A Primer on Interoception and its Importance in Psychiatry.

Interoception is the perception of signals from inside the body. It plays a significant role in the nervous, cardiovascular, respiratory, gastrointestinal, genitourinary, and endocrine systems. It is also closely related to the autonomic nervous system and inflammatory pathways and plays a significant role in our optimal functioning. Recently, interoception has gained more attention in neuropsychiatric research. Anatomical and physiological aspects of interoception like relevant brain areas, the role of the vagus nerve, and the autonomic nervous system are gradually being understood. Different facets of interoception like interoceptive attention, detection, magnitude, discrimination, accuracy, awareness, and appraisal have been proposed and their assessments and importance are being evaluated. Further, interoception is often dysregulated or abnormal in psychiatric disorders. It has been implicated in the psychopathology, etiopathogenesis, clinical features and treatment of mood, anxiety, psychotic, personality and addiction-related disorders. This narrative review attempts to provide a nuanced understanding of the pathway(s), components, functions, assessments, and problems of interoception and will help us to detect its disturbances and evaluate its impact on psychiatric disorders, leading to a better perspective and management. This will also advance interoception-related research.

Adjunct yoga therapy: Influence on heart rate variability in major depressive disorder - A randomized controlled trial.

HRV is inversely proportional to severity of depression. Effect of 12-weeks adjunct yoga therapy on HRV in patients with MDD was assessed through a randomized controlled trial. Sixty-eight subjects (40 females) with mean age 31.58 ± 8.79 years, scoring ≥ 18 on HDRS were randomized to either (YG; n = 35) or (WG; n = 33). Linear mixed model analysis showed no significant difference between groups. On comparing change in mean percentage, substantial more decrease could be elicited only for LF/HF ratio in YG compared to WG, while being comparable for other variables across the groups. Findings suggest Yoga therapy may help in bringing parasympathetic dominance in patients with MDD.

Development, Validation, and Feasibility Testing of a Yoga Module for Opioid Use Disorder.

CONTEXT: Opioid use disorder (OUD) involves excessive use of opioids-such as heroin, morphine, fentanyl, codeine, oxycodone, and hydrocodone-leading to major health, social, and economic consequences. Yoga lifestyle interventions have been found to be useful as adjunct therapies in management of substance use disorders and chronic pain conditions. OBJECTIVE: The research team intended to develop, validate, and test for feasibility a yoga program for OUD patients that could reduce opiate withdrawal symptoms-such as pain, fatigue, low mood, anxiety and sleep disturbances-and cravings associated with drugs. DESIGN: The research team first performed a literature review of traditional and contemporary yoga texts, such as Hatha Yoga Pradipika and Light on Yoga, as well as modern scientific literature in the following search engines-Google Scholar, PubMed, and PsychInfo, using the keywords yoga, pranayama, hatha yoga, relaxation. meditation, substance use, addiction, impulsivity, craving, sleep quality, and fatigue. Using the information obtained, the team developed a yoga program and designed a pilot study that used the program. SETTING: The study took place in the Department of Integrative Medicine at the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore, India. PARTICIPANTS: Participants in the pilot study were 8 inpatients, 6 males and 2 females, who were on opioid agonist treatment (buprenorphine) for OUD. INTERVENTION: The intervention was the yoga program previously validated by the research team. In the pilot study, participants were taught a one-hour, yoga-based intervention, with sessions occurring once per day, for 10 sessions. OUTCOME MEASURES: For validation, 13 experts scored the yoga program that the research team had developed and gave suggestions for each yogic practice for use during the acute phase of withdrawal and the maintenance phase respectively. A content validity ratio (CVR) was calculated from their scoring, and the research team made changes to the program base on the scoring and suggestions. For the pilot study, assessments occurred at baseline and postintervention. The participants' yoga performance was rated by the yoga trainer on a yoga performance assessment scale (YPA). Other measurements included: (1) the Clinical Opiate Withdrawal Scale (COWS), (2) the Hamilton's anxiety rating scale (HAM-A), (3) the Hamilton's depression rating scale (HAM-D), (4) buprenorphine dosage, (5) the Clinical Global Impression Severity (CGI-S) scale, (6) a visual analog scale (VAS) for pain, (7) sleep quality (latency and duration), and (8) the module's safety. RESULTS: Four practices were removed from the program due to CVR scores below the cutoff, and one practice was found not to be feasible (Kapalabhati). Two categories of yoga modules emerged: (1) for the acute symptomatic phase (40 minutes) and (2) for the maintenance phase (one hour). Practices were added or excluded based on the phase. CONCLUSIONS: The yoga module that was developed for reducing withdrawal symptoms and cravings in OUD patients was found to be safe, feasible, and potentially useful as an adjunct therapy to conventional treatment.

