María-Inés López-Ibor

Transcranial magnetic stimulation.

Purpose of review To present state-of-the-art transcranial magnetic stimulation (TMS) therapy, especially when it is used in psychiatric disorders, on the basis of an exhaustive literature search from 2006 to date (June 2008) on TMS papers published in Medline and Embase. Other references and comments from our own experience started 8 years ago have also been taken into account. Recent findings The mechanism of action of TMS is now better understood. There is strong evidence of the safety and tolerability of TMS when standard protocols are used. The efficacy of the stimulation of the dorsolateral prefrontal cortex in depression is well documented, and there is evidence of the utility of TMS in posttraumatic stress disorder, in persistent auditory hallucinations in schizophrenia and in attention-deficit disorder with hyperactivity. Summary There is enough evidence of the efficacy and safety of TMS in depression to include this technique in the therapeutic protocols of major depression. However, more research is needed on the use of this technique in other psychiatric and nonpsychiatric disorders such as posttraumatic stress disorder, persistent auditory hallucinations, attention-deficit disorder with hyperactivity and tinnitus.

Orbitofrontal dysfunction related to depressive symptomatology in subjects with borderline personality disorder

OBJECTIVE In order to explore the relationships of fronto-limbic dysfunction with the clinical features of borderline personality disorder (BPD), the authors investigated brain electrophysiological activity in BPD patients following stimulation with emotionally arousing images. METHODS Seventeen non-medicated patients with borderline personality disorder were studied with magneto-encephalography. Regional cortical activities were obtained by minimum norm estimate (MNE) of steady-state visual evoked fields (ssVEFs). Linear regression models were conducted to explore clinical correlates of brain activity. RESULTS Although no interaction group × picture category × brain region was found, a significant interaction group × brain region appeared for orbito-frontal cortex (OFC). BPD patients showed significantly reduced magnetocortical activity in left OFC across all picture categories (F = 26.4; p<.05; F = 31.4). Left OFC activity was inversely correlated with depression score in the BDI (r: -0.48, p < 0.05), with score in the Cornell Dysthymia rating scale (r: -0.52, p < 0.05) and with the number of criteria met for depressive personality disorder (r: -0.44, p < 0.05). Left orbitofrontal activity was also inversely correlated with the global score in the GAF (r-0.63, p < 0.01). No correlations were found between OFC activity and impulsivity or global severity of BPD symptoms. CONCLUSIONS Abnormal functioning at orbitofrontal areas in BPD could be related to the presence of affective symptomatology and is associated with greater functional deterioration of patients.

The perception of emotion-free faces in schizophrenia: a magneto-encephalography study.

OBJECTIVE To analyze how patients suffering from schizophrenia perceive faces of unknown individuals that show no actual emotions in order to investigate the attribution of meanings to a relatively non-significant but complex sensory experience. DESIGN Analysis of baseline and poststimulation magneto-encephalographic recordings. The stimuli consisted of four pictures with neutral emotional expression of male and female faces of Spanish individuals unknown to research subjects. PARTICIPANTS Twelve right-handed patients suffering from schizophrenia (DSM IV-TR criteria), age 18-65, with active delusional activity (SAPS score in delusions above 39) and 15 right-handed sex- and age-matched control subjects. RESULTS Compared to controls patients have a significant higher activity of both hemispheres (0-700 ms) being the activity in the right hemisphere (RH) higher than in the left hemisphere (LH). Patients also have a higher activity on the middle fusiform gyrus (BA 37) in the LH (200-300 ms), on the superior temporal areas (BA 22, 41 and 42) in both hemispheres (100-700 ms) and on the temporal pole (BA 38) in the RH (300-400 ms) and a lower activity in the LH of the latter. CONCLUSIONS The areas that are more activated in our study are those involved in the process of thinking, in attributing meanings to perceptions and in activities such as theory of mind, which are essential for social interaction. The anterior temporal areas less activated indicate a reduced semantic memory for faces that could explain the social withdrawal of schizophrenia. These alterations are suggestive of a dysfunction of left hemisphere neuronal networks.

