Annett Höse

Gray matter reduction associated with psychopathology and cognitive dysfunction in unipolar depression: A voxel-based morphometry study

BACKGROUND Functional neuroimaging studies on both cognitive processing and psychopathology in patients with major depression have reported several functionally aberrant brain areas within limbic-cortical circuits. However, less is known about the relationship between psychopathology, cognitive deficits and regional volume alterations in this patient population. METHODS By means of voxel-based morphometry (VBM) and a standardized neuropsychological test battery, we examined 15 patients meeting DSM-IV criteria for major depression disorder and 14 healthy controls in order to investigate the relationship between affective symptoms, cognitive deficits and structural abnormalities. RESULTS Patients with depression showed reduced gray matter concentration (GMC) in the left inferior temporal cortex (BA 20), the right orbitofrontal (BA 11) and the dorsolateral prefrontal cortex (BA 46). Reduced gray matter volume (GMV) was found in the left hippocampal gyrus, the cingulate gyrus (BA 24/32) and the thalamus. Structure-cognition correlation analyses revealed that decreased GMC of the right medial and inferior frontal gyrus was associated with both depressive psychopathology and worse executive performance as measured by the Wisconsin Card Sorting Test (WCST). Furthermore, depressive psychopathology and worse performance during the WCST were associated with decreased GMV of the hippocampus. Decreased GMV of the cingulate cortex was associated with worse executive performance. LIMITATIONS Moderate illness severity, medication effects, and the relatively small patient sample size should be taken into consideration when reviewing the implications of these results. CONCLUSIONS The volumetric results indicate that regional abnormalities in gray matter volume and concentration may be associated with both psychopathological changes and cognitive deficits in depression.

Working memory dysfunction in schizophrenia compared to healthy controls and patients with depression: evidence from event-related fMRI.

Studies on working memory (WM) dysfunction in schizophrenia have reported several functionally aberrant brain areas including the lateral prefrontal cortex, superior temporal areas and the striatum. However, less is known about the relationship of WM-dysfunction, cerebral activation, task-accuracy and diagnostic specificity. Using a novel WM-task and event-related functional magnetic resonance imaging (fMRI), we studied healthy control subjects (n=17) and partially remitted, medicated inpatients meeting DSM-IV criteria for schizophrenia (n=19) and major depressive disorder (n=12). Due to the event-related technique, we excluded incorrectly performed trials, thus controlling for accuracy-related activation confounds. Compared with controls, patients with schizophrenia showed less activation in frontoparietal and subcortical regions at high cognitive load levels. Compared with patients with depression, schizophrenic patients showed less prefrontal activation in left inferior frontal cortex and right cerebellum. In patients with schizophrenia, a lack of deactivation of the superior temporal cortex was found compared to both healthy controls and patients with depression. Thus, we could not confirm previous findings of impaired lateral prefrontal activation during WM performance in schizophrenic patients after the exclusion of incorrectly performed or omitted trials in our functional analysis. However, superior temporal cortex dysfunction in patients with schizophrenia may be regarded as schizophrenia-specific finding in terms of psychiatric diagnosis specificity.

Volumetric abnormalities associated with cognitive deficits in patients with schizophrenia

While functional neuroimaging studies on attention and executive function in schizophrenia have reported several functionally aberrant cortical regions, less is known about the relationship of cognitive impairment and regional volume alterations. In order to investigate the relationship between cognitive impairment and structural alterations, we studied healthy control subjects and partially remitted, medicated inpatients with DSM-IV schizophrenia using voxel-based morphometry (VBM) and a standardised neuropsychological test battery. Schizophrenic patients showed reduced grey matter (GM) density in the bilateral temporal cortex, the left inferior parietal lobule, the cingulate gyrus and the left middle frontal gyrus. Reduced GM volume was additionally found in the left hippocampal gyrus and the right superior frontal cortex. Reduced white matter density was found in the posterior corpus callosum. Structure-cognition regression analyses revealed that decreased GM density of the left inferior parietal and the right middle temporal cortex was associated with worse performance during divided attention. Worse performance during the spatial span was associated with volumetric abnormalities of the hippocampal gyrus. These results indicate that regional abnormalities in brain structure may offer an account for some impaired cognitive domains in patients with schizophrenia, while other cognitive domains may remain relatively less affected by volumetric alterations.

