J. Arturo Silva

Cingulate function in depression: A potential predictor of treatment response

THE relationship between pretreatment regional cerebral glucose metabolism and eventual antidepressant drug response was measured using positron emission tomography (PET) in hospitalized patients with unipolar depression. Rostral anterior cingulate metabolism uniquely differentiated eventual treatment responders from non-responders. Hypometabolism characterized non-responders when compared with controls, in contrast to responders who were hypermetabolic. Metabolism in no other region discriminated the two groups, nor did associated demographic, clinical or behavioral measures, including motor speed, cognitive performance, depression severity or illness chronicity. Cingulate hypermetabolism may represent an important adaptive response to depression and failure of this response may underlie poor outcome. A critical role for rostral cingulate area 24a/b in the limbic-cortical network involved in abnormal mood states is proposed.

Regional metabolic effects of fluoxetine in major depression: serial changes and relationship to clinical response

BACKGROUND Treatment of major depression with antidepressants is generally associated with a delay in onset of clinical response. Functional brain correlates of this phenomenon have not been previously characterized. METHODS Time course of changes in brain glucose metabolism were measured using positron emission tomography in hospitalized unipolar depressed patients treated with fluoxetine. Time-specific and response-specific effects were examined at 1 and 6 weeks of treatment. RESULTS Changes were seen over time, and characterized by three distinct patterns: 1) common changes at 1 and 6 weeks, 2) reversal of the 1-week pattern at 6 weeks, and 3) unique changes seen only after chronic treatment. Fluoxetine responders and nonresponders, similar at 1 week, were differentiated by their 6-week pattern. Clinical improvement was uniquely associated with limbic and striatal decreases (subgenual cingulate, hippocampus, insula, and pallidum) and brain stem and dorsal cortical increases (prefrontal, parietal, anterior, and posterior cingulate). Failed response was associated with a persistent 1-week pattern and absence of either subgenual cingulate or prefrontal changes. CONCLUSIONS Chronic treatment and clinical response to fluoxetine was associated with a reciprocal pattern of subcortical and limbic decreases and cortical increases. Reversal in the week-1 pattern at 6 weeks suggests a process of adaptation in specific brain regions over time in response to sustained serotonin reuptake inhibition. The inverse patterns in responders and nonresponders also suggests that failure to induce these adaptive changes may underlie treatment nonresponse.

The case of Jeffrey Dahmer: sexual serial homicide from a neuropsychiatric developmental perspective.

Sexual serial homicidal behavior has received considerable attention during the last three decades. Substantial progress has been made in the development of methods aimed at identifying and apprehending individuals who exhibit these behaviors. In spite of these advances, the origins of sexual serial killing behavior remain for the most part unknown. In this article we propose a biopsychosocial psychiatric model for understanding the origins of sexual serial homicidal behavior from both neuropsychiatric and developmental perspectives, using the case of convicted serial killer Jeffrey Dahmer as the focal point. We propose that his homicidal behavior was intrinsically associated with autistic spectrum psychopathology, specifically Aspergers disorder. The relationship of Aspergers disorder to other psychopathology and to his homicidal behavior is explored. We discuss potential implications of the proposed model for the future study of the causes of sexual serial homicidal crime.

Sleep patterns in borderline personality disorder

Sleep patterns of borderline patients with and without a history of affective disorder were compared to each other and to normal reference data. The three groups could not be distinguished in terms of REM latency because a wide spread of values was seen within each group. Borderlines were different from normal controls in other aspects of sleep architecture; they had less total sleep, more stage 1 sleep, and less stage 4 sleep. If one assumes that REM latency is a biological marker for mood disorder, then our results do not support the hypothesis that borderline personality disorder is a variant of affective illness. However, other data suggest that REM latency should not be used to validate the presence of affective illness.

Neuroleptic-induced akathisia and violence: a review.

Surprisingly, the association of neuroleptic-induced akathisia and aggressive behavior was not formally recognized until nearly two and one-half decades of antipsychotic prescribing had passed. Using a search of the anglophonic literature, this phenomenon is reviewed. Advances in psychopharmacology have reduced neuroleptic-induced akathisia and hold promise to eliminate it altogether. Nonetheless, important clinical and forensic aspects of neuroleptic-induced akathisia and aggression remain and are explored.

A comprehensive typology for the biopsychosociocultural evaluation of child-killing behavior

The homicide of children by their parents has been reported across numerous cultural settings around the world and in many historical periods. A comprehensive and systematic understanding of parental child killing can be optimally obtained through a biopsychosociocultural approach. In this article we present the case of a woman who committed neonaticide. We illustrate the cultural formulation of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and recommend that this formulation has a central role in the evaluation of cultural factors of parents who kill their children.

Delusion of Exchanged Doubles in an Immigrant: a New Capgras Variant?

A possible new variant of the Capgras syndrome in an immigrant to the U.S. is presented. The biopsychosocial and phenomenological aspects of this case are discussed.

A cognitive model of dangerous delusional misidentification syndromes.

The hallmark of the delusional misidentification syndromes is the presence of a misidentification delusion of the self or others. Delusional misidentification may present with an increased risk for dangerous behaviors. Individuals suffering from delusional misidentification syndromes may express hostility in ways ranging from serious verbal threats to homicidal acts. The causes of dangerous misidentification delusions remain for the most part undetermined. In this article, we report a series of six cases of individuals who harbored dangerous misidentification delusions. These individuals were studied phenomenologically and forensically. They were also studied biologically, including neuropsychological testing. A cognitive hypothesis aimed at explaining dangerousness and delusional misidentification is proposed. Implications of the hypothesis for further research are briefly outlined.

Delusional Misidentification and Dangerousness: A Neurobiologic Hypothesis

Delusional misidentification syndromes have intrigued this centurys psychiatric researchers. More recently, the dangerousness posed by individuals suffering from these syndromes has been a subject of scientific inquiry. A series of five individuals suffering from delusional misidentification syndromes was studied from a phenomenologic and neuropsychologic perspective. Using this information, a hypothesis involving the psychobiological contributions to the dangerousness of delusional misidentification can be generated. This may further our understanding of the dangerousness posed by psychotic individuals.

The Role of Traditional Medical Ethics in Forensic Psychiatry

Traditional medical ethics originated with Hippocrates and a small group of reform-minded physicians in ancient Greece. The concepts of helping and not harming have permeated medical ethics for centuries and have remained a core foundation for the special professional obligations of physicians. The tradition of helping and not harming is most strongly stated in the Latin, primum nil nocere, or, first of all, do no harm.