Empathy in family medicine postgraduate education: A mixed studies systematic review.

PURPOSE: Empathy is an important construct in patient-physician relationships, particularly critical in family physicians' daily practice. We aimed to understand how empathy has been conceived and integrated into family medicine postgraduate training. MATERIALS AND METHODS: Medline, PsyINFO, and Embase were searched in this systematic mixed studies systematic review. Two independent reviewers screened abstracts and full texts. Disagreements were solved through research team consensus-based discussion. Included studies were synthesized thematically. RESULTS: A total of 18 studies were included. Four themes were identified. (1) Empathy definition. Included studies stressed the cognitive component of empathy, paired either with a behavioural or an affective response. (2) Empathy modifiers. Starting residency right after medical school, having a role model, having high empathy levels before residency, having children, being married, and being exposed to patient involvement in education were found to have a positive impact on empathy. (3) Empathy-burnout relationship. Whereas greater burnout was related to lower empathy levels, excess empathy seems to favour burnout through 'compassion fatigue.' (4) Educational programs for empathy development. Five programs were identified: a communication workshop, a patient-led program, a mindfulness program, a family-oriented intervention, and an arts-based program. CONCLUSIONS: Studies mostly measured the cognitive component of empathy. The moral component of empathy was underrepresented in the conceptualization of empathy and the development of educational interventions. Conflicting evidence exists regarding the decline of empathy levels during the family medicine residency. Longitudinal designs should be privileged when exploring the evolution of empathy levels across the continuum of medical education.

Assessment of risk factors of treatment discontinuation among patients on paliperidone palmitate and risperidone microspheres in France, Germany and Belgium.

BACKGROUND: Long-acting antipsychotics (e.g. 1-monthly (PP1M) / 3-monthly (PP3M) injection forms of paliperidone palmitate) have been developed to improve treatment continuation in schizophrenia patients. We aim to assess risk factors of treatment discontinuation of patients on paliperidone palmitate and risperidone microsphere. Additionally, treatment discontinuation between patients with PP1M and PP3M was compared. METHODS: The IQVIA Longitudinal Prescription databases were used. Risk factors of treatment discontinuation were identified by a multilevel survival regression using Cox proportional hazards model. Kaplan Meier analyses were performed by identified significant risk factors. RESULTS: Twenty-five thousand three hundred sixty-one patients (France: 9,720; Germany: 14,461; Belgium: 1,180) were included. Over a one-year follow-up period, a significant lower treatment discontinuation was observed for patients newly initiated on paliperidone palmitate (53.8%) than those on risperidone microspheres (85.4%). Additionally, a significantly lower treatment discontinuation was found for 'stable' PP3M patients (19.2%) than 'stable' PP1M patients (37.1%). Patients were more likely to discontinue when drugs were prescribed by GP only (HR = 1.68, p < 0.001 vs. psychiatrist only) or if they were female (HR = 1.07, p < 0.001), whereas discontinuation decreased with age (31-50 years: HR = 0.95, p = 0.006 and > 50 years: HR = 0.91, p < 0.001 vs. 18-30 years). CONCLUSIONS: This study demonstrates that patients stay significantly longer on treatment when initiated on paliperidone palmitate as compared to risperidone microspheres. It also indicated a higher treatment continuation of PP3M over PP1M. Treatment continuation is likely to be improved by empowering GPs with mental health knowledge and managing patients by a collaborative primary care-mental health model. Further research is needed to understand why females and younger patients have more treatment discontinuation.

Cortical reactivations during sleep spindles following declarative learning.

Increasing evidence suggests that sleep spindles are involved in memory consolidation, but few studies have investigated the effects of learning on brain responses associated with spindles in humans. Here we used simultaneous electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) during sleep to assess haemodynamic brain responses related to spindles after learning. Twenty young healthy participants were scanned with EEG/fMRI during (i) a declarative memory face sequence learning task, (ii) subsequent sleep, and (iii) recall after sleep (learning night). As a control condition an identical EEG/fMRI scanning protocol was performed after participants over-learned the face sequence task to complete mastery (control night). Results demonstrated increased responses in the fusiform gyrus both during encoding before sleep and during successful recall after sleep, in the learning night compared to the control night. During sleep, a larger response in the fusiform gyrus was observed in the presence of fast spindles during the learning as compared to the control night. Our findings support a cortical reactivation during fast spindles of brain regions previously involved in declarative learning and subsequently activated during memory recall, thereby promoting the cortical consolidation of memory traces.

Happiness and Social Behavior.