Changes over time in frontotemporal activation during a working memory task in patients with schizophrenia

Studies on working memory (WM) dysfunction in schizophrenia have reported several functionally aberrant brain areas including prefrontal and temporal cortex. Longitudinal studies have shown changes in prefrontal activation during treatment. We used event-related functional magnetic resonance imaging and a parametric verbal WM task to investigate cerebral function during WM performance in healthy subjects and medicated patients with schizophrenia with an acute symptom exacerbation. Patients were scanned twice: within the first week after admission to the hospital and after 7-8 weeks of a multimodal treatment including atypical antipsychotic agents. There were no differences in activation of lateral prefrontal regions in patients relative to healthy controls neither at baseline nor after 7-8 weeks. Controls showed relatively more activation in parietal, striatal and cerebellar regions. In patients with schizophrenia, frontotemporal function was bilaterally enhanced after 7-8 weeks. This activation change was associated with improved accuracy in a verbal WM task, improved verbal WM-span and symptom reduction as measured by the BPRS global score and the BPRS factor for thought disturbance. Although we could not replicate findings of functional hypofrontality in the patients with schizophrenia, frontotemporal activation changed with treatment and was associated with verbal WM performance and significant reduction of psychopathology.

The neural correlates of movement intentions: a pilot study comparing hypnotic and simulated paralysis

The distinct feeling of wanting to act and thereby causing our own actions is crucial to our self-perception as free human agents. Disturbances of the link between intention and action occur in several disorders. Little is known, however, about the neural correlates of wanting or intending to act. To investigate these for simple voluntary movements, we used a paradigm involving hypnotic paralysis and functional magnetic resonance imaging. Eight healthy women were instructed to sequentially perform left and right hand movements during a normal condition, as well as during simulated weakness, simulated paralysis and hypnotic paralysis of the right hand. Right frontopolar cortex was selectively hypoactivated for attempted right hand movement during simulated paralysis while it was active in all other conditions. Since simulated paralysis was the only condition lacking an intention to move, the activation in frontopolar cortex might be related to the intention or volition to move.

Psychiatrische Notfälle im Notfall- und Rettungswesen@@@Psychiatric emergencies in emergency and rescue services: Grundlagen der Diagnostik und Therapie@@@Fundamentals of diagnosis and treatment

ZusammenfassungVor dem Hintergrund einer wirksamen Pharmakotherapie und vielfältiger wohnortnaher Therapieangebote leben seelisch Kranke vermehrt in der eigenen Wohnung, in Wohngemeinschaften oder bei ihrer Familie. Dementsprechend erfordern psychiatrische Notfälle, die vor der Ära der Psychiatrie-Enquête von den Landes- und Bezirkskrankenhäusern aufgefangen wurden, heute nicht selten den Einsatz des Notarztes, der sich als Anästhesist, Internist oder Chirurg auf die einschlägigen Zustandsbilder oft unzureichend vorbereitet fühlt. In diesem Beitrag werden diejenigen psychiatrischen Syndrome dargestellt, die typischerweise zu Notarzteinsätzen Anlass geben, etwa akute Suizidalität, Selbstbeschädigungen und Intoxikationen, Angst-, Erregungs- und Verwirrtheitszustände, akute Psychosen und Katatonien. Es werden wichtige Grundsätze der prästationären psychiatrischen Notfallbehandlung erläutert und Besonderheiten des psychiatrischen Notfalls diskutiert, wie die Behandlung gegen den erklärten, aber unwirksamen Willen des Patienten und die rechtlichen Grundlagen einer Zwangseinweisung.AbstractWhile psychiatric care before the German ‘psychiatry enquête’ (inquiry) was mostly provided by psychiatric institutions, a considerable number of patients with mental disorders are nowadays able to live independently with their families, or in housing facilities provided by the general community. This process has additionally been facilitated by effective drug treatment options and a growing improvement of community-based medical care. Thus, psychiatric emergency interventions outside an institutionalized environment increasingly require the assignment of less specialized emergency personnel, e.g. anaesthetists, surgeons or internists, who may feel inadequately prepared for providing sufficient psychiatric emergency care. This article describes relevant psychiatric syndromes which often require the acute intervention of an emergency physician. Moreover, this overview elucidates basic principles of ambulatory psychiatric emergency treatment, including suicidal or self-injurious behaviour, intoxication with psychotropic drugs, states of panic and agitation, acute psychotic syndromes and catatonia. With respect to these emergency settings, several specific characteristics, such as coercive treatment and other related forensic aspects are illustrated and discussed.

