Martin Jandl

Treating Auditory Hallucinations by Transcranial Magnetic Stimulation: A Randomized Controlled Cross-Over Trial

Background: In a previous functional magnetic resonance imaging study, the authors succeeded in demonstrating the activation of Heschl’s gyrus during auditory hallucinations (AH). Objectives: This study aims to treat AH specifically by repetitive transcranial magnetic stimulation (rTMS). Methods: 16 patients with AH were included in a randomized, cross-over, sham-controlled trial. 1 Hz rTMS was administered over the left and right temporo-parietal cortex and sham position, respectively, on 5 consecutive days; 900 stimuli each, strength 100% of motor threshold. Using the Psychotic Symptom Rating Scales (PSYRATS), the hallucinations during the stimulation periods and 4-week follow-ups were quantified. Electroencephalograms (EEG) were acquired before and after each period. Results: Treatment responses were observed after left hemisphere rTMS only. The 5 patients who showed a response did so already after 2 days. However, group mean hallucination scores did not differ across treatment conditions. No significant changes were found in EEG after rTMS. Conclusions: A subgroup of patients suffering from AH benefits soon after treatment start from rTMS over the left superior temporal gyrus as revealed by the decrease of AH scores compared to right-sided and sham procedures.

Adolescent attention deficit hyperactivity disorder and susceptibility to psychosis in adulthood: a review of the literature and a phenomenological case report

Aim: In contrast to affective disorders, some forms of personality disorders and drug addiction, schizophrenia is commonly not considered to be a sequela of attention deficit hyperactivity disorder. However, attention deficit hyperactivity disorder and the prodromal stages of schizophrenia spectrum disorders do exhibit a number of common central features. To facilitate the early treatment of schizophrenic symptoms, the detection of discrete and subtle alterations in the prodromal stages of incipient psychoses is particularly important.

Electroencephalographic risk markers of suicidal behaviour

Since its inception nearly 100 years ago, EEG (electroencephalography) has offered a non-invasive approach to recording the intrinsic electrical activity of the brain. Despite its limitations and the

Treatment of Therapy-Resistant Auditory Verbal Hallucinations in Schizophrenia Patients by Repetitive Transcranial Magnetic Stimulation

A high percentage of schizophrenic patients suffer from auditory verbal hallucinations (AVH). The chronic nature of AVH presents a serious therapeutic challenge, as up to one third of these patients are resistant to antipsychotic pharmacotherapy. Low-frequency repetitive transcranial magnetic stimulation (rTMS) is a therapeutic option that may disrupt or attenuate treatment-resistant AVH. In this chapter, we review the literature on the application of rTMS from the initial studies, more than a decade ago, to the current randomized controlled trials (RCT), which also include ‘super-refractory’ schizophrenia (SRS) patients, active comparator stimulation strategies and imaging-guided stimulations. We also consider 3 meta-analyses, which found moderate rates of AVH attenuation in response to rTMS. We believe that larger maintenance and follow-up studies with clearer definitions of treatment resistance are required to confirm the beneficial effects of rTMS in AVH. In addition, the underlying mechanism of action of rTMS at different cortical sites related to speech networks needs further clarification. We suggest that future trials should focus on standardizing; methods for assessing AVH changes, time courses of response, placebo strategies, RCT designs, and also the further development of potential response markers, and inclusion of both unmedicated and SRS patients.

An act of catharsis or a cry for help? Decreased anxiety as a postcedent of a non-fatal suicide attempt

Introduction More than 40 years ago, an American physician called R. Gregory Austin suggested that suicide was an act of catharsis. He coined the terms attempters (mostly women appealing for a change in their lives) and committers (mostly men driven by self-hatred) to describe two distinct populations of suicidal patients. Austin was convinced that only the latter group really sought catharsis. Method We compared reported mean anxiety levels in male and female inpatients (N = 629) presenting with either no suicidal behavior, death wish, suicidal ideation or who had recently made a non-fatal suicide attempt. Results We found that female patients with suicidal ideation had much higher levels of anxiety compared to their non-suicidal counterparts. However, the anxiety levels of female patients who had recently made a non-fatal suicide attempt were not significantly different to those of non-suicidal women. No similar trends were found in male patients. Conclusion Catharsis (Greek: κάθαρσις) means to purge or cleanse the emotions (of fear, pity). Our results suggest that, in contrast to Austin’s original observation, both women and men undertake acts of catharsis: it is simply that the focus of their cathartic act differs. For men, anxiety appears to play no significant role or has no consequence in their suicidal behavior. For women, their catharsis appears to be the purging or normalizing of anxiety.

