Massimo Salviati

Deep transcranial magnetic stimulation as a treatment for psychiatric disorders: a comprehensive review.

Deep transcranial magnetic stimulation (TMS) is a technique of neuromodulation and neurostimulation based on the principle of electromagnetic induction of an electric field in the brain. The coil (H-coil) used in deep TMS is able to modulate cortical excitability up to a maximum depth of 6 cm and is therefore able not only to modulate the activity of the cerebral cortex but also the activity of deeper neural circuits. Deep TMS is largely used for the treatment of drug-resistant major depressive disorder (MDD) and is being tested to treat a very wide range of neurological, psychiatric and medical conditions. The aim of this review is to illustrate the biophysical principles of deep TMS, to explain the pathophysiological basis for its utilization in each psychiatric disorder (major depression, autism, bipolar depression, auditory hallucinations, negative symptoms of schizophrenia), to summarize the results presented thus far in the international scientific literature regarding the use of deep TMS in psychiatry, its side effects and its effects on cognitive functions.

ECT, rTMS, and deepTMS in pharmacoresistant drug-free patients with unipolar depression: a comparative review

Background Biological treatments are considered as additional options for the treatment of resistant unipolar depression. Controversial data exist about the efficacy and tolerability of three of the most used somatic treatments: electroconvulsive therapy (ECT), transcranial magnetic stimulation (rTMS), and deep transcranial magnetic stimulation (deepTMS). The aim of this review is to investigate and compare the efficacy and tolerability of these three techniques in drug-free patients with pharmacoresistant unipolar depression. Methods Three independent reviewers extracted data and assessed the quality of methodological reporting of selected studies. The first outcome was the clinical response to the three different techniques defined as a percentage improvement of Hamilton Depression Rating Scale (HDRS). The second outcome was the evaluation of their neuropsychological effects. The third outcome was the evaluation of the number of remitted patients; remission was defined as an absolute HDRS-24 score of ≤11 or as an absolute HDRS-17 score of ≤8. Tolerability was the fourth outcome; it was evaluated by examining the number of dropped-out patients. Results The comparative evaluation of HDRS percentage variations shows ECT as the most effective method after 4 weeks of therapy; on the other hand, a better efficacy is obtainable by deepTMS after 2 weeks of therapy. DeepTMS is the technique that gives the best improvement of cognitive performances. The percentage of remitted patients obtained with ECT treatment is the same obtained in the deepTMS group. Both techniques have a remitted patients percentage two times larger than the rTMS. DeepTMS shows a tolerability, measured by the number of dropped-out patients, worse than ECT. Conclusion Our investigation confirms the great therapeutic power of ECT. DeepTMS seems to be the only therapy that provides a substantial improvement of both depressive symptoms and cognitive performances; nevertheless it is characterized by a poor tolerability. rTMS seems to provide a better tolerability for patients, but its therapeutic efficacy is lower. Considering the small therapeutic efficacy of deepTMS in the last 2 weeks of treatment, it could be reasonable to shorten the standard period of deepTMS treatment from 4 to 2 weeks, expecting a reduction of dropped-out patients and thus optimizing the treatment outcome.

The Tinnitus Handicap Inventory as a Screening Test for Psychiatric Comorbidity in Patients with Tinnitus

BACKGROUND Psychiatric comorbidity is common in patients who seek help for tinnitus. The perceived severity of tinnitus correlates closer to psychological and general health factors than to audiometrical parameters. Audiologists need valid screening tools in order to identify patients with psychiatric disorders and to tailor treatment in a multidisciplinary setting. The tinnitus handicap inventory (THI) has gained widespread acceptance as a self-report measure of tinnitus handicap. In several studies, THI test score correlates with the level of psychopathologic distress. The aim of our study was to investigate the predictive power of the test THI in relation to psychiatric disorders. METHODS We recruited 156 patients with chronic tinnitus who have requested help at our tinnitus center. All patients underwent psychiatric evaluation, the diagnosis was made in agreement with the DSMIV-TR criteria; all patients filled out the following questionnaires: THI, Symptomatic Check List-90-Revised (SCL-90-R) and Stress-related Vulnerability Scale (VRS). Sensibility and specificity of tests as screening tool for psychiatric disorders was evaluated using Receiver Operating Characteristic (ROC) curve. RESULTS Sixty-eight patients (prevalence: 43.59%) were found to be affected by a psychiatric disorder. AUC = 0.792 (p > 0.001) shows that THI is a moderately accurate test to individuate psychiatric affected people among our sample. We identified a score of 36 at THI (sensibility = 86.76%; specificity = 59.09%) as an appropriate cut-off point. CONCLUSIONS If a patient reports a THI score greater than 36, the audiologist should supplement diagnostic studies with a psychiatric evaluation.

