Predictors of poor treatment response to additional CBT in real panic disorder patients: The role of DLPF, orbitofrontal cortex, parietal lobule, frontal eye field and amygdala in PD.

OBJECTIVE: Previous functional brain imaging studies have described various and contradictory activation findings in patients with panic disorder (PD). Our study focused on patients with a chronic PD, who were investigated and treated in a conventional manner, which represents the real PD patients in clinical practice. METHODS: Continuing their medication, patients were included in a six-week cognitive-behavioral therapy (CBT) program in the psychiatry department. At the onset of the study, participants underwent clinical evaluation using standard scales and were examined using fMRI while listening to verbal threat-related stimuli contrasted to neutral words. According to the therapeutic outcome, they were subsequently divided into two groups, responders, and nonresponders and the two groups were mutually compared. RESULTS: In non-responders compared to responders, we found increased pre-treatment activation in dorsolateral prefrontal cortex bilaterally, left orbitofrontal cortex, left frontal eye field, right parietal lobule and left amygdala. In addition, both groups showed negative fMRI BOLD correlation with BAI improvement and positive correlation with CGI improvement across the ROIs. We suggest that DLPFC over-activation may reveal a lack of cognitive control over emotional processing, which makes subsequent CBT less effective. CONCLUSION: Despite several limitations, we found neuroimaging predictors of poor CBT response, under the conditions of standard clinical practice, in real PD patients.

What are demographic and EEG differences between responding and non-responding panic disorder patients.

BACKGROUND: Standardized low-resolution electromagnetic tomography (sLORETA) is a new quantitative EEG method for determining distribution of neuronal electrical activity in the form of three-dimensional images of current density of the cerebral cortex. Unlike standard quantitative EEG, it allows noninvasive and detailed localization of neuronal generators responsible for surface EEG with zero localization error. The study aimed at finding electrotomographic differences between patients with panic disorder who respond well to cognitive behavioral therapy (CBT) and those with an inadequate response and to determine factors predicting a response to treatment. METHODS: The study comprised 24 patients diagnosed with panic disorder with or without agoraphobia (ICD-10 F41.0). The severity of symptoms was measured with the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Sheehan Anxiety Scale, subjective and objective Clinical Global Impression (CGI) and Dissociative Experiences Scale (DES). Additionally, quality of life was evaluated using the Q-LES-Q questionnaire. Based on final BAI score decreases by 25%, the patients were classified into two groups - responders and non-responders. 21-channel EEGs were recorded at baseline and after completion of therapy. Power spectra and intracortical tomography were computed by sLORETA in seven frequency bands and compared between (responders vs. non-responders) and within (pre- vs. post-treatment) groups. RESULTS: There were no differences between responders and non-responders with respect to age, gender and baseline disorder symptomatology. Statistical analysis of sLORETA values demonstrated no significant inter-group differences in the pretreatment current density distribution. After treatment, only responders showed a significant decrease of alpha-2 sources (p<0.05) in the occipital lobes and cuneus and a statistical trend for increased beta-3 sources (p<0.10) in the posterior cingulate. In non-responders, there were no statistically significant changes in sLORETA findings following therapy. CONCLUSIONS: The study failed to use pretreatment sLORETA in the prediction of therapeutic response in patients with panic disorder. However, we clearly demonstrated that only treatment response was associated with significant changes of electric neuronal activity. An analysis of demographic data suggested that duration of the disease, age, level of dissociation and employment may be considered as factors influencing the response.

Comparison of heart rate variability in patients with panic disorder during cognitive behavioral therapy program.

BACKGROUND: Many authors suggest that there is low reactivity of autonomic nervous system and reduced heart rate variability in patients with panic disorder. The patients are therefore exposed to increased cardiac mortality. Power spectral analysis is a successful tool in detecting autonomic instabilities in many disorders. SUBJECTS AND METHODS: The aim of our study is to monitor the activity of the autonomic nervous system through heart rate variability measured in the beginning and end of a therapeutic cognitive behavioral therapy (CBT) program in patients with panic disorder. We measured 31 patients with panic disorder in the beginning (1st measurement) and end of a therapeutic CBT program (2nd measurement). The autonomic nervous system (ANS) has been evaluated in three positions (supine - standing - supine). The evaluated parameters of the HRV linear analysis were: RR interval, HF, LF, VLF band and VLF + LF / HF ratio. RESULTS: Spectral activity in the very low frequency band was significantly higher in the 2nd measurement compared to the 1st measurement in the standing position. The ratio of the spectral activity at lower frequencies (VLF+LF) to high frequency (HF) was significantly lower in the supine position. CONCLUSION: This study demonstrated an improvement of neurocardiac control regulation after a therapeutic CBT program in patients suffering from panic disorder.

