Bernardo Barahona-Correa

Obsessive-compulsive symptoms in primary focal dystonia: A controlled study†‡§

Primary focal dystonia is an idiopathic neurological disorder causing involuntary muscle contraction. Its pathophysiology probably involves the basal ganglia and cortical‐basal pathways. Primary dystonia appears to be associated with significant obsessive‐compulsive symptoms, but evidence remains scarce and contradictory. We addressed the following research questions: (1) Do primary dystonia patients have high obsessive‐compulsive symptom scores? (2) Are these symptoms more severe in dystonia than in controls with equivalent peripheral neurological disorders? and (3) Is psychopathology different in botulinum toxin‐treated and ‐untreated dystonia patients? This work was a cross‐sectional, descriptive, controlled study comprising 45 consecutive patients with primary focal dystonia (i.e., blepharospasm, spasmodic torticollis, or writers cramp) 46 consecutive patients with hemifacial spasm, cervical spondylarthropathy, or carpal tunnel syndrome, and 30 healthy volunteers. Assessment included the DSM‐IV based psychiatric interview, Symptom Checklist 90R, Yale‐Brown Obsessive‐Compulsive Scale and Checklist, and the Unified Dystonia Rating Scale. Dystonia patients had higher Yale‐Brown Obsessive‐Compulsive Symptom scores than both control groups. Dystonia patients with obsessive‐compulsive symptom scores above cut‐off for clinical significance predominantly developed hygiene‐related symptoms. Major depression and generalized anxiety disorder were the most frequent psychiatric diagnoses in primary focal dystonia. Obsessive‐compulsive disorder frequency was 6.7%. Primary focal dystonia patients have higher obsessive‐compulsive symptom scores than individuals with similar functional disabilities resulting from other neurological disorders, suggesting that obsessive‐compulsive symptoms in dystonia are not reactive to chronic disability. Dystonic muscle contractions and obsessive‐compulsive symptoms may share a common neurobiological basis related to cortical‐basal dysfunction. Psychopathology, especially obsessive‐compulsive symptoms, should be actively explored and treated in primary focal dystonia.

P01-08 - Mania, mania with delirium and delirious mania

Since Bells original description delirious mania (DM) has been repeatedly rediscovered and renamed, resulting in much confusion as to its meaning.Definitions range from mania with self-limited temporal-spatial disorientation to a fatal, delirious catatonic syndrome with euphoric mood, high fever and autonomic instability. Moreover, it remains unclear whether DM is a specific clinical entity or an unspecific, unpredictable complication of mania, and whether it is a useful diagnostic category. Objective To identify the frequency and clinical features of DM and mania with delirium. Methods We reviewed all admissions to our acute inpatient unit with mania, hypomania or mixed affective state, in 2006 and 2007. Cases with delirious features and cases with a working diagnosis of DM, were reviewed in detail. The three groups (no delirium, delirious features and DM) were compared for general demographic and clinical variables, as well as features specifically associated with DM (e.g., catatonia; nakedness; inappropriate toileting; unexplained fever, etc). Results We found 100 patients with mania, hippomania or mixed affective state. 14 had medically unexplained delirium, 4 of them with a final diagnosis of DM. DM cases (but not non-DM mania cases with delirious features) had extremely long durations of stay, acute onset, hypertermia, catatonia, autonomic instability, anarchic sleep, shouting/coprolalia, delirium persisting for over a week, and were more likely to receive ECT. Moreover, in three of them DM occurred in most manic/mixed affective episodes. Conclusion DM is a rare occurrence in bipolar disorder. It has typical clinical features and may be recurrent.

Holistic processing of faces is intact in adults with autism spectrum disorder

ABSTRACT Are face recognition difficulties in Autism Spectrum Disorders (ASD) related to impaired holistic processing? Gauthier et al. [Gauthier, I., Klaiman, C., & Schultz, R. T. (2009). Face composite effects reveal abnormal face processing in Autism spectrum disorders. Vision Research, 49, 470–478. doi:10.1016/j.visres.2008.12.007] used the face composite task in adolescents with autism and found a congruency effect that was not modulated by alignment, a result which was interpreted as reflecting qualitatively different face processing mechanisms. In the present study we tested adults with ASD in a composite face task where presentation times were manipulated and further explored whether these participants were sensitive to holistic information in faces using a new version of the composite task: VHFPT 2.0 (The Vanderbilt Holistic Face Processing Test 2.0). Results suggest that adults with ASD process faces holistically and that their facial identity processing abilities are qualitatively similar and as efficient as that of typical adults. The difference between the results of Gauthier et al. (2009) with adolescents and the results with adults here reported are interpreted in terms of a developmental delay.