It is often assumed that there is a robust positive symmetrical relationship between happiness and social behavior: Social relationships are viewed as essential to happiness, and happiness is thought to foster social relationships. However, empirical support for this widely held view is surprisingly mixed, and this view does little to clarify which social partner a person will be motivated to interact with when happy. To address these issues, we monitored the happiness and social interactions of more than 30,000 people for a month. We found that patterns of social interaction followed the hedonic-flexibility principle, whereby people tend to engage in happiness-enhancing social relationships when they feel bad and sustain happiness-decreasing periods of solitude and less pleasant types of social relationships that might promise long-term payoff when they feel good. These findings demonstrate that links between happiness and social behavior are more complex than often assumed in the positive-emotion literature.

Increased Reactivity of the Mesolimbic Reward System after Ketamine Injection in Patients with Treatment-resistant Major Depressive Disorder.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: The antidepressant effect of ketamine is associated with increased activity in the reward circuitry of the brain and a suppression of circuitry that mediates perceptual processing of negative emotions. The duration of ketamine effect on these brain structures remains to be defined. WHAT THIS ARTICLE TELLS US THAT IS NEW: As expected, ketamine administration led to an improvement in mood and global vigilance. The improvement in mood was accompanied by an increased recruitment of the orbitofrontal cortex, ventral striatum, medial substantial nigra and ventral tegmental area, structures that are part of the reward circuitry.Responses in the mesolimbic structures (amygdala, medial substantial nigra and ventral tegmental area, orbitofrontal cortex) to negative stimuli were decreased after ketamine administration.The data are consistent with the premise that ketamine induces sustained changes in the mesolimbic neural circuits to reset pathological reward and emotional processing. BACKGROUND: Ketamine rapidly improves maladaptive mood states in major depressive disorder, and some of the neural substrates underlying this therapeutic effect have been identified. This study aimed to identify functional changes within neural networks that may underlie the impact of ketamine on both reward and emotional processing in patients with treatment-resistant major depression. METHODS: Ten adult patients with a Montgomery-Åsberg Depression Rating Scale score above 25 were enrolled to receive a single intravenous administration of ketamine (0.5 mg/kg). Patients' performance along with related neural network activations were analyzed in a game-like reward task and in an emotional judgment task using functional magnetic resonance imaging 1 day before and 1 and 7 days after ketamine administration. RESULTS: A significant correlation (R = 0.46, P = 0.03) between the improvement of depression scores and the enhanced reaction time for positive items was found in the game-like reward task 1 day after ketamine administration. This enhanced sensitivity for rewarded items was accompanied by increased activity of reward-related brain regions, including the orbitofrontal cortex, ventral striatum, and the ventral tegmental area, an effect that persisted up to 1 week after ketamine injection. In the emotional judgment task, it was found that ketamine rapidly modified local brain activities in response to emotionally negative, positive, or neutral stimuli in the amygdala, insula, anterior cingulate cortex, and in the ventral tegmental area. CONCLUSIONS: Single bolus ketamine administration rapidly triggers lasting changes in mesolimbic neural networks to improve pathologic reward and emotional processing in patients with major depressive disorder.

Hedonism and the choice of everyday activities.

Most theories of motivation have highlighted that human behavior is guided by the hedonic principle, according to which our choices of daily activities aim to minimize negative affect and maximize positive affect. However, it is not clear how to reconcile this idea with the fact that people routinely engage in unpleasant yet necessary activities. To address this issue, we monitored in real time the activities and moods of over 28,000 people across an average of 27 d using a multiplatform smartphone application. We found that people's choices of activities followed a hedonic flexibility principle. Specifically, people were more likely to engage in mood-increasing activities (e.g., play sports) when they felt bad, and to engage in useful but mood-decreasing activities (e.g., housework) when they felt good. These findings clarify how hedonic considerations shape human behavior. They may explain how humans overcome the allure of short-term gains in happiness to maximize long-term welfare.

Beyond reduction with the representation: The need for causality with full complexity to unravel mental health.

In this commentary on Borsboom et al.'s target article, we argue that researchers should be aware of the historical development of models in neuroscience. Considering the importance of causality in anatomo-clinical approach and stressing the complexity of mental phenomenon, we provide new insight on reductionism and representation limitation.

Altered brain connectivity in patients with schizophrenia is consistent across cognitive contexts.

