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.

Psychiatric morbidity and predisposing factors in a primary care population in Madrid.

OBJECTIVES: The aim of this article is to estimate the prevalence of mental disorders in patients in primary care centers in an urban area of Madrid and to study possible associated risk factors. METHODS: Cross-sectional month prevalence was evaluated in two phases in an urban area of Madrid. The sample for the first phase included 635 individuals (aged 18-65 years), and the second phase included 320 individuals. Socio-demographic variables (age, sex, educational level, living conditions and country of origin) and clinical variables (psychiatric diagnosis and level of psychosocial stress) were studied. The instruments used for screening were the General Health Questionnaire (GHQ)-28 item questionnaire and the MULTICAGE-CAD 4test. The Mini International Neuropsychiatric Interview (M.I.N.I.) was used in the second phase (in 'possible cases' and 20% of the 'non-cases'). Prevalence was calculated using weighted logistic regression with the observed sampling fractions of the patients in study phase 2 as sample weights. RESULTS AND CONCLUSIONS: The month prevalence of mental disorders was 31.3% (95% confidence interval (CI) = [27.6, 35.2]). Anxiety disorders were the most frequent diagnoses with a prevalence of 22.4% (95% CI = [17.8, 27.1]), followed by depressive disorders (16.6%; 95% CI = [12.9, 20.3]), substance abuse or dependence disorders (5.6%; 95% CI = [3.2, 6.9]) and posttraumatic stress disorder (PTSD; 4.4%; 95% CI = [2.0, 2.8]). Factors associated with mental disorders were the presence of stressful life events in the previous 12 months, Latin American region of origin, being woman aged 25 and 34 years and having a low education level.

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.

Una alternativa de auditoría en psiquiatría más cercana a Europa y al residente / An alternative way of auditing in psychiatry, closer to Europe and the trainee

Introducción. En este trabajo se presenta la experiencia de una auditoría externa piloto realizada en el Servicio de Psiquiatría del Hospital Príncipe de Asturias de Alcalá de Henares, y los beneficios derivados del modelo de la UEMS (Unión Europea de Médicos Especialistas) aquí expuesto. En España, los sistemas de evaluación y calidad de formación de los especialistas están bien establecidos. Existen todavía aspectos que se pueden mejorar. El modelo de auditoría de la UEMS reconoce la diversidad de programas de los distintos países miembros, pero trata de estandarizar la calidad de la formación mediante el proceso de auditorías externas. Objetivo. Mostrar un modelo más centrado en la formación del residente, con mayor participación de éste y de las sociedades profesionales y científicas. Materiales y métodos. Se expone la experiencia de auditoría externa realizada en una unidad de psiquiatría siguiendo el modelo de la UEMS. Resultados. Se analizan los beneficios de este tipo de auditorías en el proceso de revisión de la formación de los residentes. Conclusión. Este tipo de auditorías favorece la supervisión del sistema de formación de residentes y promueve el acercamiento a los estándares de calidad de la Unión Europea, garantizando que los residentes obtengan el mejor nivel de formación (AU)

Introduction. This paper relates the experience of a pilot external audit visit conducted at the University Hospital Príncipe de Asturias in Alcalá de Henares and its benefits, following the UEMS (Union Européenne des Médecins Spécialistes) model. In Spain, systems of evaluation and quality of the specialists training are well established. Some aspects can be still improved. The UEMS model of audit, recognises the diversity of programs in member countries, but is trying to standardize the quality of training through external audits. Aim. To show a model that mainly focuses on the training of residents with a greater participation of them and professional and scientific societies. Materials and methods. To exhibit the experience of an external audit visit in a Psychiatry unit following the UEMS model. Results. Multiple benefits derive from this kind of audits in the revision and improvement of the residents' training. Conclusion. This kind of audits provides an assessment of the resident's training system and encourages movement towards European Union standards of quality, ensuring that all trainees get the highest standard of training which can be provided (AU)

Changes in the MEG background activity in patients with positive symptoms of schizophrenia: spectral analysis and impact of age.