Tinnitus: clinical experience of the psychosomatic connection

Background The connection between psychopathology and tinnitus is complex and not adequately studied. The aim of this study is to investigate the relationship between tinnitus and psychiatric comorbidities from different points of view: categorical, dimensional, temperamental, and perceived stress level. Methods Two hundred and thirty-nine patients affected by tinnitus were recruited between January and October 2012. Patients underwent a preliminary battery of tests including the Tinnitus Handicap Inventory (THI), Symptom Check List (SCL90-R), Temperament and Character Inventory (TCI), and Stress-Related Vulnerability Scale (VRS), and eventually a full psychiatric evaluation. Results One hundred and fourteen patients (48% of the total sample) presented psychiatric comorbidity. Among these, a higher prevalence of depression, somatization, obsession, and anxiety was found. More than 41% of patients affected by decompensated tinnitus reported a family history of psychiatric disorders. Significant positive correlations between the psychopathological screening tools (SCL90-R and VRS) and THI were found. Patients affected by comorbid psychiatric disorder showed specific temperamental and characterial predispositions. Conclusion Psychiatric comorbidity in subjects affected by tinnitus is frequent. Stress can be considered as a factor leading to damage and dysfunction of the auditory apparatus. The vulnerability to neurotic disorders and the lack of coping capabilities can play a critical role in the clinical history of patients affected by severe tinnitus.

Tinnitus Holistic Simplified Classification (THoSC): A New Assessment for Subjective Tinnitus, With Diagnostic and Therapeutic Implications.

Objective: One of the most debated topics in tinnitus is its standard and practical classification. The most popular classification distinguishes subjective from objective tinnitus. Other classifications are based on different features. On the whole, they seem incomplete, and the diagnostic and therapeutic algorithms are often difficult for practical purposes. The aim of this work is to develop a new diagnostic and therapeutic algorithm. Methods: Our model is based on 10 years of experience. In particular, the starting point is the data retrieved from 212 consecutive patients in our Tinnitus Unit between May and December 2013: We found a clear auditory disorder in 74.5% of the population, muscolo-skeletal disorders and/or trigeminal disease in 57.1%, and psychiatric comorbidities in 43.8%. Different features coexisted in 59.9% of the population. Results: Following such data we propose the Tinnitus Holistic Simplified Classification, which takes into account the different tinnitogenic mechanisms and the interactions between them. It differentiates tinnitus that arises from: (1) auditory alterations (Auditory Tinnitus), (2) complex auditory-somatosensory interactions (Somatosensory Tinnitus), (3) psychopathological-auditory interactions (Psychopathology-related Tinnitus), and (4) 2 or all of the previous mechanisms (Combined Tinnitus). Conclusions: In our opinion this classification provides an accurate and easy tailored path to manage tinnitus patients.

Somatosensory Tinnitus: Correlation between Cranio-Cervico-Mandibular Disorder History and Somatic Modulation

