[Training in iterative hypothesis testing as part of psychiatric education. A randomized study]. / Training in iterativer Hypothesenbildung in der psychiatrischen Lehre. Eine randomisierte Studie.

BACKGROUND: The improvement of medical education is at the center of efforts to reform the studies of medicine. Furthermore, an excellent teaching program for students is a quality feature of medical universities. Besides teaching of disease-specific contents, the acquisition of interpersonal and decision-making skills is important. However, the cognitive style of senior physicians leading to a diagnosis cannot easily be taught. Therefore, the following study aimed at examining whether specific training in iterative hypothesis testing (IHT) may improve the correctness of the diagnostic process. MATERIALS AND METHODS: Seventy-one medical students in their 9th-11th terms were randomized to medical teaching as usual or to IHT training for 4 weeks. The intervention group received specific training according to the method of IHT. All students were examined by a multiple choice (MC) exam and additionally by simulated patients (SP). The SPs were instructed to represent either a patient with depression and comorbid anxiety and substance use disorder (SP1) or to represent a patient with depression, obsessive-compulsive disorder and acute suicidal tendencies (SP2). RESULTS: All students identified the diagnosis of major depression in the SPs, but IHT-trained students recognized more diagnostic criteria. Furthermore, IHT-trained students recognized acute suicide tendencies in SP2 more often and identified more comorbid psychiatric disorders. The results of the MC exam were comparable in both groups. An analysis of the satisfaction with the different training programs revealed that the IHT training received a better appraisal. CONCLUSIONS: Our results point to the role of IHT in teaching diagnostic skills. However, the results of the MC exam were not influenced by IHT training. Furthermore, our results show that students are in need of training in practical clinical skills.

Frontostriatal activation in patients with obsessive-compulsive disorder before and after cognitive behavioral therapy.

BACKGROUND: Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) is the psychotherapeutic treatment of choice for obsessive-compulsive disorder (OCD). However, little is known about the impact of CBT on frontostriatal dysfunctioning, known to be the neuronal correlate of OCD. METHOD: A probabilistic reversal learning (RL) task probing adaptive strategy switching capabilities was used in 10 unmedicated patients with OCD and 10 healthy controls during an event-related functional magnetic resonance imaging (fMRI) experiment. Patients were scanned before and after intensive CBT, controls twice at comparable intervals. RESULTS: Strategy change within the RL task involved activity in a broad frontal network in patients and controls. No significant differences between the groups or in group by time interactions were detected in a whole-brain analysis corrected for multiple comparisons. However, a reanalysis with a more lenient threshold revealed decreased responsiveness of the orbitofrontal cortex and right putamen during strategy change before treatment in patients compared with healthy subjects. A group by time effect was found in the caudate nucleus, demonstrating increased activity for patients over the course of time. Patients with greater clinical improvement, reflected by greater reductions in Yale-Brown Obsessive Compulsive Scale (YBOCS) scores, showed more stable activation in the pallidum. CONCLUSIONS: Although these findings are preliminary and need to be replicated in larger samples, they indicate a possible influence of psychotherapy on brain activity in core regions that have been shown to be directly involved both in acquisition of behavioral rules and stereotypes and in the pathophysiology of OCD, the caudate nucleus and the pallidum.

Psychological and neuroendocrine responses to social stress and to the administration of the alpha-2-receptor antagonist, yohimbine, in highly trained endurance athletes in comparison to untrained healthy controls.