Psychiatrische Notfälle im Notfall- und Rettungswesen

ZusammenfassungPsychiatrische Notfälle gehören zu den häufigsten Ursachen für Notarzteinsätze, Behandlungsleitlinien fehlen jedoch bisher. Angetroffen werden Suizidalität, Selbstbeschädigungen und Intoxikationen, Angst- und Erregungszustände, akute Psychosen, Delirien und Verwirrtheitszustände sowie katatone Syndrome. In der Notfallsituation beschränkt sich die Differenzialdiagnose auf den Ausschluss ursächlicher organischer Faktoren. Psychische Störungen sind typischerweise mit mangelnder Krankheitseinsicht verbunden. Im Einzelfall können Kranke feindselig bis zum tätlichen Angriff sein. Die Beachtung der Sicherheit des Kranken, aber auch des notärztlichen Teams ist eine Grundvoraussetzung für eine erfolgreiche Notfallintervention. Eine Deeskalation kann in vielen Fällen durch geschickte Gesprächsführung erreicht werden.AbstractPsychiatric emergencies rank third when considering all emergency medical situations outside of medical care. However, treatment guidelines are not yet available. Psychiatric emergencies that are frequently encountered are suicidal crises, intoxications, states of panic and agitation, delirious syndromes and catatonia. In emergency psychiatric situations, it is pivotal to exclude possible organic aetiologies. Psychiatric patients are often uncooperative, and they may even react aggressively. To be aware of the risks is crucial for a successful intervention. In many cases, the psychiatric emergency situation can be de-escalated by the use of adequate conversation techniques.

Marginal case of a practice fee for psychiatric emergency service

Since 1 January 2004, the German Act for the Modernisation of Health Insurance (GMG) has regulated collection of a so-called practice fee-a charge to patients for their first outpatient health care in any given quarter. We report the case of a slightly inebriated patient who, against his will, was taken to a psychiatric outpatient department by local authorities, where he had to pay the quarterly charge of 10 EUR. Considering that he was forced and therefore had to pay the fee against his will, the present regulation is being discussed with respect to legal and moral implications in psychiatric emergency cases.

Grenzfälle der Praxisgebühr im psychiatrischen Notfalldienst@@@Legal questions of a German medical care fee

Since 1 January 2004, the German Act for the Modernisation of Health Insurance (GMG) has regulated collection of a so-called practice fee-a charge to patients for their first outpatient health care in any given quarter. We report the case of a slightly inebriated patient who, against his will, was taken to a psychiatric outpatient department by local authorities, where he had to pay the quarterly charge of 10 EUR. Considering that he was forced and therefore had to pay the fee against his will, the present regulation is being discussed with respect to legal and moral implications in psychiatric emergency cases.

Grenzfälle der Praxisgebühr im psychiatrischen Notfalldienst

Since 1 January 2004, the German Act for the Modernisation of Health Insurance (GMG) has regulated collection of a so-called practice fee-a charge to patients for their first outpatient health care in any given quarter. We report the case of a slightly inebriated patient who, against his will, was taken to a psychiatric outpatient department by local authorities, where he had to pay the quarterly charge of 10 EUR. Considering that he was forced and therefore had to pay the fee against his will, the present regulation is being discussed with respect to legal and moral implications in psychiatric emergency cases.