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.

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.

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.

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.

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.

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. 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.

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.

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.

Sex-related similarities and differences in the neural correlates of beauty.

The capacity to appreciate beauty is one of our species' most remarkable traits. Although knowledge about its neural correlates is growing, little is known about any gender-related differences. We have explored possible differences between men and women's neural correlates of aesthetic preference. We have used magnetoencephalography to record the brain activity of 10 male and 10 female participants while they decided whether or not they considered examples of artistic and natural visual stimuli to be beautiful. Our results reveal significantly different activity between the sexes in parietal regions when participants judged the stimuli as beautiful. Activity in this region was bilateral in women, whereas it was lateralized to the right hemisphere in men. It is known that the dorsal visual processing stream, which encompasses the superior parietal areas, has been significantly modified throughout human evolution. We posit that the observed gender-related differences are the result of evolutionary processes that occurred after the splitting of the human and chimpanzee lineages. In view of previous results on gender differences with respect to the neural correlates of coordinate and categorical spatial strategies, we infer that the different strategies used by men and women in assessing aesthetic preference may reflect differences in the strategies associated with the division of labor between our male and female hunter-gatherer hominin ancestors.

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.

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.

Psychological factors affecting response to antidepressant drugs in fibromyalgia.

BACKGROUND: The use of antidepressant drugs in fibromyalgia is extensive despite small evidence of the real impact in the clinical practice setting. This study was aimed to evaluate the long-term efficiency of antidepressant treatment in fibromyalgia and the role of psychosocial factors in treatment response. METHODS: A total of 102 consecutive patients with fibromyalgia from primary health care centers were studied with psychopathological and psychological assessment interviews and questionnaires. Sustained release venlafaxine was added to previous treatments in flexible doses from 150 to 300 mg daily for a 6-month period. Efficacy measures included the Clinical Global Impression (CGI) scale (patient and clinician versions) and the Fibromyalgia Impact Questionnaire (FIQ) score reduction. RESULTS: At 6 months, 48% patients were considered responders to treatment (CGI change score 1 or 2) and 23.5% had a mild response. Of note, 57.8% had less fatigue and 31.4% had less pain. The proportion of responders was greater in the group with major depression (65%) than in those without depression (45%), but the difference did not reach statistical significance. However, the reduction of FIQ scores was significantly greater in depressed (21.1; IQR: 1.4-42.0) than in non-depressed patients (41.4; IQR: 23.6-52.6) (P<0.05). FIQ score reduction was significantly smaller in patients taking concomitant opiate treatment (P<0.01) and in patients seeking incapacitation (P<0.01). CONCLUSION: Antidepressant treatment in fibromyalgia was effective in patients with and without major depression, but the functional response was greater in depressed patients. Treatment response to antidepressants might be significantly influenced by attitudinal and psychosocial factors of the disease.

Psychobiology of borderline personality traits related to subtypes of eating disorders: a study of platelet MAO activity.

Increased and decreased levers of platelet monoamine oxidase (MAO) activity have been reported in patients with eating disorders, indicating abnormalities of the serotonin turnover. However, whether these findings are related to eating disorders or are rather reflecting the pathophysiology of borderline personality traits in these patients is still unknown. Platelet MAO activity and comorbid personality disorders were investigated in 72 patients with different subtypes of eating disorders (ED) and in a group of 28 healthy controls. ED patients comprised the following subtypes: 25 anorexia nervosa (AN) restrictive, 14 AN binge eating-purging (AN b-p), 3 anorexia nervosa not otherwise specified (AN NOS) and 30 bulimia nervosa (BN). Personality disorders and traits were assessed with the Structured Interview for Personality Disorders (SCID-II), the Zanarini Rating Scale for Borderline Personality Disorder, and the Barrat Impulsiveness Scale. Platelet MAO activity was significantly lower in ED patients with comorbid borderline personality disorder (BPD) than in ED without Borderline personality disorder (BDP). Platelet MAO activity was significantly and inversely correlated with the number and severity of BPD clinical features. In the subsample of patients with binge eating-purging symptoms (AN b-p, AN NOS and BN), platelet MAO activity was significantly lower in binge-purge patients with comorbid BPD than in binge-purge patients without BPD. The whole group of eating disorders had a significantly reduced lever of platelet MAO activity compared with the control group. The results suggest that low platelet MAO activity might characterize eating disorders with comorbid borderline personality traits, reflecting greater serotonin dysfunction in these patients. The role of decreased platelet MAO as an endophenotype with specific clinical manifestations should be explored in future studies.

Perception, experience and body identity.