INTRODUCTION: Several clinical studies suggest antidepressive and anxiolytic effects of regular endurance training. The mechanisms by which exercise exerts these effects are still unclear. It was hypothesized that athletes might show a diminished reaction to psychosocial stress and noradrenergic stimulation. METHODS: 12 male athletes and 12 healthy untrained male controls underwent a challenge paradigm on 3 separate days: the alpha-2-receptor antagonist yohimbine (0.4 mg/kg), placebo or a psychosocial stress test (SST) were administered. Responses were measured by psychometric scales, plasma cortisol, blood pressure and heart rate. RESULTS: Before testing, psychometric variables and cortisol levels were not different between the 2 groups. In comparison to placebo conditions, both the social stress test and the administration of yohimbine were followed by significant increases of anxiety symptoms, plasma cortisol, heart rate and blood pressure in both groups. However, these responses were not significantly different between the group of athletes and the control group. DISCUSSION: These results do not support the hypotheses that high aerobic fitness is associated with attenuated psychological and neuroendocrine responses to yohimbine or to psychosocial stress.

[Evidence-based pharmacotherapy and other somatic treatment approaches for obsessive-compulsive disorder: state of the art]. / Evidenzbasierte Pharmakotherapie und andere somatische Therapieverfahren bei Zwangsstörungen : State of the art.

Meta-analyses of the randomized controlled trials (RCT) in obsessive-compulsive disorder (OCD) have clearly demonstrated that selective serotonin reuptake inhibitors (SSRIs) are the medication treatment of choice, while cognitive behavioural therapy (CBT) with exposure and response prevention is the psychotherapy of choice in OCD. Several guidelines emphasized that SSRIs are the first choice of medication in OCD. It has been noted that these agents may need to be given at a higher dose, and for a longer duration, than is usually the case in disorders such as depression. In the management of refractory patients, medication history should be carefully reviewed and adherence to the recommendations of the guideline established. Antipsychotics (risperidone, quetiapine, haloperidol) are currently the pharmacotherapy augmentation strategy of choice. In those OCD patients who fail to respond to a range of SSRIs and augmentation strategies combined with CBT, more unusual interventions (including deep brain stimulation) can be considered.

A randomized study of iterative hypothesis testing in undergraduate psychiatric education.

OBJECTIVE: Iterative hypothesis testing (IHT) or related strategies of diagnostic decision making have been taught in many curricula for medical students but not in psychiatry. We therefore asked whether the addition of training in IHT may add to the quality of the psychiatry course. METHOD: Seventy-two medical students were randomized to four weeks problem-based learning or to IHT. Knowledge and skills of the students were tested using a multiple choice exam and simulated patients. RESULTS: Iterative hypothesis testing-trained students recognized more diagnostic items and more often identified comorbid psychiatric disorders and acute suicidal tendencies. Acquisition of general psychiatric knowledge and global satisfaction with the course were similar in both groups. CONCLUSION: We conclude that teaching IHT to medical students may enhance their clinical ability to recognize complex disease patterns. Further studies are required concerning the enhancement of clinical skills in the psychiatric specialty.

[Obsessive-compulsive disorders: how to recognize and treat them]. / Zwangsstörungen differenziert behandeln. So helfen Sie lhrem Patienten aus der Endlosschleife.

Obsessive-compulsive disorders are characterized by recurrent and persistent obsessive thoughts that are experienced as obtrusive and inappropriate, and (often stereotypic and repetitive) compulsive actions. Their lifetime prevalence is estimated to be 1-2%. Men and women are affected by such disorders in about equal numbers. The most common comorbidities are depression and anxiety. The etiology is considered to encompass both psychological and neurobiological aspects. The most effective therapeutic approach is cognitive behavioral therapy with exposure and response prevention as the central element, which leads to a lasting improvement in symptoms in some 60-80% of the patients. If a depressive disorder is also present, or if obsessive thoughts are predominant, a combination of cognitive behavioral therapy and pharmacological treatment with (selective) serotonin reuptake inhibitors has proven effective.

Identification of selected psychopharmaceuticals and their metabolites in hair by LC/ESI-CID/MS and LC/MS/MS.