P02-309 - Action-inhibition hierarchies: Using a simple gastropod model to investigate serotonergic and dopaminergic control of action selection and reinforcement learning

Introduction Basal ganglia (BG) activity plays an important role in action selection and reinforcement learning. Inputs from and to other areas of the brain are modulated by a number of neurotransmitter pathways in the BG. Disturbances in the normal function of the BG may play a role in the aetiology of psychiatric disorders such as schizophrenia and bipolar disorder. Aims Develop a simple animal model to evaluate interactions between glutamatergic, dopaminergic, serotonergic and GABAergic neurones in the modulation of action selection and reinforcement learning. Objectives To characterise the effects of changing dopaminergic and serotonergic activity on action selection and reinforcement learning in an animal model. Methods The food seeking / consummation (FSC) activity of the gastropod Planorbis corneus was suppressed by operant conditioning using a repeated unconditioned stimulus-punishment regime. The effects of elevated serotonin or dopamine levels (administration into cerebral, pedal and buccal ganglia), on operantly-conditioned FSC activity was assessed. Results Operantly-conditioned behaviour was reversed by elevated ganglia serotonin levels but snails showed no food consummation motor activity in the absence of food. In contrast, elevated ganglia dopamine levels in conditioned snails elicited food consummation motor movements in the absence of food but not orientation towards a food source. Conclusions The modulation of FSC activity elicited by reinforcement learning is subject to hierarchical control in gastropods. Serotoninergic activity is responsible establishing the general activity level whilst dopaminergic activity appears to play a more localised and subordinate ‘command’ role.

Are antipsychotics antipsychotics

As some of us may remember, this class of drugs formerly was called “neuroleptics”, based on the Greek words neuron and leptein (to control sth.). Within the past 20 years, the term “neuroleptic” has increasingly been replaced by “antipsychotic” in the literature (Fig. 1). “Antipsychotic” insinuates a specific effect similar to antibiotics or anti-diabetics. Certainly, psychiatrists would appreciate the idea of having specific therapeutic options for specific diseases. However, there is rather good evidence that this is not the case—neither for diagnosis (van Os 2009) nor for therapy. “Antipsychotic” drugs have been suggested to be effective in schizophrenia, mania, other psychotic states (Poewe 2009), and, at least as an adjunctive treatment, bipolar depression (Cruz et al. 2010), unipolar depression (Weisler et al. 2009), borderline personality disorder (Ingenhoven et al. 2010), posttraumatic stress disorder, anxiety disorders, obsessive–compulsive disorder (Gao et al. 2006), and alcohol dependence (Vergne and Anton 2010), i.e., in nearly every kind of mental disorder. Though robust evidence from randomized controlled trials is missing for most of these indications so far, the findings suggest that antipsychotics are psychoactive drugs with antipsychotic and several other properties rather than having a specific anti-psychotic efficacy. This is not very surprising, taking into account the different receptor profiles of many of the substances beyond blocking dopamine receptors. However, the nomination has impact not only on theory but also on clinicians’ thinking. Calling them antipsychotics hinders clinicians as well as patients in accepting these substances for use in other disorders, and it might impede the insight that other classes of substances can exert some desirable effects in psychotic states, such as some of the so-called antidepressants (Joffe et al. 2009), mood stabilizers (Tiihonen et al. 2009) or benzodiazepines (Volz et al. 2007). Terms constitute implicit theories and reflecting on this might provide opportunities for progress in both pathophysiological understanding and treatment.