34 A lesion map of secondary bipolar disorder

Objective Bipolar Disorder (BPD) is a severe mood disorder, affecting 1.5%–4.4% of the population, and manifesting as an episodic, recurrent disturbance of mood, sleep, and behaviour. Secondary BPD (SBPD) develops following a brain insult, and is traditionally associated with right frontal lobe lesions. Yet, evidence supporting this association is mostly anecdotal. Here, we use two methodologies to study the neuroanatomy of SBPD: a systematic review of SBPD cases published in the literature, and reconstitution of brain lesions from a cohort of patients with SBPD in a single 3D template brain. Method Systematic search of pubmed and WebOfScience for SBPD. For the lesion-map, data were collected from 16 consecutive patients (6 women, 10 men, mean age 60,75±14,27 years) with SBPD developing after an MRI-documented right-sided brain-lesion. For each scan we selected the sequence (T1, T2, or FLAIR) providing the best lesion discrimination. Lesions were manually segmented using MITK software.1 After segmentation, each scan was co-registered onto a template reference brain2 using 3DSlicer software.3 Co-registration applies a transformation vector along the three axes of the source image, such that its voxels match the reference brain voxels to the highest possible degree. The resulting transformation vector was then applied to the image of each segmented lesion, and all the co-registered lesions were overlapped on the template brain scan (Automated anatomical labelling atlas or John Hopkins University white matter tractography Atlas for gray- and white-matter analysis, respectively). Results 1476 articles were found in literature review, with 207 eligible cases, including 193 with focal brain lesions, mostly right-sided (84.5%) and more rarely left-sided (34.7%). Lesions were overrepresented in the frontal and temporal lobes bilaterally. In the 3D lesion-map, lesions were spread over the right hemisphere, with highest overlap in a medial area of the superior frontal gyrus (6 patients). Grey-matter quantitative mapping showed that the right superior frontal gyrus right anterior cingulate and supramarginal gyrus and right insula were lesioned in the highest number of patients (respectively 8, 7 and 6 patients). White-matter analysis highlighted the right superior longitudinal fasciculus and superior corona radiata (6 patients each), anterior corona radiata and body of corpus callosum (5 patients each). Conclusion Our systematic review confirmed that right-sided frontotemporal lesions predominate in SBPD. In our cohort lesions converged on areas of the right executive control and anterior salience networks. Both have been implicated in the neurophysiology of primary BPD.4,5

Early use of 80 Hz subthalamic stimulation in Parkinson's disease as an alternative for High-frequency stimulation induced gait changes and postural instability

Subthalamic nucleus (STN) Deep Brain Stimulation (DBS) is a well-established therapy for Parkinsons Disease (PD) motor symptoms and fluctuations. Symptomatic benefit is usually obtained through High Frequency Stimulation (HFS, 130e185 Hz). However, long-term benefit in appendicular symptoms contrasts with the relative lack of effectiveness in axial symptoms. In fact, HF STNDBS may cause freezing of gait [1] and is associated with worse dynamic postural control, and higher gait variability [2], mechanisms that could be a cause for the increase in falls reported after DBS in PD, particularly when STN is the target [3]. Low-Frequency Stimulation (LFS, at 60e80 Hz) has been suggested as a therapeutic option for patients with worsening of their gait at long-term [4]. However, early use of LFS on patients has been only reported in a small number of patients [1,5]. Most of these reports evaluated patients using UPDRS or other rating-scale based assessment of movement. There is a lack of use of inertial-sensor based measurement. We have used 80 Hz LFS in a PD patient with HFS-related gait and postural changes. We observed a reduction in falls and improvement of postural symptoms. However, besides usual rating scales, we assessed limb angular velocity during gait using an inertial sensor. This allowed us to observe a reduction in step-to-step variability in the 80 Hz situation. A 48 year-old man, diagnosed with PD 9 years before, was proposed to STN-DBS. Motor symptoms started with right hand rest tremor and bradykinesia. He suffered from motor fluctuations including wearing-off and unpredictable no-ons requiring medication every 3 hours. He scored 65 in the MDS-UPDRS III in the OFF state with moderate postural stability changes (3 points in Postural Stability item of MDS-UPDRS). After 300 mg of Levodopa, he scored 38 with a normal (0) postural stability. Besides levodopa and ropinirole, he was on trihexyphenidyl due to a dopamine-refractory tremor. He underwent bilateral implantation of DBS electrodes (Medtronic 3389 electrodes, Activa PC pulse generator) in the subthalamic nuclei, without surgical complications. With the initial programing (Right STN, monopolar stimulation with the contact

2853 – Arachnoid cyst and psychosis: a case report

Introduction Arachnoid cysts (ACs) are intra-arachnoidal space occupying lesions, typically of a benign and congenital nature. They reportedly occur in more than 1% of the population, and are usually considered incidental when found in people with psychiatric symptoms. However, some authors argue for a putative causal relationship, based mainly on reports of improvement of a co-existing mental condition after surgical decompression of a cyst. Objectives We describe a patient with schizophrenia-like psychosis and a temporal AC. Aims We will argue for the possibility of an association between the AC and psychotic symptoms. Methods We used a multidisciplinary approach to the patient, with emphasis given to diagnosis and treatment. We also reviewed the literature on the association between AC and psychosis. Results We describe a 46-year-old woman with schizophrenia-like psychotic symptoms and visual hallucinations, refractory to antipsychotic treatment (including clozapine). Magnetic resonance imaging revealed a volumous AC with mass effect on temporal parenchyma. The patient was considered eligible for possible removal of the cyst, but refused to consult with a neurosurgeon. Conclusions The meaning of ACs found in patients with psychosis remains controversial. In our case, the lesions volume and mass effect, the involvement of a region with a central role in the pathophysiology of psychosis, and the refractoriness to clozapine treatment, all argue for a causal role in the patients psychosis. Surgical decompression might have improved the patients outcome. Yet, the lack of a solid evidence-base made it ethically unacceptable to advocate for this option in a reluctant patient.