Prodromes, precipitants, and risk factors for relapse in bipolar disorder.

OBJECTIVE: The purpose of this qualitative review is to examine prodromes, precipitants, and risk factors for repeated episodes of mania and depression in bipolar disorder. METHODS: PubMed, EMBASE, and PsychInfo were searched for "bipolar disorder" in conjunction with: "prodromes", "triggers", and "life change events". RESULTS: Phenomenology and prevalence of prodromes, precipitants, and risk factors are described, and their therapeutic implications are outlined. CONCLUSIONS: Most patients with bipolar disorder are able to recognize their prodromes. This ability depends largely on insight. Psychoeducation focused on improving various aspects of insight, including treatment adherence, reduces incidence of relapses in bipolar disorder.

Heart rate variability spectral analysis in patients with panic disorder compared with healthy controls.

OBJECTIVES: The aim of our study is to measure very low frequency band (VLF), low frequency band (LF) and high frequency band (HF) components of R-R interval during orthostatic test in patients with panic disorder and a comparison with healthy controls. METHODS: We measured HRV in 31 patients with panic disorder and 20 healthy controls. Diagnosis was done according to the ICD-10 research diagnostic criteria confirmed with MINI (MINI international neuropsychiatric interview). Autonomic nervous system (ANS) has been evaluated during orthostatic change in three positions. Intensity of symptoms was assessed using psychiatric scales. RESULTS: There were highly statistically significant differences between panic patients and control group in all components of power spectral analysis in 2nd and 3rd VLF components and in HF components of 2nd. We have found highly statistically significant negative correlations between level of dissociation measured by DES and some parameters of ANS. We found negative correlations between the age of the patient and activity of ANS, and negative correlations between activity of ANS and duration and onset of disorder and dosage of antidepressants. CONCLUSION: These findings demonstrate a lower parasympathetic activity and higher sympathetic/parasympathetic ratio in panic disorder patients measured during the changes of postural position in comparison with healthy controls. Autonomic dysregulation is associated with panic disorder and has the relation with the level of dissociation, the age of patiens and age of onset of disorder.

Panic disorder, autonomic nervous system and dissociation - changes during therapy.

OBJECTIVES: Alarming somatic symptoms and in particular the cardiovascular symptoms, are the characteristic features of panic attacks. Increased cardiac mortality and morbidity have been proposed in these patients. Power spectral analysis of electrocardiogram R-R intervals is known to be a particularly successful tool in the detection of autonomic instabilities in various clinical disorders. Heart rate variability (HRV) has been found to be the outcome of rapidly reacting cardiovascular control systems. The aim of our study is to measure very low frequency band (VLF), low frequency band (LF) and high frequency band (HF) components of R-R interval during orthostatic experiment in patients with panic disorder before and after treatment and compares it with healthy controls. METHODS: We assessed heart rate variability in 19 patients with panic disorder before and after 6-weeks treatment with antidepressants combined with cognitive behavioral therapy (CBT) and in 18 healthy controls. Diagnosis was done according to the ICD-10 research diagnostic criteria confirmed with MINI (MINI international neuropsychiatric interview). Patients were treated with CBT and psychotropics. They were regularly every week assessed using CGI (Clinical Global Impression), BAI (Beck Anxiety Inventory) and BDI (Beck Depression Inventory). Heart rate variability was assessed during 3 positions (1st - 5 min supine; 2nd - 5 min standing; 3rd - 5 min supine) before and after the treatment. Power spectra were computed for very low frequency - VLF (0.0033-0.04 Hz), low-frequency - LF (0.04-0.15 Hz) and high frequency - HF (0.15-0.40 Hz) bands using fast Fourier transformation. RESULTS: Nineteen panic disorder patients resistant to pharmacological treatment entered a 6-week open-label treatment study with combination of SSRI and CBT. The combination of CBT and pharmacotherapy proved to be an effective treatment in these patients. The patients significantly improved during the study period in all rating scales. There were highly statistical significant differences between panic patients and control group in all components of power spectral analysis in 2nd (VLF, LF and H in standing) and in two component of 3rd (LF and HF in supine) positions. There was also a statistically significant difference between these two groups in LF/HF ratio in standing position (2nd). During therapy there was a tendency increasing values in all three positions in components of HRV power spectra, but HF in 1st supine position was the only component where the increase reached the level os statistical significance. CONCLUSIONS: These findings demonstrate a lower autonomic activity in panic disorder patients measured during the changes of postural position in comparison with healthy controls and tendency to increase this autonomic power during the treatment.