Does Yoga Have a Role in Schizophrenia Management?

PURPOSE OF REVIEW: To review the efficacy of add-on yoga therapy in improving symptoms of schizophrenia and quality of life and examine the possible underlying biological mechanisms of yoga in schizophrenia. RECENT FINDINGS: Quality of life, cognitive symptoms, and negative symptoms have been found to improve with add-on yoga therapy in schizophrenia (pooled mean effect size 0.8, 0.6, and 0.4, respectively). Yoga also seems to have a small effect on improving positive symptoms. Less explored areas include adverse effects of yoga itself as well as its effects on antipsychotic-induced complications. Preliminary findings suggest that the effects of yoga may be mediated by neurohormonal mechanisms and functional changes in brain activity. Add-on yoga therapy is a potential treatment option for improving quality of life, cognitive symptoms, and negative symptoms in schizophrenia. Future studies should explore efficacy in multicentric trials as well as possible neurobiological changes underlying the effects.

Yoga and schizophrenia-a comprehensive assessment of neuroplasticity: Protocol for a single blind randomized controlled study of yoga in schizophrenia.

INTRODUCTION: Schizophrenia is one of the most severe mental disorders with a prevalence of about 1% and a leading cause of disability among young adults. Pharmacotherapy is the mainstay in the management of schizophrenia. However, even with the best of medication, several problems like refractoriness, negative symptoms, frequent relapses, and cognitive impairments persist. METHODS: This is a randomized-controlled clinical study including patients from an urban tertiary hospital and a semi-urban community center, with a between-group, repeated-measures, longitudinal design. This study will recruit 160 patients with DSM 5 diagnosis of schizophrenia who are on stable medication for a minimum of 6 weeks; they will be randomly assigned into 2 arms viz., yoga therapy (YT), and treatment-as-usual (TAU) with 80 patients in each arm. Participants will undergo Clinical, Laboratory, and Radiological assessments at baseline and at intervals of 1 month, 3 months, and 6 months from the baseline. It is hypothesized that yoga will improve psychopathology and emotion processing, increase serum brain derived neurotrophic factor (BDNF) and plasma oxytocin levels and effect changes in cerebral activation in areas of the brain associated with schizophrenia. DISCUSSION: This study aims to measure the efficacy of a Yoga-based intervention as an adjunct in patients with schizophrenia as well as the mechanisms of these effects. TRIAL REGISTRATION: Registered retrospectively with Clinical Trial Registry - India (CTRI) with registration number CTRI/2017/08/009219.

Directional brain networks underlying OM chanting.

OM chanting is an ancient technique of Indian meditation. OM chanting is associated with an experience of relaxation, changes in autonomic balance and deactivation of limbic brain regions. While functional localization is important, how brain regions interact with each other has been shown to underlie various brain functions. Therefore, in this study, we tested the hypothesis that there is reduced communication between deactivated regions during OM chanting. In order to do so, we employed multivariate autoregressive model (MVAR) based Granger causality to obtain directional connectivity between deactivated regions. fMRI scans of 12 right handed healthy volunteers (9 Men) from a previously published study was used in which participants performed OM chanting and a control condition in a block design. We found that outputs from insula, anterior cingulate and orbitofrontal cortices were significantly reduced in OM condition. Of interest is the reduction of outputs from these regions to limbic area amygdala. Modulation of brain regions involved in emotion processing and implicated in major depressive disorder (MDD) raises a potential possibility of OM chanting in the treatment of MDD.

Metacognition and Mindfulness Integrated Therapy Reduces Severity of Hallucination in a Patient Not Taking Antipsychotic Medication.

Psychological interventions have proven efficacy in treating psychotic symptoms such as delusions and hallucinations. However, the efficacy of these interventions has primarily been evaluated in the context of their use as an adjunct to antipsychotics or on patients who do not respond to adequate trials of antipsychotics. There is paucity of research about the effectiveness of psychological interventions in patients who do not take antipsychotics either because they are not willing to take medications or are not able to tolerate antipsychotics due to the side effects. We report here the case of a patient who had distressing auditory hallucinations and was not able to take antipsychotic medications because of severe reactions. She responded to metacognition and mindfulness integrated therapy for auditory hallucination. A total of eight sessions of therapy with the major focus on enhancement of metacognitive insight into the mechanisms of genesis and maintenance of hallucinations followed by encouraging the patient to use mindfulness-based strategies and regular self-monitoring of hallucinatory experiences were conducted. The patient was assessed pre-post intervention on the auditory hallucination subscale of the Psychotic Symptom Rating Scale (PSYRATS). There was significant improvement as reflected by more than 50% reduction in the PSYRATS score. This case highlights that metacognition and mindfulness integrated therapy has the potential to help patients with hallucination who do not take antipsychotic medications. The insight building helps in developing a detached approach towards hallucinatory experiences which, in turn, reduces distress caused by the hallucinations.