In a subpopulation of patients, tinnitus can be modulated by movements of the jaw or head and neck due to complex somatosensory-auditory interactions. In some of these subjects, tinnitus could be related to an underlying temporomandibular (TMJ) or craniocervical (NECK) dysfunction that, if correctly identified, could streamline treatment and increase chances of tinnitus improvement. However, it is still unclear whether somatic modulation of tinnitus could be used as a screening tool for identifying such patients. In this study, we included 310 tinnitus patients with normal hearing, no psychiatric comorbidities, and a positive history of TMJ and/or NECK dysfunction and/or a positive modulation of tinnitus to evaluate the characteristics of somatic modulation, investigate the relationship between positive history and positive modulation, and identify factors most strongly associated with somatic modulation. Tinnitus modulation was present in 79.67% of the patients. We found a significant association within the same subjects between a positive history and a positive tinnitus modulation for the same region, mainly for TMJ in unilateral tinnitus patients and for TMJ + NECK in bilateral tinnitus patients. A strong correlation between history and modulation in the same somatic region within the same subgroups of subjects was also identified. Most TMJ maneuvers resulted in an increased loudness, while NECK maneuvers showed an increase in tinnitus loudness in about 59% of cases. High-pitched tinnitus and male gender were associated with a higher prevalence of modulation; no differences were found for tinnitus onset, Tinnitus Handicap Inventory score, and age. In this paper, we report a strong association between history and modulation for the same regions within the same patients; such an association should always be investigated to improve chances of a correct diagnosis of somatosensory tinnitus.

Capgras-like syndrome in a patient with an acute urinary tract infection

Delusional misidentification syndromes are a group of delusional phenomena in which patients misidentify familiar persons, objects, or themselves, believing that they have been replaced or transformed. In 25%–40% of cases, misidentification syndromes have been reported in association with organic illness. We report an acute episode of Capgras-like delusion lasting 8 days, focused on the idea that people were robots with human bodies, in association with an acute urinary infection. To our knowledge, this is the first case report associating urinary tract infection with Capgras-like syndrome. Awareness of the prevalence of delusional misidentification syndromes associated with acute medical illness should promote diligence on the part of clinicians in recognizing this disorder.

On the role of noradrenergic system in PTSD and related sleep disturbances. The use of terazosin in PTSD related nightmares: a case report

In PTSD, sleep disorders represent an important symptoms dimension which is associated with more severe PTSD and increased risk of relapse. The basic treatment for PTSD is not always associated to an improvement of sleep disturbances and nightmares. Alpha-blockers, and more specifically Prazosin, have shown a specific action on sleep disorders in PTSD. We report the clinical case of a young women with PTSD, who was suffering from severe sleep disorder and distressing nightmare. The patient was treated with Terazosin, a conger of Prazosin, and has shown symptom remission. Further studies on the use of alpha-blokers might reveal new therapeutic options in PTSD.

Bipolar Spectrum Disorders in Patients With Cerebellar Lesions: A Comparison With Parkinson's Disease.

Abstract Nonmotor functions of the cerebellum are well known. Within this frame, the aim of this study was to compare psychiatric morbidity rates among patients affected by cerebellar diseases or Parkinsons disease (PD). Forty-seven patients (27 cerebellar and 20 PD) underwent a comprehensive psychiatric evaluation (psychopathological rating scales and the Structured Clinical Interview for DSM-IV-TR Axis I Disorders). Psychiatric disorders were slightly more frequent among cerebellar than among PD patients (89% vs. 75%; p = 0.21). Mood disorders were more frequent in the cerebellar than in the PD group (90% vs. 55%; p < 0.01). Among those subjects with no psychiatric history prior to the onset of neurological disease, bipolar spectrum disorders were more frequent within the cerebellar group (p < 0.01). These results confirm high rates of psychiatric disorders among cerebellar patients. The higher frequency of bipolar spectrum presentations found in the cerebellar group may suggest a specific involvement of cortico-cerebellar circuits in the pathophysiology of mood dysregulation.

Acute psychiatric presentation of steroid-responsive encephalopathy: The underrecognized side of autoimmune thyroiditis

Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), also known as Hashimoto encephalopathy, represents a rare disorder of presumed autoimmune origins that can be diagnosed when a protean variety of psychiatric symptoms are present in association with elevated titers of anti-thyroid antibodies. Symptoms can have a rapid and complete remission with corticosteroid treatment. A 19-year-old girl, with clinical history of Basedow-Graves disease, has been admitted to our department after presenting acute psychiatric symptomatology. Clinical and serological findings were used to formulate the diagnosis of SREAT, confirmed by subsequent positive response to corticosteroid treatment. SREAT can mimic an acute psychiatric symptomatology, thus it seems extremely relevant for psychiatrists to consider this syndrome in differential diagnosis algorithm, especially in those patients presenting a history of autoimmune thyroid disorder, in order to ensure adequate diagnosis and treatment.