Charles-Siegfried Peretti

Current research on cognitive aspects of anxiety disorders

Purpose of review Cognitive dysfunction is frequently reported in anxiety disorders. Our aim is to describe recent advances concerning these cognitive aspects. Recent findings Cognitive dysfunction in anxiety disorders can be classified into four domains. The first concerns executive functions, mainly attentional processes. The second concerns memory, including deficits in working, episodic, and autobiographical memory. The third encompasses maladaptive cognitions, or thoughts and beliefs. Finally, a burgeoning area of research (mainly in obsessive–compulsive disorder and posttraumatic stress disorder) concerns metacognitions, or thoughts and beliefs about ones own thoughts and beliefs. All of these dysfunctions may contribute to maintain or aggravate anxiety disorders. When developing and implementing interventions, researchers and clinicians alike must consider these cognitive aspects, and may need to tailor their approaches accordingly. Summary Advances have clearly been made in the elucidation of the cognitive functioning associated with anxiety disorders. It remains unclear if particular cognitive profiles can help to distinguish anxiety disorders from one another, although emerging evidence suggests this may be the case. Further clarification will add to our understanding of the development and maintenance of these disorders, and may provide targets for future therapy and endophenotypes.

Management of post traumatic stress disorder after childbirth: a review

Prevalence and risk factors for the development of post traumatic stress disorder (PTSD) after childbirth is well described in the literature. However, its management and treatment has only begun to be investigated. The aim of this article is to describe the studies that examine the effects of interventions on PTSD after childbirth. MedLine, PILOTS, CINAHL and ISI Web of Science databases were systematically searched for randomised controlled trials, pilot studies and case studies using key words related to PTSD, childbirth, treatment and intervention. The reference lists of the retrieved articles were also used to supplement the search. A total of nine studies were retrieved. Seven studies that examined debriefing or counselling were identified; six randomised controlled trials and one pilot study. Also found were one case report describing the effects of cognitive behavioural therapy (CBT) on two women, and one pilot study of eye movement desensitisation and reprocessing (EMDR). Overall, there is limited evidence concerning the management of women with PTSD after childbirth. The results agree with the findings from the non-childbirth related literature: debriefing and counselling are inconclusively effective while CBT and EMDR may improve PTSD status but require investigation in controlled trials before conclusions could be drawn.

Cognitive Impairment in Systemic Lupus Erythematosus Women with Elevated Autoantibodies and Normal Single Photon Emission Computerized Tomography

Background: Systemic lupus erythematosus (SLE) is known to induce psychiatric disorders, from psychoses to maladaptive coping. Brain autoantibodies were proposed to explain SLE neuropsychiatric disorders and found to be elevated before the onset of clinical symptoms. We assessed cognition in Caucasian SLE women with elevated autoantibodies without overt neuropsychiatric syndromes, in conjunction with single photon emission computerized tomography (SPECT). Methods: 31 women meeting SLE criteria of the American College of Rheumatology (ACR) were included. Patients who met the ACR neuropsychiatric definition were excluded. Matched controls were 23 healthy women from the Champagne-Ardenne region, France. Participants completed neuropsychological and autoantibodies measurements, and 19 completed SPECT. Results: 61% (19/31) of women with SLE and 53% (9/17) of those with normal SPECT had significant global cognitive impairment defined as 4 T-scores <40 in cognitive tests, compared to 0% (0/23) of controls. SLE women also had significantly greater cognitive dysfunction (mean T-score) on the Wechsler Adult Intelligence Scale (WAIS) visual backspan, Trail Making Test A and B, WAIS Digit Symbol Substitution Test and Stroop Interference, compared to controls. Elevated antinuclear antibody correlated with impairment in the WAIS visual span, WAIS visual backspan, and cancellation task; elevated anti-double-stranded DNA antibody and anticardiolipin correlated respectively with impairment in the Trail Making Test A and WAIS auditive backspan. Two SLE women had abnormal SPECT. Conclusions: A high prevalence of cognitive deficits was found in Caucasian SLE women compared to normal women, which included impairment in cognitive domains important for daily activities. Elevated autoantibodies tended to correlate with cognitive dysfunction.

Antipsychotic-Induced Dopamine Supersensitivity Psychosis: Pharmacology, Criteria, and Therapy.

