[Implementation of exercise therapy in daily clinical practice in psychiatric clinics in Germany]. / Angebot und Inanspruchnahme von Sporttherapie in psychiatrischen Kliniken in Deutschland.

Exercise therapy has proven to be effective in the treatment of multiple mental illnesses. As mental disorders result in tremendous costs for the healthcare system as well as a huge burden for the affected individuals, improving treatment strategies according to latest scientific evidence should be of highest priority. In 2016 a first study provided indications that only a minority of patients are treated with exercise therapy during their stay in hospital. Hence, the aim of this study was to assess the actual extent of exercise therapy usage in psychiatric inpatients in Germany, thereby giving a scientific foundation to the call for a better standard of care. To achieve this, a retrospective analysis was performed on pre-existing data from 2693 patients who were treated in 1 of 4 participating university hospitals. Only 23% of these patients participated in exercise therapy with a mean training duration of 36 min per week. Patients with the diagnosis of schizophrenia or patients with multiple comorbidities were even less likely to participate in exercise therapy. With these findings it becomes evident that the healthcare situation concerning exercise therapy is insufficient. Solid evidence for the effectiveness of exercise therapy, the current treatment guidelines as well as the positive side effects, especially when compared to side effects of pharmacotherapy (i.e. weight gain) should motivate healthcare officials to make an effort to improve this situation.

The medial forebrain bundle as a target for deep brain stimulation for obsessive-compulsive disorder.

Deep brain stimulation (DBS) is a promising putative modality for the treatment of refractory psychiatric disorders such as major depression and obsessive-compulsive disorder (OCD). Several targets have been posited; however, a clear consensus on differential efficacy and possible modes of action remain unclear. DBS to the supero-lateral branch of the medial forebrain bundle (slMFB) has recently been introduced for major depression (MD). Due to our experience with slMFB stimulation for MD, and because OCD might be related to similar dysfunctions of the reward system, treatment with slMFB DBS seams meaningful. Here we describe our first 2 cases together with a hypothetical mode of action. We describe diffusion tensor imaging (DTI) fiber tractographically (FT)-assisted implantation of the bilateral DBS systems in 2 male patients. In a selected literature overview, we discuss the possible mode of action. Both patients were successfully implanted and stimulated. The follow-up time was 12 months. One patient showed a significant response (Yale-Brown Obsessive-Compulsive Scale [YBOCS] reduction by 35%); the other patient reached remission criteria 3 months after surgery (YBOCS<14) and showed mild OCD just above the remission criterion at 12 months follow-up. While the hypermetabolism theory for OCD involves the cortico-striato-thalamo-cortical (CSTC) network, we think that there is clinical evidence that the reward system plays a crucial role. Our findings suggest an important role of this network in mechanisms of disease development and recovery. In this uncontrolled case series, continuous bilateral DBS to the slMFB led to clinically significant improvements of ratings of OCD severity. Ongoing research focuses on the role of the reward system in OCD, and its yet-underestimated role in this underlying neurobiology of the disease.

Quality of life changes following inpatient and outpatient treatment in obsessive-compulsive disorder: a study with 12 months follow-up.

BACKGROUND: Quality of life (QoL) is increasingly recognized as a critical outcome parameter in mental health studies. The aim of this study was to investigate different domains of the QoL in persons with obsessive-compulsive disorder (OCD) before and after a multimodal, disorder-specific in- and outpatient treatment. METHODS: Data of 73 persons with OCD treated in an inpatient setting followed by outpatient treatment were analyzed. The World Health Organization Quality of Life abbreviated (a multidimensional measure of the QoL) and the Beck Depression Inventory were administered prior to (baseline) and 12 months after the inpatient treatment (follow-up). RESULTS: At baseline, participants reported a significantly diminished psychological, social, physical, and global QoL compared to the German general population. Environmental QoL was not impaired in the present sample. The QoL was significantly improved at follow-up, except for social QoL, but remained below norm values. The QoL improvement was predicted by improvements of depressive symptoms. CONCLUSIONS: The results indicate that persons with OCD suffer from a very low QoL. The QoL was significantly improved after 12 months of intensive state-of-the-art treatment. However, the QoL indices remained considerably lower than population norm values, indicating the need for additional research into novel treatment options for persons with OCD.