The frequency spectrum of the magnetoencephalogram (MEG) background activity was analysed in 15 schizophrenia (SCH) patients with predominant positive symptoms and 17 age-matched healthy control subjects using the following variables: median frequency (MF), spectral entropy (SpecEn) and relative power in delta (RPδ), theta (RPθ), lower alpha (RPα1), upper alpha (RPα2), beta (RPß) and gamma (RPγ) bands. We found significant differences between the two subject groups in the average level of MF and RPγ in some regions of the scalp. Additionally, the MF, SpecEn, RPß and RPγ values of SCH patients with positive symptoms had a different dependence on age as compared with the results of control subjects, suggesting that SCH affects the way in which the brain activity evolves with age. Moreover, we also classified the MEG signals by means of a cross-validated feature selection process followed by a logistic regression. The subjects were classified with 71.3% accuracy and an area under the ROC curve of 0.741. Thus, the spectral and classification analysis of the MEG in SCH may provide insights into how this condition affects the brain activity and may help in its early detection.

No effect of polymorphisms in the non-duplicated region of the CHRNA7 gene on sensory gating P50 ratios in patients with schizophrenia and bipolar disorder.

Previous research has reported that bipolar disorder and schizophrenic patients evidence sensory gating deficits. The use of intermediate phenotypes may facilitate genetic studies. Four single nucleotide polymorphisms (SNPs) located on the non-duplicated region of the alpha-7 nicotinic receptor gene (CHRNA7) were genotyped in 95 healthy subjects, 127 bipolar disorder and 153 schizophrenic patients. We evaluated the association of these polymorphisms with P50 evoked potential measures. Our results do not support a role for the candidate gene in this neurophysiological disturbance.

Complexity and schizophrenia.

Complexity estimators have been broadly utilized in schizophrenia investigation. Early studies reported increased complexity in schizophrenia patients, associated with a higher variability or "irregularity" of their brain signals. However, further investigations showed reduced complexities, thus introducing a clear divergence. Nowadays, both increased and reduced complexity values are reported. The explanation of such divergence is a critical issue to understand the role of complexity measures in schizophrenia research. Considering previous arguments a complementary hypothesis is advanced: if the increased irregularity of schizophrenia patients' neurophysiological activity is assumed, a "natural" tendency to increased complexity in EEG and MEG scans should be expected, probably reflecting an abnormal neuronal firing pattern in some critical regions such as the frontal lobes. This "natural" tendency to increased complexity might be modulated by the interaction of three main factors: medication effects, symptomatology, and age effects. Therefore, young, medication-naïve, and highly symptomatic (positive symptoms) patients are expected to exhibit increased complexities. More importantly, the investigation of these interacting factors by means of complexity estimators might help to elucidate some of the neuropathological processes involved in schizophrenia.

Aspectos neuropsicológicos, clínicos y sociales de dos casos de síndrome de Capgras / Neuropsychological, clinical and social issues in two patients with capgras syndrome

En este trabajo se presentan dos casos de Síndrome de Capgras (SC), a los que se les han realizado pruebas de neuroimagen y neuropsicológicas, cuyos resultados se contrastan con las teorías etiopatogénicas existentes. En la actualidad, sigue sin explicarse satisfactoriamente la etiopatogenia del SC aunque se han propuesto diversos e interesantes modelos holísticos que tratan de aprehender algunos aspectos de las diferentes perspectivas teóricas, que se discutirán. Así mismo, se analizan las consecuencias psicosociales que la agresividad ha generado en estos dos enfermos y que han sido poco reconocidas en la literatura. El SC nos debería alertar acerca del riesgo de agresividad así como de sus consecuencias desfavorables, con el fin de tomar las medidas oportunas para prevenirlas (AU)

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 (AU)

De la experiencia corporal a la identidad corporal / No disponible

No disponible

Percepción, vivencia e identidad corporales / Perception, experience and body identity