The first-line treatment for psychotic disorders remains antipsychotic drugs with receptor antagonist properties at D2-like dopamine receptors. However, long-term administration of antipsychotics can upregulate D2 receptors and produce receptor supersensitivity manifested by behavioral supersensitivity to dopamine stimulation in animals, and movement disorders and supersensitivity psychosis (SP) in patients. Antipsychotic-induced SP was first described as the emergence of psychotic symptoms with tardive dyskinesia (TD) and a fall in prolactin levels following drug discontinuation. In the era of first-generation antipsychotics, 4 clinical features characterized drug-induced SP: rapid relapse after drug discontinuation/dose reduction/switch of antipsychotics, tolerance to previously observed therapeutic effects, co-occurring TD, and psychotic exacerbation by life stressors. We review 3 recent studies on the prevalence rates of SP, and the link to treatment resistance and psychotic relapse in the era of second-generation antipsychotics (risperidone, paliperidone, perospirone, and long-acting injectable risperidone, olanzapine, quetiapine, and aripiprazole). These studies show that the prevalence rates of SP remain high in schizophrenia (30%) and higher (70%) in treatment-resistant schizophrenia. We then present neurobehavioral findings on antipsychotic-induced supersensitivity to dopamine from animal studies. Next, we propose criteria for SP, which describe psychotic symptoms and co-occurring movement disorders more precisely. Detection of mild/borderline drug-induced movement disorders permits early recognition of overblockade of D2 receptors, responsible for SP and TD. Finally, we describe 3 antipsychotic withdrawal syndromes, similar to those seen with other CNS drugs, and we propose approaches to treat, potentially prevent, or temporarily manage SP.

Normal and Pathological Aging of Attention in Presymptomatic Huntington’s, Huntington’s and Alzheimer’s Disease, and Nondemented Elderly Subjects

Background: Attention models view attention as having at least two components: endogenous attention defined as executive and directed by voluntary acts, and exogenous attention defined as automatic and directed by external stimulation. Methods: Three studies (2 of our own) were designed to evaluate the decline of these two components of attention in normal aging and two neurodegenerative diseases. Standardized tests derived from Posner’s model of visuospatial attention were administered to normal healthy elderly participants (n = 13), patients suffering from Huntington’s disease (HD; n = 17) and Alzheimer’s disease (n = 15), and matched control subjects (n = 57). Outcome measures were reaction time (RT) and RT difference score (defined as invalid RT minus valid RT). Results: In healthy elderly participants, the decline was more pronounced for endogenous attention in situations of perceptual conflict. In Alzheimer’s disease, there was a significant decline in both attention components, while in HD, voluntary attention was markedly impaired and automatic attention preserved. Conclusions: Normal aging and HD are characterized by decreased endogenous attention in situations of perceptual conflict. Our data support previous findings that older people display impairment of attention in complex perceptual situations. We propose a model which allows for the separation of attention pathologies, thus improving therapeutic strategies for patients and elderly.

Cocaine Use Disorder Treated with Specific Cognitive Behavioral Therapy and Adjunctive Propranolol.