Hair samples of patients of psychiatry and hair samples of suicide cases were analysed by liquid-chromatography/ionspray-mass spectrometry (LC/MS) for antidepressants and neuroleptics. Electrospray ionisation (ESI) with in-source collision induced dissociation (ESI/CID) and tandem-mass spectrometry (MS/MS) were used for drug and metabolite identification. Mass spectra library searching was performed using an ESI/CID mass spectra library and a MS/MS spectra library. Furthermore, extracted ion chromatograms were used for the detection of N-desmethyl-metabolites, which were also identified by their fragment-ion spectra. Three examples using these methods are shown: The tricyclic antidepressant maprotiline, the selective serotonin receptor inhibitor (SSRI) citalopram and their desmethylmetabolites as well as the neuroleptic pipamperone were detected and identified in hair extracts. For extraction powdered hair was treated by ultrasonication in methanol and solid-phase extraction was used for sample clean-up prior to LC/MS or MS/MS analysis. These examples demonstrate the power of LC/MS and LC/MS/MS for the detection and identification of drugs in hair extracts using full-scan mode and ESI/CID with library searching or using highly selective LC/MS/MS-analysis with library searching or in multiple reaction monitoring mode.

[Obsessive-compulsive disorders in general practice. How the obsessive-compulsive neurotic is revealed by skin and hair]. / Zwangsstörungen in der Allgemeinarztpraxis. Wie Haut und Haar den Zwangsneurotiker verraten.

Obsessive-compulsive disorder (OCD) is characterized by obsessions, compulsions, or both, which cause significant personal distress or social dysfunction. OCD is a common psychiatric illness with a prevalence of 1-2%. Because most people have regular contact with primary health care services, the patient with OCD is likely to see their general practitioner even though psychological problems may not be the main reason for consultation. Early recognition of the disorder facilitates early intervention. This reduces distress, disability and burden of illness. Pharmacological treatment with serotonin reuptake inhibitors (SRI) and cognitive-behavioral therapy have both been proven to be effective and are evidence based.

Obsessive-Compulsive Disorder (OCD) is still an unrecognised disorder: a study on the recognition of OCD in psychiatric outpatients.

OBJECTIVE: The study aims to investigate the recognition of patients with Obsessive-Compulsive Disorder (OCD) in psychiatric outpatients. SUBJECTS AND METHODS: A total of 2282 outpatients seen at 14 different psychiatric clinics in South Germany were asked to participate in the study. Five hundred and eighty-nine (30%) of the original 2282 patients met screening criteria for OCD, and of those, 237 (42%) participated in the final interview including DSM-IV diagnosis, and comorbidity. RESULTS: Sixty-nine of 589 participating patients who screened positively for obsessive symptoms actually had an Obsessive-Compulsive Disorder. Only 19 (28%) of the outpatients diagnosed with OCD according to DSM-IV criteria were also given this diagnosis by their consultant. The psychopathology scores indicated that the OCD patients had clinically relevant OCD with a mean Yale-Brown Obsessive Compulsive Score (Y-BOCS) of 17.5 (± 5.4), and a mean Clinical Global Impression Score (CGI) of 5.2 (± 1.2). CONCLUSIONS: In outpatient clinics over 70% of OCD patients remain unrecognised and thus untreated by consultants. Screening questions provide a rapid way of identifying those who may have OCD and should be incorporated into every mental state examination by consultants.

A new understanding of attention-deficit disorders--beyond the age-at-onset criterion of DSM-IV.

For decades, ADHD has been seen primarily as a behavior disorder affecting only young children, primarily boys, causing them to be inattentive and disruptive in school. Research has now established that ADHD affects females as well as males, and that impairing symptoms, for most, persist into adulthood. It has also been shown that this disorder impacts many aspects of life that extend well beyond problems in school. This disorder impairs not only one's ability to sit still and listen, but also the capacity to organize tasks and materials, to sustain effort on tasks, and to utilize short-term memory for daily activities. Studies of children, adolescents, and adults with ADHD indicate that many suffer from a variety of cognitive impairments that extend beyond symptoms listed in the DSM-IV diagnostic criteria for ADHD. These include chronic problems in regulating alertness, in reading comprehension, and in modulating emotions, that occur more frequently in persons with ADHD than in the general population. This article describes recent research findings demonstrating the wide range of cognitive impairments associated with ADHD, which are related to a new model of ADHD, such as developmental impairment of executive functions of the brain.