Physician has to know the patient in the disease and not only the disease in the patient, from the dual perspective of the body as object and the body as subject. This also affects the patient who has to cope with the reality of having a body that bursts into the subject's consciousness as a vital threat, as source of discomfort and inability and being a body (Marcel). The human body in its dual aspect has been and is a great unknown, if not a great outrage in spite of the fact that we are our body and our body is each of us. We sometimes do not feel as we are and thus a confrontation arises, sometimes more normal, others more morbid. This forces the physician to face complex ethics considerations and the scientist to accept a personal identity disorder. Dualism considers that there are two substances in us, one that distinguishes us from other beings and from the rest of the individuals of the human species, the soul, the psychic life, mind or consciousness, and another more insubstancial one, the body. The aim of the first substance is to dominate the body, to survive it after death when it is, already a corpse is meant to become putrefied, is buried, incinerated or thrown to the depth of the sea. This dualism aims to explain the origin of the evil and the attitude to defeat it and it does so efficiently. This anthropology has very ancient roots (the Upvanishads, in the orphic texts, in Plato), it is the core of Gnostic thought and the foundation of the modern science since Descartes. Some monist perspectives are a masked dualism or a mereologic fallacy, according to which, the brain is conscious, when that what is conscious is the subject, although the subject, with the brain could not be conscious. Therefore, a new perspective is proposed, chiasmatic or janicular monism, that considers the adaptive value of focusing on the reality from two perspectives, as physical universe and the world of interpersonal relationships. In the agnosias and in the phantom limb there is a confrontation between the body object and the body subject that has made it possible to investigate how the perception of the own body is and how the brain generates the schema and the body image. The study of the body experience, from the phenomenology and the anthropological psychiatry perspective, has made it possible to go greater in-depth into the knowledge of the alterations of the experience of the own body in different mental diseases, especially in those in which a confrontation between the body and the personal identity arises makes it necessary to consider the process of individual identification and a category of personal identity disorders that would include body dysmorphic disorder, erythrophobia, anorexia nervosa, body integrity identity as well as the gender-type disorders (transsexualism, nonfetishistic transvestism, gender identity disorder during childhood). Key words: Dualism, Monism, Agnosia, Phantom limb, Cenesthesia, Body schema, Body image, Body experience, Personal identity disorders, Body dysmorphic disorder, Anorexia nervosa, Personal integrity identity disorder.

[Neuropsychological, clinical and social issues in two patients with Capgras Syndrome]. / Aspectos neuropsicológicos, clínicos y sociales de dos casos de síndrome de Capgras.

Two patients suffering Capgras Syndrome (CS) were evaluated with neuroimaging and neuropsychological tests, the results of which are compared with the existing etiopathogenic theories. To date, the etiopathogeny of the CS continues to lack satisfactory explanation. However, several holistic models have been proposed to better understand the many different theoretical proposals circulating for CS. These theories are discussed and the psychosocial consequences of aggressiveness, an aspect not frequently commented in the literature, are analyzed. Risk for aggressiveness and its negative consequences should be taken into consideration upon diagnosis of CS in order to design effective preventive measures.

The evolving concept of Treatment- Resistant Schizophrenia.

Schizophrenia is a chronic disease of body and mind that affects 1% of the population. The existence of the person with schizophrenia should be understood, at least, from two perspectives: one considering the integration of the individual into the social community, another understanding that there is a patient with a medical problem treatable with medications and psychotherapies. There is a large group of patients with 'treatment-resistant schizophrenia," that is, cases in which a minimum degree of remission with conventional treatments is not obtained. These cases have pointed to the fact that even today we still lack an integrative treatment model obtained through the assembling of specific interventions with verifiable effectiveness. The concept of treatment-resistant schizophrenia should have evolved in accordance with the advancing of the currently available knowledge and therapeutic resources. Why hasn't this happened? This article reviews the history of the concept of "resistance" to account for such failure and proposes a methodological approach to overcome this stagnation.

The opinion of psychiatric residents on the training they receive.

The results of a survey carried out by the Spanish National Board for Psychiatric Training among psychiatric trainees in their third and fourth year of training are presented and discussed. The aim of the survey was to know the resident's opinion and level of satisfaction on the training they had received. The results indicate that the majority of residents had complied with the National Program for Psychiatric Training requirements and that their level of satisfaction was fair. However a small but substantial percentage did not comply adequately with the program, particularly in relation with the training in psychotherapy, research methodology, old age psychiatry, neurology and general medicine. Based on these results the National Board puts forward some recommendations meant for those involved in the training of psychiatrists in Spain.