Acute effects of 3G mobile phone radiations on frontal haemodynamics during a cognitive task in teenagers and possible protective value of Om chanting.

Mobile phone induced electromagnetic field (MPEMF) as well as chanting of Vedic mantra 'OM' has been shown to affect cognition and brain haemodynamics, but findings are still inconclusive. Twenty right-handed healthy teenagers (eight males and 12 females) in the age range of 18.25 ± 0.44 years were randomly divided into four groups: (1) MPONOM (mobile phone 'ON' followed by 'OM' chanting); (2) MPOFOM (mobile phone 'OFF' followed by 'OM' chanting); (3) MPONSS (mobile phone 'ON' followed by 'SS' chanting); and (4) MPOFSS (mobile phone 'OFF' followed by 'SS' chanting). Brain haemodynamics during Stroop task were recorded using a 64-channel fNIRS device at three points of time: (1) baseline, (2) after 30 min of MPON/OF exposure, and (3) after 5 min of OM/SS chanting. RM-ANOVA was applied to perform within- and between-group comparisons, respectively. Between-group analysis revealed that total scores on incongruent Stroop task were significantly better after OM as compared to SS chanting (MPOFOM vs MPOFSS), pre-frontal activation was significantly lesser after OM as compared to SS chanting in channel 13. There was no significant difference between MPON and MPOF conditions for Stroop performance, as well as brain haemodynamics. These findings need confirmation through a larger trial in future.

Insight facilitation with add-on tDCS in schizophrenia.

Impaired insight in schizophrenia patients has been linked with prefrontal deficits. In this open-label study, we examined for potential insight facilitation effects of add-on tDCS (with anodal stimulation of left DLPFC and cathodal stimulation over left temporo-parietal junction) in schizophrenia patients (N=21) with persistent auditory hallucinations despite adequate antipsychotic treatment. Following tDCS, there was a significant improvement in insight with concurrent significant reduction in auditory hallucination severity. Improvement in insight correlated significantly with improvement in severity of auditory hallucinations. These findings suggest improvement of insight with add-on tDCS in schizophrenia with persistent auditory hallucinations.

Neural basis of tDCS effects on auditory verbal hallucinations in schizophrenia: a case report evidence for cortical neuroplasticity modulation.

Transcranial direct current stimulation (tDCS) has been reported to ameliorate auditory hallucinations that are nonresponsive/minimally responsive to antipsychotic treatment in schizophrenia. The neurobiological basis of the tDCS effects in ameliorating auditory hallucinations is yet to be explored. In this case report, for the first time, using the novel method for noninvasive assessment of cortical plasticity, we demonstrate potential neuroplasticity effect of tDCS in improving treatment-resistant auditory hallucinations in a schizophrenic patient.

Rapid improvement of auditory verbal hallucinations in schizophrenia after add-on treatment with transcranial direct-current stimulation.

Treatment of nonresponsive auditory hallucinations in schizophrenia have been reported to improve with transcranial direct-current stimulation. This case description illustrates the use of add-on transcranial direct-current stimulation for rapid amelioration of auditory hallucinations in schizophrenia during the acute phase. Because transcranial direct-current stimulation is safe, largely well tolerated, and relatively inexpensive, this add-on treatment option is worth exploring through further rigorous studies.

Recent advances in psychoneuroimmunology relevant to schizophrenia therapeutics.

PURPOSE OF REVIEW: Immunological understanding of neurological and cognitive alterations of schizophrenia has made a significant breakthrough in unfolding the pathophysiological mechanisms of schizophrenia, at least in a group of patients. Such psychoneuroimmunological aberrations essentially argue for an alternative treatment approach based on immunomodulation in schizophrenia. RECENT FINDINGS: Recent findings in schizophrenia have shown exaggerated immuno-inflammatory responses due to persistent systemic inflammation and neuroinflammation involving microglia activation. The existing antipsychotic drugs have shown substantial benefits in the control of positive symptoms, but they have not demonstrated adequate immuno-dampening effects specifically and effectively. However, a group of emerging nonsteroidal as well as other anti-inflammatory drugs currently being used as an adjunct therapy seem to exhibit increased target specificity and effectiveness in reducing symptom severity to some extent. SUMMARY: The anti-inflammatory drugs that have been shown to reduce the levels of pro-inflammatory mediators and inhibit microglia activation have paved the way for better outcomes of schizophrenia treatment. However, many of the currently tested anti-inflammatory drugs often lack methodological robustness. The identification of novel target(s) that will integrate the processes evoked by various risk determinants into a common signalling pathway is urgently required, and this may take immunomodulation into a new therapeutic domain in schizophrenia.