cue exposure based on the capacity of virtual reality to elicit craving. Virtual reality of food had been used to elicit craving in normal psychology students and to treat bulimia nervosa. The craving self-report concepts of Sayette et al. [5] were used to measure drug craving. The authors emphasized self-report assessment of craving induced by cues, concepts they derived from their data on cueelicited cigarette craving in smokers [5] . Finally, paired contextual cues are well recognized to trigger drug-seeking behavior [5] . In addition to cue exposure, we used specific CBT consisting of self-monitoring, recognition of conditioned craving, identification of seemingly irrelevant decisions, and preparation for coping with a relapse [2] . Problematic life styles associated with drug abuse were treated with well-being therapy derived from Fava and Tomba [6] . We report the case of a 40-year-old male lawyer with a cocaine use disorder diagnosed by an experienced psychiatrist using DSM5 criteria. The patient had started taking an average dose of 0.5 g of cocaine intranasally twice a day, 8 years before his first visit to our clinic. Three years after initiating cocaine consumption, the dose was increased to an average of 1.5 g/day. During the 2 years before we saw him, he had written CBT-guided self-help material, which did not prevent panic attacks, insomnia, anhedonia, morning tiredness or cocaine abuse with nearly daily intake. At that time, cocaine made him elated, working long hours without being tired. He said that sadness, frustration and emptiness triggered cocaine intake. One year before we saw him, his cocaine intake had been increased to an average dose of 2–3 g per day taken nearly every day, at which time he became demotivated at work, had professional failures, and a major depressive episode, which led to the referral to our clinic. Upon referral, it was decided to initiate specific CBT with a protocol that included ten sessions of 60 min ( table 1 ), with an 80mg propranolol tablet taken orally 2 h before each session. Two types of session were used, therapist-conducted and home-based sessions. During the session with the therapist, the patient was asked to list and then classify cue-related cocaine craving by intensity. Then, the patient classified cocaine-related cues into 3 categories: (1) Insight: internal cues related to inner life, (2) Professional: external cues related to work, and (3) Friends: external cues associated with interpersonal relationship and social environment. During the home sessions, the patient repeated the list of cue-inducing cocaine craving by decreasing intensity. At the end of each session, memories and behaviors related to cue-eliciting cocaine craving were rated by the patient on the Halikas Minnesota Cocaine Craving Scale (MCCS) [7] , item 2, frequency of craving. In addition, the patient completed at baseline and week 10 the self-rating Hospital Anxiety and Depression Scale (HADS) [8] . Scores for each HADS Subscale, Anxiety and Depression, range from 0 to 21 with scores Recently, we have reported two types of paroxetine-induced persistent postwithdrawal disorders, treated with specific cognitive behavioral therapy (CBT) and adjunctive clonazepam [1] . We would like to report a case of cocaine abuse treated with specific CBT and propranolol given 2 h prior to each session. Carroll and Onken [2] reviewed 30 years of CBT research in drug abuse and concluded that there was a greater efficacy of CBT when combined with medications. In individuals with cocaine abuse, skills learned through CBT are known to remain after treatment completion [2] . The specificity of CBT treatment as skill learning therapy is based on processes that identify and correct disturbed behaviors [2] . Blockade of β-receptors by propranolol impaired reward-seeking behavior memories [3] , and reduced reconsolidation of fear-related and spatial memory [3] . Using f-MRI in 3 subjects exposed to prior traumatic events, 2 with and 1 without posttraumatic stress disorder, we found that propranolol abolished amygdala activation and prevented traumatic recurrence memories during cue-induced reactivation. We hypothesize that adjunctive propranolol given prior to CBT sessions will potentiate CBT by reducing cocaine-craving paired emotional memories. In the present case report, CBT was based on desensitization and reactivation of drug seeking behaviour with cocaine-paired contextual cues, while the subject received propranolol 2 h prior to CBT. It is expected that reactivated cocaine-paired cue-craving memories will acquire a lower physiological response with prior propranolol intake and reduce cue-induced craving [4] . We used Received: December 22, 2014 Accepted after revision: September 10, 2015 Published online: November 27, 2015

Endogenous Attention in Normal Elderly, Presymptomatic Huntington’s Disease and Huntington’s Disease Subjects

Charles-Siegfried Peretti1,3, Charles Peretti1, Virginie-Anne Chouinard2,3 and Guy Chouinard3,4 1Service de Psychiatrie, Hopital Saint-Antoine, Universite Pierre et Marie Curie, Paris, 2Massachusetts General Hospital/McLean Adult Psychiatry, Residency Training Program, Harvard Medical School, Boston, Massachusetts, 3Clinical Psychopharmacology Unit, McGill University, Montreal, 4Fernand Seguin Research Center, University of Montreal, Montreal, 1France 2USA 3,4Canada

New technologies: are psychiatrists ready for disruption? An original nationwide study (Preprint)

Background Recent discoveries in the fields of machine learning (ML), Ecological Momentary Assessment (EMA), computerized adaptive testing (CAT), digital phenotype, imaging, and biomarkers have brought about a new paradigm shift in medicine. Objective The aim of this study was to explore psychiatrists’ perspectives on this paradigm through the prism of new clinical decision support systems (CDSSs). Our primary objective was to assess the acceptability of these new technologies. Our secondary objective was to characterize the factors affecting their acceptability. Methods A sample of psychiatrists was recruited through a mailing list. Respondents completed a Web-based survey. A quantitative study with an original form of assessment involving the screenplay method was implemented involving 3 scenarios, each featuring 1 of the 3 support systems, namely, EMA and CAT, biosensors comprising a connected wristband-based digital phenotype, and an ML-based blood test or magnetic resonance imaging (MRI). We investigated 4 acceptability domains based on International Organization for Standardization and Nielsen models (usefulness, usability, reliability, and risk). Results We recorded 515 observations. Regarding our primary objective, overall acceptability was moderate. MRI coupled with ML was considered to be the most useful system, and the connected wristband was considered the least. All the systems were described as risky (410/515, 79.6%). Regarding our secondary objective, acceptability was strongly influenced by socioepidemiological variables (professional culture), such as gender, age, and theoretical approach. Conclusions This is the first study to assess psychiatrists’ views on new CDSSs. Data revealed moderate acceptability, but our analysis shows that this is more the result of the lack of knowledge about these new technologies rather than a strong rejection. Furthermore, we found strong correspondences between acceptability profiles and professional culture profiles. Many medical, forensics, and ethical issues were raised, including therapeutic relationship, data security, data storage, and privacy risk. It is essential for psychiatrists to receive training and become involved in the development of new technologies.