El médico ha de conocer al enfermo en la enfermedad y no sólo a la enfermedad en el enfermo, desde la doble perspectiva del cuerpo como objeto y el cuerpo como sujeto. Esto también afecta al enfermo que ha de enfrentarse a la realidad de tener un cuerpo que irrumpe en su conciencia como amenaza vital, como fuente de malestar y discapacidad y el ser un cuerpo. (Marcel). El cuerpo humano en su doble vertiente ha sido y es un gran desconocido, cuando no un gran ultrajado a pesar del hecho somos nuestro cuerpo y nuestro cuerpo es cada uno de nosotros. A veces no nos sentimos como somos y surgen así confrontaciones, unas veces más normales, otras más morbosas, que obligan al clínico a consideraciones éticas complejas y al científico a aceptar una patología de la identidad personal. El dualismo considera que hay en nosotros dos sustancias una que nos distingue de los demás seres y del resto de los individuos de la especie humana, el alma, vida psíquica, mente o conciencia, y otra más insustancial, el cuerpo. La primera está destinada a dominar a éste, a sobrevivirle tras la muerte cuando éste, ya cadáver destinado a la putrefacción, es sepultado, incinerado o arrojado a la profundidad del mar. Este dualismo pretende, explicar el origen del mal y la actitud para derrotarlo, y lo hace con eficacia. Esta antropología tiene raíces muy antiguas (los Upvanisvads, en los textos órficos, en Platón), es el núcleo del pensamiento gnóstico y la base de la ciencia moderna desde Descartes. Algunas perspectivas monistas son un dualismo enmascarado o una falacia mereológica, según la cual, el cerebro es consciente, cuando el que es consciente es el sujeto, aunque sin su cerebro no podría serlo, y por eso se propone una nueva perspectiva, monismo quiasmótico o janicular que considera el valor adaptativo de enfocar la realidad desde dos perspectivas, como universo físico y mundo de relaciones interpersonales. En las agnosias y en el miembro fantasma existe una confrontación entre el cuerpo objeto y el cuerpo sujeto que ha permitido investigar cómo es la percepción del propio cuerpo y cómo genera el cerebro el esquema y la imagen corporal. El estudio de la vivencia corporal desde la perspectiva de la fenomenología y de la psiquiatría antropológica permite profundizar en el conocimiento de alteraciones de la experiencia del propio cuerpo en diferentes enfermedades mentales, en especial en aquellas en las que se presenta una confrontación entre cuerpo e identidad personal obliga a considerar el proceso de la identificación individual y una categoría de trastornos de la identidad personal en la que se incluirían el trastorno dismórfico corporal, la eritrofobia, la anorexia nerviosa, el trastorno de identidad de integridad corporal y los de naturaleza sexual (transexualismo, transvestis mono fetichista, trastorno de identidad sexual en la infancia) (AU)

The 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 in substancial 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 that will 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 amereologic 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 in to 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, non-fetishistic transvestism, gender identity disorder during childhood (AU)

Diagnosis and clinical features of major neuropsychiatric disorders in HIV infection.

The prevalence of neuropsychiatric disorders is high in HIV-infected individuals. Despite being frequent, these disorders are often underdiagnosed and undertreated. Many of these conditions show differential clinical features as compared with HIV-uninfected individuals. The main neuropsychiatric disorders observed in HIV patients are described. Routine psychiatric evaluation of HIV-infected persons may enhance adherence to antiretroviral treatment, decrease risk behaviors, reduce medical complications and use of hospital services and, ultimately, may improve the quality of life.

Lempel-Ziv complexity in schizophrenia: a MEG study.

OBJECTIVE: The neurodevelopmental-neurodegenerative debate is a basic issue in the field of the neuropathological basis of schizophrenia (SCH). Neurophysiological techniques have been scarcely involved in such debate, but nonlinear analysis methods may contribute to it. METHODS: Fifteen patients (age range 23-42 years) matching DSM IV-TR criteria for SCH, and 15 sex- and age-matched control subjects (age range 23-42 years) underwent a resting-state magnetoencephalographic evaluation and Lempel-Ziv complexity (LZC) scores were calculated. RESULTS: Regression analyses indicated that LZC values were strongly dependent on age. Complexity scores increased as a function of age in controls, while SCH patients exhibited a progressive reduction of LZC values. A logistic model including LZC scores, age and the interaction of both variables allowed the classification of patients and controls with high sensitivity and specificity. CONCLUSIONS: Results demonstrated that SCH patients failed to follow the "normal" process of complexity increase as a function of age. In addition, SCH patients exhibited a significant reduction of complexity scores as a function of age, thus paralleling the pattern observed in neurodegenerative diseases. SIGNIFICANCE: Our results support the notion of a progressive defect in SCH, which does not contradict the existence of a basic neurodevelopmental alteration.

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.

Practicing exorcism in schizophrenia.