BACKGROUND: Schizophrenia has been defined as a dysconnection syndrome characterized by aberrant functional brain connectivity. Using task-based fMRI, we assessed to what extent the nature of the cognitive context may further modulate abnormal functional brain connectivity. METHODS: We analyzed data matched for motion in patients with schizophrenia and healthy controls who performed 3 different tasks. Tasks 1 and 2 both involved emotional processing and only slighlty differed (incidental encoding v. memory recognition), whereas task 3 was a much different mental rotation task. We conducted a connectome-wide general linear model analysis aimed at identifying context-dependent and independent functional brain connectivity alterations in patients with schizophrenia. RESULTS: After matching for motion, we included 30 patients with schizophrenia and 30 healthy controls in our study. Abnormal connectivity in patients with schizophrenia followed similar patterns regardless of the degree of similarity between cognitive tasks. Decreased connectivity was most notable in the medial prefrontal cortex, the anterior and posterior cingulate, the temporal lobe, the lobule IX of the cerebellum and the premotor cortex. LIMITATIONS: A more circumscribed yet significant context-dependent effect might be detected with larger sample sizes or cognitive domains other than emotional and visuomotor processing. CONCLUSION: The context-independence of functional brain dysconnectivity in patients with schizophrenia provides a good justification for pooling data from multiple experiments in order to identify connectivity biomarkers of this mental illness.

Beyond sensorimotor imitation in the neonate: Mentalization psychotherapy in adulthood.

Despite the persuasiveness of Keven & Akins' (K&A) review, we argue that mentalization, or the ability to interpret the mental states of oneself and others, is required to construct the neonate mind, going far beyond sensorimotor imitation. This concept, informed by certain psychoanalytic and attachment theories, has produced a form of therapy called mentalization-based psychotherapy, which aims to improve emotional regulation. Our aim here is to shed light on a form of neonatal imitation that goes beyond sensorimotor imitation.

Alterations in neural systems mediating cognitive flexibility and inhibition in mood disorders.

Impairment in mental flexibility may be a key component contributing to cardinal cognitive symptoms among mood disorders patients, particularly thought control disorders. Impaired ability to switch from one thought to another might reflect difficulties in either generating new mental states, inhibiting previous states, or both. However, the neural underpinnings of impaired cognitive flexibility in mood disorders remain largely unresolved. We compared a group of mood disorders patients (n = 29) and a group of matched healthy subjects (n = 32) on a novel task-switching paradigm involving happy and sad faces, that allowed us to separate generation of a new mental set (Switch Cost) and inhibition of the previous set during switching (Inhibition Cost), using fMRI. Behavioral data showed a larger Switch Cost in patients relative to controls, but the average Inhibition Cost did not differ between groups. At the neural level, a main effect of group was found with stronger activation of the subgenual cingulate cortex in patients. The larger Switch Cost in patients was reflected by a stronger recruitment of brain regions involved in attention and executive control, including the left intraparietal sulcus, precuneus, left inferior fontal gyrus, and right anterior cingulate. Critically, activity in the subgenual cingulate cortex was not downregulated by inhibition in patients relative to controls. In conclusion, mood disorder patients have exaggerated Switch Cost relative to controls, and this deficit in cognitive flexibility is associated with increased activation of the fronto-parietal attention networks, combined with impaired modulation of the subgenual cingulate cortex when inhibition of previous mental states is needed.

How cognition affects perception: Brain activity modelling to unravel top-down dynamics.

In this commentary on Firestone & Scholl's (F&S's) article, we argue that researchers should use brain-activity modelling to investigate top-down mechanisms. Using functional brain imaging and a specific cognitive paradigm, modelling the BOLD signal provided new insight into the dynamic causalities involved in the influence of cognitions on perceptions.

[Adaptation and Neurosciences II: Biological, Psychological and Social Adaptation, and Psychopathology]. / Adaptation et neurosciences II : adaptation biologique, psychique, sociale et psychopathologie.

In this article, we address adaptation in relation to the neurosciences. Adaptation is examined at the individual as well as various environmental levels: biological, psychological, and social. We then briefly discuss, from a neuroscientific perspective, the concept of adaptation in relation to psychopathology, including attachment theory and the third wave of cognitive-behavioral therapies.

[Adaptation and Neuroscience I: Fears, society, methodology, finality]. / Adaptation et neurosciences I : craintes, société, méthodologie, finalité.

This article is a first article in a series of two articles exploring the bidirectional links between the concept of adaptation and of neuroscience. In this first article, first of all we will see that neurosciences can be seen as ambitious and all-powerful oscillating between a reductionist and dehumanizing threat or crystallizing some control fantasies. We will then see that society adapts itself to neurosciences methodologies and incorporate some discoveries in various fields so that we can ask ourselves about the neuro-society of tomorrow. Then we will see that the methodology of neurosciences themselves is frequently challenged and requires that everyone knows the limitations and not only stick to promises. After that, we will see that the adaptation seen as the promise of a determined and finite goal may be reassuring but is most unlikely.