Research on obsessive-compulsive disorder

The symptoms of obsessive-compulsive disorder comprise various obsessions and compulsions with rituals, sensory abnormalities, doubts, overvalued ideas, speech abnormalities, emotional disturbances (depression, anxiety, irritability and others), immediate memory deficits and minor (soft) neurological signs. Actually, obsessive-compulsive disorder is a heterogeneous syndrome that includes subtypes that overlap with both anxiety and mood disorders. Although new findings on obsessive-compulsive disorder allow the development of theories on the etiology and suggest therapeutic approaches, new pathways are still being sought to explain the intriguing enigma of obsessions. The search for biological markers in obsessive-compulsive disorder is relatively new, as most literature in this field has been produced in the past decade. The major hypothesis on the pathophysiology of obsessive-compulsive disorder relates to serotonin (5-hydroxytryptamine), on the basis of an almost exclusive response to serotonergic drugs by patients with the disorder. Furthermore, in recent years a growing number of neuropsychiatric studies have documented an impairment in both cognitive and sensory motor functions in obsessive-compulsive disorder. Together with neuroimaging studies and neurosurgical research, some neuroanatomical models of obsessive-compulsive disorder have been developed. These models have focused on reciprocal connections between frontal cortex and basal ganglia. Advances in brain-imaging techniques (positron emission tomography (PET), single-photon computed tomography, magnetoencephalography, functional magnetic resonance) and the development of specific radiolabeled serotonergic ligands should allow the in-vivo visualization of structure-function relationship, and may lead to a better understanding of this illness.

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.

Ethics of Diagnosis and Classification in Psychiatry

The ethical obligation of the psychiatrist includes acting in the best interest of the patient, doing no harm, and observing justice, i.e. acting with regard to the limited resources of the community. The psychiatrist can perform this best if he is sensitive on the one hand to the consequences of his determination that an illness value is a disorder, i.e. if he considers not only the medical but also the psychic and social consequences of his diagnosis, and, on the other hand, if he has the diagnostic competence not only to apply the standardised diagnostic algorithms for assessing the illness of the patient but also for the patient’s personal experience of ill being. Furthermore, the moral valuation of our language (and of our scientific instruments expressed in language) should be recognized and its influence should be reflected in the diagnostic assessment of a disorder; it should be considered particularly in assessing the individuality of the patient as a sick person and should be used in dealing with him and optimizing his treatment.

Anxiety and logos: Toward a linguistic analysis of the origins of human thinking

BACKGROUND Delving in the origins and meanings of key words of the psychiatric terminology can help understanding the nature of mental disorders. In the present paper we analyze the meanings of anxiety and related words in modern European languages and we traced the etymology back to Protonostratic. At a certain point the archaeology of the word anxiety is confronted with the Greek word logos. METHODS Review of dictionaries of modern and of Indo-European and Nostratic families of languages. RESULTS The Protonostratic root of anxiety (nk) has lead to words signifying fear and constriction but also to others referring to destiny or the origin or sense of life. Logos is the answer to the anxiety produced by the confrontation with the meaning of existence. The Protonostratic root of logos (leg) has two meanings: One is to lie in front of, the second one is to gather put in order, what is in front of us. This second meaning is present in the Greek logos which means both though and language. LIMITATIONS The study considers only a few modern and ancient languages. Research on hypothetical non-written and extinct languages is sometimes speculative and there is no full agreement among scholars. CONCLUSIONS Anxiety is a symptom present in many psychiatric disorders; it is also a fundamental feeling of human beings confronting the meaning of life. Thinking and verbalizing are the strategies to confront anxiety. They manifest themselves in everyday clinical practice, but they were also present at the origins of rational thinking in the human species.

Anthropological Perspectives in Psychiatric Nosology

Psychiatry and clinical psychology, as we learn in this paper, are disciplines in need of an ontological perspective. Very few branches of contemporary learning share this characteristic. Probably only theoretical physic and theology—as the rest have long ago given up trying to define and understand the essence of their object, for example, life in the case of biology or mind in psychology. Consequently, the paper by Pérez-Álvarez, Sass and García-Montes, “The Ontology of Mental Disorders in Constructivist Perspective,” (2008) should be welcomed and indeed included in the reading lists for trainees in psychiatry and clinical psychology. The authors propose an approach to the understanding of mental disorders that is extremely attractive and well articulated, and which also has practical implications for clinicians. It is not just another “philosophical divertimento” devoid of scientific and practical importance. Let us analyze the article in an orderly way. Less DSM