0·32], p=0·001); at least one lifetime psychiatric hospital admission (0·29 [0·15-0·42], p=0·001); poorer levels of social functioning (widowed, separated, or divorced 0·10 [0·01-0·19], p=0·032; unpaid employed 0·34 [0·09-0·60], p=0·007; looking for a job 0·26 [0·09-0·43], p=0·002; and unemployed 0·22 [0·03-0·41], p=0·022). Experienced discrimination was also associated with lower willingness to disclose a diagnosis of depression (mean discrimination score 4·18 [SD 3·68] for concealing depression vs 2·25 [2·65] for disclosing depression; p<0·0001). Anticipated discrimination is not necessarily associated with experienced discrimination because 147 (47%) of 316 participants who anticipated discrimination in finding or keeping a job and 160 (45%) of 353 in their intimate relationships had not experienced discrimination. INTERPRETATION: Discrimination related to depression acts as a barrier to social participation and successful vocational integration. Non-disclosure of depression is itself a further barrier to seeking help and to receiving effective treatment. This finding suggests that new and sustained approaches are needed to prevent stigmatisation of people with depression and reduce the effects of stigma when it is already established. FUNDING: European Commission, Directorate General for Health and Consumers, Public Health Executive Agency.

Personality profiles between obese and control subjects assessed with five standardized personality scales.

BACKGROUND/AIM: Psychopathology may exert influence on developing and maintaining obesity. Studies of personality traits or psychopathology of personality in obesity are scarce and contradictory. The aim of this study was to compare personality profiles between obese and normal-weight subjects and to determine the most useful tool to detect differences, considering that psychological assessment and psychotherapeutical support should be included within the overall management of these patients.* METHOD: We examined 55 obese subjects (mean BMI=43kg/ m2) and 66 controls (mean BMI =21.7kg/m2). We used the personality assessment tools: MCMI-II, TCI-R, EPQ-A, BIS-111 and SSS. Factorial multivariate analysis of variance was applied; with factors BMI, Gender and Age as a covariate. RESULTS: Significant differences between groups were more marked in the clinical syndrome scales of MCMI-II, particularly in Major-Depression, Thought-Disorder, Anxiety, Somatoform and Alcohol-Dependence. Among obese, women scored higher than men in all scales but not significantly. We have found significant differences in normal personality dimensions between both groups in TCI-R. Obese showed higher scores in Harm Avoidance, and lower in Novelty Seeking, Persistence and Self-transcendence. The remaining tests have not been useful for differentiating personality traits between both groups. CONCLUSION: Obese subjects showed different personality profiles than control subjects. The most useful scales for determining these differences might be those designed to assess pathological personality such as MCMI-II. Less important would be those intended to measure normal personality traits, such as TCI-R and EPQ-A.

A study of verbal memory in a sample of euthymic patients with bipolar disorder.

BACKGROUND: Recent studies have confirmed the presence of cognitive impairment in euthymic patients with Bipolar Disorder (BD). A significant relationship between memory difficulties and poor psychosocial adjustment has also been found in these subjects. While some studies suggest that these memory deficits may be secondary to executive functioning instead of being directly related to a primary impairment of the memory systems, others suggest that these memory deficits may be secondary to clinical symptoms. Some authors reject the existence of any relationship between clinical state and neurocognitive impairments and suggest that this relationship may be mediated by other factors. The goal of this research was to replicate the findings of verbal memory impairment in euthymic patients with Bipolar Disorder and relate these impairments with neocortex structures. METHODOLOGY: We carried out a cross-sectional study. The sample was made up of 44 BDI and 9 BDII euthymic patients and 32 healthy subjects, aged 18-65 years. Both groups were evaluated with the California Verbal Learning Test. RESULTS: Both bipolar patients performed worse than healthy control subjects in most memory measures and showed difficulties in components of memory that are associated with both frontal (semantic organization) and temporal lobe function (recall and recognition). CONCLUSIONS: We have hypothesized that verbal memory could be a trait marker of bipolar disorder.

Psychopharmacological treatments in HIV patients under antiretroviral therapy.

Human immunodeficiency virus-infected patients have high rates of psychiatric disorders, including substance and alcohol abuse. Prompt identification and effective management of mental disorders can improve the quality of life and antiretroviral adherence in HIV patients. Additive side effects and drug interactions may complicate the psychopharmacological treatment in this population. This article reviews the indications and precautions needed when prescribing psychoactive drugs to HIV patients with mental disorders.