Sleep sharpens sensory stimulus coding in human visual cortex after fear conditioning.

Efficient perceptual identification of emotionally-relevant stimuli requires optimized neural coding. Because sleep contributes to neural plasticity mechanisms, we asked whether the perceptual representation of emotionally-relevant stimuli within sensory cortices is modified after a period of sleep. We show combined effects of sleep and aversive conditioning on subsequent discrimination of face identity information, with parallel plasticity in the amygdala and visual cortex. After one night of sleep (but neither immediately nor after an equal waking interval), a fear-conditioned face was better detected when morphed with another identity. This behavioral change was accompanied by increased selectivity of the amygdala and face-responsive fusiform regions. Overnight neural changes can thus sharpen the representation of threat-related stimuli in cortical sensory areas, in order to improve detection in impoverished or ambiguous situations. These findings reveal an important role of sleep in shaping cortical selectivity to emotionally-relevant cues and thus promoting adaptive responses to new dangers.

Interplay between spontaneous and induced brain activity during human non-rapid eye movement sleep.

Humans are less responsive to the surrounding environment during sleep. However, the extent to which the human brain responds to external stimuli during sleep is uncertain. We used simultaneous EEG and functional MRI to characterize brain responses to tones during wakefulness and non-rapid eye movement (NREM) sleep. Sounds during wakefulness elicited responses in the thalamus and primary auditory cortex. These responses persisted in NREM sleep, except throughout spindles, during which they became less consistent. When sounds induced a K complex, activity in the auditory cortex was enhanced and responses in distant frontal areas were elicited, similar to the stereotypical pattern associated with slow oscillations. These data show that sound processing during NREM sleep is constrained by fundamental brain oscillatory modes (slow oscillations and spindles), which result in a complex interplay between spontaneous and induced brain activity. The distortion of sensory information at the thalamic level, especially during spindles, functionally isolates the cortex from the environment and might provide unique conditions favorable for off-line memory processing.

Mapping collective emotions to make sense of collective behavior.

While Bentley et al.'s model is very appealing, in this commentary we argue that researchers interested in big data and collective behavior, including the way humans make decisions, must account for the emotional factor. We investigate how daily choice of activities is influenced by emotions. Results indicate that mood significantly predicts people's decisions about what to do next, stressing the importance of emotional state on decision-making.

Neural substrates of cognitive switching and inhibition in a face processing task.

We frequently need to change our current occupation, an operation requiring additional effortful cognitive demands. Switching from one task to another may involve two distinct processes: inhibition of the previously relevant task-set, and initiation of a new one. Here we tested whether these two processes are underpinned by separate neural substrates, and whether they differ depending on the nature of the task and the emotional content of stimuli. We used functional magnetic resonance imaging in healthy human volunteers who categorize emotional faces according to three different judgment rules (color, gender, or emotional expression). Our paradigm allowed us to separate neural activity associated with inhibition and switching based on the sequence of the tasks required on successive trials. We found that the bilateral medial superior parietal lobule and left intraparietal sulcus showed consistent activation during switching regardless of the task. On the other hand, no common region was activated (or suppressed) as a consequence of inhibition across all tasks. Rather, task-specific effects were observed in brain regions that were more activated when switching to a particular task but less activated after inhibition of the same task. In addition, compared to other conditions, the emotional task elicited a similar switching cost but lower inhibition cost, accompanied by selective decrease in the anterior cingulate cortex when returning to this task shortly after inhibiting it. These results demonstrate that switching relies on domain-general processes mediated by postero-medial parietal areas, engaged across all tasks, but also provide novel evidence that task inhibition produces domain-specific decreases as a function of particular task demands, with only the latter inhibition component being modulated by emotional information.

Sleep stabilizes visuomotor adaptation memory: a functional magnetic resonance imaging study.

The beneficial effect of sleep on motor memory consolidation is well known for motor sequence memory, but remains unsettled for visuomotor adaptation in humans. The aim of this study was to characterize more clearly the influence of sleep on consolidation of visuomotor adaptation using a between-subjects functional magnetic resonance imaging (fMRI) design contrasting sleep to total sleep deprivation. Our behavioural results, based on seven different parameters, show that sleep stabilizes performance whereas sleep deprivation deteriorates it. During training, while a set of cerebellar, striatal and cortical areas is activated in proportion to performance improvement, the recruitment of the hippocampus and frontal cortex protects motor memory against the detrimental effects of sleep deprivation. During retest after sleep loss a cerebello-cortical network, usually involved in the earliest stage of learning, was recruited to perform the task. In contrast, no changes in cerebral activity were observed after sleep, suggesting that it may only support the stabilization of the visuomotor adaptation memory trace.