Relevance of orbitofrontal neurochemistry for the outcome of cognitive-behavioural therapy in patients with obsessive-compulsive disorder.

Since the advent of non-invasive methods such as proton magnetic resonance spectroscopy ((1)H-MRS), obsessive-compulsive disorder (OCD) has been increasingly associated with an altered composition of neurometabolites and neurotransmitters in several brain areas. Particularly, Inositol has not only been implicated in OCD pathophysiology, but also shown effective in pilot studies in therapy-refractory OCD patients. However, the relevance of regional brain neurochemistry for therapy outcome has not yet been investigated. Whereas numerous neuroimaging findings support a dysfunction of the orbitofrontal cortex (OFC) in OCD, MR-spectroscopic investigations of this region are missing. (1)H-MRS and psychometric measurements were obtained from twenty unmedicated patients with OCD, subsequently enrolled in a 3-month structured inpatient cognitive-behavioural therapy programme, and from eleven matched control subjects. Multiple regression of symptom score changes (Y-BOCS) on (myo-)inositol concentrations in three areas (right orbitofrontal cortex (OFC), right striatum and anterior cingulate cortex) was performed. The concentration of (myo-)inositol in the OFC only predicted the outcome of subsequent CBT regarding Y-BOCS score reduction (Spearman's r(s) = .81, P < 0.003, corrected). The (myo-)inositol concentration did not differ between OCD patients and healthy controls and did not change during therapy. We provide preliminary evidence for a neurochemical marker that may prove informative about a patient's future benefit from behaviour therapy. Inositol, a metabolite involved in cellular signal transduction and a spectroscopic marker of glial activity, predicted the response to CBT selectively in the OFC, adding to the evidence for OFC involvement in OCD and highlighting neurobiological underpinnings of psychotherapy.

Frontocingular dysfunction in bulimia nervosa when confronted with disease-specific stimuli.

OBJECTIVE: Bulimia nervosa (BN) is characterized by dysregulation of impulse control, in other words, uncontrolled eating. Functional neuroimaging studies have been sparse and have used variable methodologies. METHOD: Thirteen medication-free female BN patients and 13 female healthy controls were investigated by functional magnetic resonance imaging using a disease-specific food paradigm. Stimuli were rated after the scanning procedure. RESULTS: Bulimia nervosa patients showed increased fear ratings and a trend for increased disgust. Magnetic resonance imaging data of 10 BN patients could be analysed. Three BN patients had to be excluded from the analysis because of minimal blood oxygen level dependent signals. Compared with healthy controls, BN patients showed less activation of the anterior cingulate cortex, which extended into the lateral prefrontal cortex. Furthermore, the right temporal pole showed decreased reactivity. DISCUSSION: This study substantiates a key role of lateral prefrontal dysfunction in BN, a brain region involved in impulse control. Furthermore, the anterior cingulate cortex, which plays a key role in emotion processing, is dysfunctional. A major limitation of this study is the small sample size.

Amygdala hyperreactivity in restrictive anorexia nervosa.

Functional imaging studies had often investigated heterogeneous samples of anorexia nervosa (AN) patients with varying paradigms and methodologies that had resulted in divergent results. The present study aimed to examine these issues by studying a well-defined sample of restrictive AN patients with a disorder-specific paradigm which had been used previously. Subjects showed increased blood oxygen level dependent responses of the cingulate, frontal, insular and parietal cortices. Group comparisons demonstrated increased activity of the right amygdala in the sample of restrictive AN patients. Our results are in support of other recently published functional imaging studies and point to a pivotal role of the right amygdala in AN. Signals of the midcingulum were reduced in comparison to healthy controls. The constellation of increased activity of the amygdala and decreased activity of the cingulate cortex likely represents parts of a negative feedback loop of emotional processing. Disgust ratings correlated with the amygdala signal negatively, which points to the complex role of this structure within eating disorders.