Resistant schizophrenia in a patient with epilepsy.

Psychotic syndromes associated with epilepsy are classified according to their chronological association with seizures into ictal, pos-ictal and interictal (brief or chronic) (Sachdev, 1998). Chronic interictal psychotic syndromes bear remarkable clinical similarity with primary schizophrenia and were therefore dubbed Schizophrenia-Like Psychoses of Epilepsy (SLPE). This similarity is at times so striking that some have questioned whether SLPE are not merely a coincidence (Toone, 2000). Moreover, two contradictory observations complicate our understanding of SLPE: seizures of growing intensity and frequency often precede psychotic symptoms (post-ictal psychosis) (Logsdail and Toone, 1988); alternatively, psychosis may emerge following seizure suppression and EEG normalization (“forced normalization”; Langosch and Trimble, 2002). Antipsychotic (AP) use in epilepsy is alsoproblematic: 1. APdecrease seizure threshold; 2. Many adverse effects of anticonvulsants (AC) and AP are cumulative; 3. Pharmacokinetic interactions are frequent (Koch-Stoecker, 2002); 4. SomeACmay lead tonew-onset orworsening psychotic symptoms (Xavier et al., 2000). Clozapine, indicated for treatment-resistant schizophrenia (Tandon and Fleischhacker, 2005), is particularly problematic, as it lowers seizure threshold (Jarbin et al., 2001; Langosch and Trimble, 2002).

P01-159 Autoantibodies in bipolar and cluster B personality disorders

Prevalence of depression and other common psychiatric disorders in autoimmune diseases has been extensively documented. The association between subclinical autoimmunity and behavioural or psychiatric syndromes remains less studied. The best known example is raised titres of autoantibodies with high affinity for the basal ganglia in some obsessive compulsive spectrum syndromes (e.g. Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). The possible role of autoimmunity in impulse control disorders remains understudied. We proposed to study the relation between autoimmunity, affective bipolarity and impulsive psicopathology. Methods 14 bipolar, 10 cluster B personality disorder inpatients. Titres for rheumatoid factor (RA), antithyroglobulin (ATG), antiperoxidase (APO) antinuclear (ANA), anti-neutrophil cytoplasmic (ANCA) and antistreptolysin (ASO) antibodies were measured in all subjects. Psychiatric assessment: non-structured psychiatric interview, MINI International Neuropsychiatric Interview and Millon Clinical Multiaxial Inventory-II. Results 21,4% of bipolar patients had positive ATG titre vs 11,1% in the cluster B personality group. 28,6% of bipolar patients had positive APO titre vs 22,2% in the cluster B personality group. 16,7% of bipolar patients had positive ASO titre vs 30,0% in the cluster B personality group. None of this differences reached significance. ASO titre correlated significantly with antisocial (rho=0,435, p=0,043) and autodestructive (rho=0,461, p=0,031) ratings and almost significantly with borderline (rho=0,420, p=0,052) ratings. Conclusions The results obtained partly agree with the existing studies. As far as we know a possible correlation between ASOs and impulsive behaviour has not been previously described. The results obtained call for further investigation in the subject.

FC02-03 Obsessive-compulsive symptoms in primary dystonia: Reactive and psychogenic or primary and neurophysiological?

Introduction Primary dystonia (PDy) is an idiopathic neurological disorder causing involuntary muscle contraction. Its pathophysiology is believed to involve basal-ganglia (BG) dysfunction. A possible association with Obsessive-compulsive symptoms (OCS) is regarded as further evidence of BG involvement but remains controversial due to contradictory research data. We proposed to answer three questions: 1. Do PDy patients have high OCS scores? 2. Are OCS in PDy reactive? 3. Does botulinum toxin treatment (BT) influence PDy psycopathology? Subjects 45 patients with blepharospasm, spasmodic torticollis, writers cramp; 43 patients with hemifacial spasm, cervical spondilarthropathy, peripheral hand neuropathy; 27 healthy volunteers. Assessment: non-structured DSM-IV based psychiatric interview; Symptom Checklist 90 Revised (SCL-90R); Yale-Brown Obsessive-Compulsive Scale (YBOCS); Unified Dystonia Rating Scale (UDRS). Results PDy patients scored significantly higher than controls and healthy controls on the YBOCS (11.1 ± 7.24; 5.98 ± 4.33; 2.07 ± 0.92, both p Discussion Higher ratings of OCS but not of depression, anxiety or somatization in PDy patients suggests a neurophysiological origin for OCS in PDy. However, diseased controls also scored higher than healthy subjects, suggesting that OCS may nevertheless be partly reactive in PDy. BT may decrease anxiety/depressive symptoms but not OCS, lending further strength to a possible neurophysiological aetiology for OCS in PDy.