[Neuroimaging findings in posttraumatic stress disorder: review of the literature]. / Bildgebende Befunde bei der posttraumatischen Belastungsstörung (PTBS): Literaturübersicht.

The knowledge about the development and maintenance of the posttraumatic stress disorder (PTSD) has increased significantly in the past 10 years with important insights coming from imaging studies. Through these insights PTSD has changed from "traumatic neurosis" to a biologically based psychological disorder. This paper summarises the recent literature on morphological, functional and metabolic neuroimaging on PTSD. Of special interest are four brain areas, the hyperactive amygdala, the hippocampus with volume reduction as well as the cingulate gyrus and orbitofrontal cortical regions, which may not be able to inhibit the hyperactive amygdala to trauma related stimuli. Based on these imaging data the current understanding of the pathophysiology of PTSD as well as present methodological limitations of imaging methods will be discussed.

[Pharmacological strategies for clozapine-induced hypersalivation: treatment with botulinum toxin B in one patient and review of the literature]. / Therapie der Clozapin-induzierten Hypersalivation mit Botulinum-Toxin B.

Hypersalivation is frequently observed in patients treated with clozapine. Current strategies to counteract sialorrhea include the introduction of antimuscarinergic (anticholinergic) and alpha(2)-agonistic treatment. However, the use of these substances is limited in part by lack of efficacy and by adverse side effects. In cases of intractable sialorrhea, the application of botulinum toxin may be a new and safe therapeutic option. We here present an overview on current treatment strategies for sialorrhea and describe a patient who received botulinum toxin B for clozapine-induced hypersalivation.

[Neurobiological aspects of the etiology and pathophysiology of obsessive-compulsive disorder]. / Neurobiologische Aspekte zur Atiologie und Pathophysiologie der Zwangsstörung.

Obsessive-compulsive disorder (OCD) is a common psychiatric illness characterized by intrusive, repetitive thoughts and behaviours which cause marked distress. During the last decade, different models were developed for the pathophysiology of the obsessive-compulsive-disorder. Three different neurobiological models are introduced in this article: 1. model of dysfunctional kortikostriatal circuitry, 2. amygdalocentric model, 3. neurochemical model. These models don't exclude themselves mutually but supplement themselves and should ideally be integrated into a biopsychosocial concept. Such increased understanding of the neurobiology can be translated into better diagnosis and treatment for those patients who suffer from obsessive-compulsive-disorder.

Smooth pursuit deficits in schizophrenia, affective disorder and obsessive-compulsive disorder.

BACKGROUND: In schizophrenia, affective disorders, and obsessive-compulsive disorder (OCD) dysfunction of frontal neuronal circuits has been suggested. Such impairments imply corresponding oculomotor deficits. METHOD: Eye movement response to foveofugal and foveopetal step-ramp stimuli was recorded within the same study design in patients with schizophrenia (N= 16), affective disorder (N= 15), and OCD (N= 18) and compared with controls (N=23) using infra-red reflection oculography. RESULTS: In the foveofugal task steady-state velocity was lower in all patient groups compared with controls. Post-saccadic eye velocity was also decreased in patients with schizophrenia and affective disorder. In the foveopetal stimulus steady-state velocity was reduced in schizophrenic patients, only. Changes of saccadic latencies or position errors were not found in any of the patient groups. Also, pursuit latency was unchanged and initial eye acceleration was not decreased. CONCLUSIONS: Unaltered saccadic parameters indicate intact motion perception in cortical visual area V5. Therefore, the observed deficit of pursuit maintenance implies a dysfunction of frontal networks in all patient groups including the pursuit region of the frontal eye field (FEF). In patients with schizophrenia and affective disorder reduced post-saccadic pursuit initiation may indicate an impaired interaction between the pursuit and the saccadic system.