Magnetic resonance spectroscopy of the anterior cingulate cortex in eating disorders.

The anterior cingulate cortex plays a key role in eating disorders (ED), but it remains an open question whether there are deviations of the neurochemistry of this region in patients with ED. Seventeen adult female patients with ED (10 with bulimia nervosa, 7 with anorexia nervosa) were compared to 14 matched female healthy controls using single voxel magnetic resonance spectroscopy of the anterior cingulate cortex. Group comparisons did not reveal any differences between patients and controls, but a positive correlation between glutamate and myo-inositol signals with "drive for thinness" in patients with bulimia nervosa was found in exploratory correlation analyses.

Voxel-based morphometry in eating disorders: correlation of psychopathology with grey matter volume.

Twenty-nine adult female patients with eating disorders (17 with bulimia nervosa, 12 with restrictive anorexia nervosa) were compared with 18 age-matched female healthy controls, using voxel-based morphometry. Restrictive anorexia nervosa patients showed a decrease of grey matter, particularly affecting the anterior cingulate cortex, frontal operculum, temporoparietal regions and the precuneus. By contrast, patients with bulimia nervosa did not differ from healthy controls. A positive correlation of "drive for thinness" and grey matter volume of the right inferior parietal lobe was found for both eating disorder groups. The strong reduction of grey matter volume in adult patients with restrictive anorexia nervosa is in line with results of adolescent patients. Contrary to other studies, this first voxel-based morphometry report of bulimic patients did not find any structural abnormalities. The inferior parietal cortex is a critical region for sensory integration of body and spatial perception, and the correlation of "drive for thinness" with grey matter volume of this region points to a neural correlate of this core psychopathological feature of eating disorders.

Test-retest reliability of event-related functional MRI in a probabilistic reversal learning task.

Repeated functional magnetic resonance imaging (fMRI) studies aim to detect changes in brain activity over time, e.g. to analyze the cerebral correlates of therapeutic interventions. This approach requires a high test-retest reliability of the measures used to rule out incidental findings. However, reliability studies, especially for cognitive tasks, are still difficult to find in the literature. In this study, 10 healthy adult subjects were scanned in two sessions, 16 weeks apart, while performing a probabilistic reversal learning task known to activate orbitofrontal-striatal circuitry. We quantified the reliability of brain activation by computing intra-class correlation coefficients. Group analysis revealed a high concordance for activation patterns in both measurements. Intra-class correlation coefficients (ICCs) were high for brain activation in the associated regions (dorsolateral prefrontal, anterior prefrontal/insular and cingulate cortices), often exceeding 0.8. We conclude that the probabilistic reversal learning task has a high test-retest reliability, making it suitable as a tool for evaluating the dynamics of deterioration in orbitofrontal-striatal circuitry, e.g. to illustrate the course of a psychiatric disorder.

Reversal learning as a neuropsychological indicator for the neuropathology of obsessive compulsive disorder? A behavioral study.

A dysfunction of the fronto-striatal loop has been associated with obsessive-compulsive disorder (OCD). Functional imaging studies suggest that reversal learning is affected by deficits in fronto-striatal brain areas and thus should be impaired in patients with OCD. The authors compared patients with OCD and healthy comparison subjects on a reversal learning task. Correlation analyses and group comparisons showing prolonged reaction times of different response parameters are associated with increasing severity of compulsions. The reversal learning task has been shown to be associated with ventral fronto-striatal brain activation by functional magnetic resonance imaging (fMRI) in healthy comparison subjects. The purpose of this article is to suggest that the reversal learning task can be used as a neuropsychiatric measurement of the ventral fronto-striatal dysfunction in OCD.