Historically, many cases of demonic possession have masked major psychiatric disorder. Our aim is to increase awareness that symptoms of schizophrenia are still being classified as demonic possession by priests today. We report the case of a 28-year-old patient who had been diagnosed 5 years previously with paranoid schizophrenia (treated with clozapine, risperidone, ziprasidone and onlanzapine without a complete response) and was also receiving treatment in a first episode psychosis unit in Spain. The patient was led to believe by priests that her psychotic symptoms were due to the presence of a demon. This was surprising because some of the priests were from the Madrid archdiocese and knew the clinical situation of the patient; however, they believed that she was suffering from demonic possession, and she underwent multiple exorcisms, disrupting response to clinical treatment. Patient insight is an important factor in response to treatment, so religious professionals should encourage appropriate psychiatric treatment and learn about mental illnesses.

Otitis and autism spectrum disorders.

The case of a 5-year-old child diagnosed as having pervasive developmental disorder (PDD), autistic type, from age 1 is reported. After surgery of vegetation in middle ear for repetitive otitis, the child presented an improvement in autistic behaviours, previously expressed as impaired social interactions, qualitative abnormalities in communication, a marked delay in language development, echolalia, stereotypies and self-aggressive behaviours. The aim of this paper is to bring attention to occurrences of misdiagnosis of PDD, which can occur when an adequate screening of the autistic syndrome is not realised. The result of the surgery was an improvement in autistic behaviours, despite the persistence of less severe autistic traits that may be more closely related to Asperger's syndrome.

Factors predicting drop-out in community mental health centres.

This study aimed to identify treatment, therapist and patient factors associated with dropping out of treatment in four outpatient mental health services. The experimental group comprised all 789 individuals who attended for the first time the mental health services during one year and dropped out of treatment in the same year or during the two following ones. The control group consisted of the same number of individuals, chosen at random from patients who, in the same year, attended for the first time the services and did not subsequently drop out of treatment. The overall drop-out rate was 33.2%. According to logistic regression analysis, the predictive factors of dropping out were: being treated in a particular centre, the involvement of more than one therapist in treatment, having no previous history of psychiatric disorders, being young and being male.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision.

In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.

What can be learnt from the natural history of anxiety disorders?

BACKGROUND: There is insufficient knowledge of the long-term course of panic disorder (PD). AIM: To determine the long-term course and prognostic variables in patients diagnosed with PD. METHODS: Patients who were diagnosed of anxiety states between 1950 and 1961, were examined using a structured clinical interview (SCID-DSM-III-R) between 1984 and 1988 (n=144). A re-examination was performed in the period 1997-2001 (N=125). Mean length of follow-up from onset was 47 years. RESULTS: PD tends to be chronic. Among those who recovered, 93% had done so already by the 1980s. Lack of regular treatment compliance, progression to agoraphobia and number of episodes of panic disorder were associated with worse outcome. Agoraphobia without panic attacks and somatization symptoms were the most prevalent clinical status at follow-up. CONCLUSION: After several decades, participants improve with regard to number of panic attacks, though most continue to have residual symptoms.

Increased occipital delta dipole density in major depressive disorder determined by magnetoencephalography.

OBJECTIVE: To test the hypothesis that there is increased low-frequency activity located predominantly in the frontal lobe in patients with major depressive disorder using magnetoencephalography. METHODS: We carried out an unmatched or separate sampling case-control study of 31 medication-free patients who met the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), criteria for major depressive disorder and were outpatients of the Hospital Central de la Defensa, Madrid, and 22 healthy control subjects with no history of mental illness. A logistic regression analysis was employed to examine the predictive value of magnetoencephalography dipole density scores in the diagnosis of depression. We attempted to locate generators of focal magnetic slow waves by employing a single moving dipole model and by calculating dipole densities in prefrontal, frontal, parietal, temporal and occipital areas. The study lasted from February 2001 to January 2003. RESULTS: Only 2 dipole density scores, right occipital delta and left temporal delta, were significantly related to depression. According to the comparison of univariate and multivariate models and odds ratios, the right occipital delta dipole density is the factor with the greatest predictive power for depression, and the only one to show a significant correlation with severity of depression. CONCLUSIONS: We did not find any frontal lobe functional alteration. Our study provides, to the best of our knowledge, the first evidence of abnormal focal magnetic low-frequency activity in the occipital lobe of untreated patients with depression. Increased occipital lobe delta dipole density seems to be a reliable risk factor for depression, which correlates with disease severity according to the Hamilton Rating Scale for Depression.