Bipolar affective disorder and dissociation--comparison with healthy controls.

INTRODUCTION: According to recent findings, certain clinical symptoms of patients suffering from affective and anxiety disorder can be related to dissociation. The aim of our study was to examine if the level of dissociation in bipolar affective disorder differed from the level of dissociation in healthy volunteers. METHODS: 41 patients suffering from bipolar disorder (51.2% females), and 198 healthy controls ( 71.2% females) were included in the study. The patients with bipolar affective disorder in remission were recruited from the Outpatient department of the Department of Psychiatry of the University Hospital Olomouc. They were psychiatrically assessed and the state of the disorder was evaluated by an experienced psychiatrist. Only patients in remission, evaluated as 1 or 2 points of clinical global impression-severity scale, were included in the study. All participants were assessed with the Dissociative Experiences Scale (DES). RESULTS: There were no differences in the two groups in demographic variables like age, gender and education. Patients had a significantly higher mean score on the DES and pathological DES than healthy controls. CONCLUSION: Our results suggest that the level of psychological dissociation in bipolar affective patients is higher than in healthy controls.

Cognitive impairment in bipolar disorder.

AIM: Provide an overview of how bipolar disorder affects cognitive function in patients. METHODS: MEDLINE and PsycInfo data bases were searched for articles indexed by the combinations of MESH term or key word "bipolar disorder" with the following terms: "cognition", "memory", "neuropsychology", "neuropsychological tests", "lithium", "anticonvulsants", "antipsychotics", and "schizophrenia". Constraints limiting time period of publications or their language were not applied. Reference lists of publications identified by these procedures were hand-searched for additional relevant citations. RESULTS: There is evidence of stable and lasting cognitive impairment in all phases of bipolar disorder, including the remission phase, particularly in the following domains: sustained attention, memory and executive functions. But research on the cognitive functions has yielded inconsistent results over recent years. There is a growing need for clarification regarding the magnitude, clinical relevance and confounding variables of cognitive impairment in bipolar patients. The impact of bipolar illness on cognition can be influenced by age of onset, pharmacological treatments, individual response, familial risk factors, and clinical features. In addition to the mood state, cognitive performance in bipolar patients is influenced by seasonality. CONCLUSION: Previous optimistic assumptions about the prognosis of bipolar disorder were based on the success of the control of mood symptoms by pharmacotherapy. However, it is now clear that the "remitted" euthymic bipolar patients have distinct impairments of executive function, verbal memory, psychomotor speed, and sustained attention. Mood stabilizers and atypical antipsychotics may reduce cognitive deficits in certain domains and may have a positive effect on quality of life and social functioning.

Quality of life in patients with bipolar disorder--a comparison with schizophrenic patients and healthy controls.

BACKGROUND: In the past, the first goal of bipolar disorder treatment was the reduction of symptoms of mania or depression, rather than the recovery of social functioning. Recently, as a result of an increased emphasis on patient needs, the concept of quality of life (QoL) has been brought into the treatment of physical illnesses. SUBJECTS AND METHODS: The purpose of the present study was to examine QoL data in patients with bipolar disorder in clinical remission and to determine the extent of the effects of demographic and clinical data on QoL in these patients. The second aim was to compare the QoL data of these patients to that of patients with schizophrenia in clinical remission and to that of healthy controls. Data were obtained using a QoL questionnaire (Quality of Life Enjoyment and Satisfaction Questionnaire, or Q-LES-Q) for 41 bipolar patients in clinical remission. The data were then compared with the data of 40 schizophrenic patients in clinical remission and with 40 healthy controls. RESULTS: There were higher mean scores in most Q-LES-Q summary scales in the bipolar patients than in the schizophrenic patients. There were higher mean scores in the bipolar patients in some summary scales than in the healthy controls. CONCLUSIONS: Our results suggest the same or higher subjective QoL in bipolar patients in clinical remission in comparison with healthy controls and higher subjective QoL in bipolar patients in clinical remission than in schizophrenic patients in clinical remission.

Cognitive dysfunction, dissociation and quality of life in bipolar affective disorders in remission.

BACKGROUND: Bipolar disorders are often associated with cognitive deficits, which have an influence on social functioning and the course of the illness. These deficits have an impact on occupational ability and social integration. SUBJECTS AND METHODS: To ascertain cognitive function, level of dissociation and quality of life and their interrelations in patients with bipolar affective disorder in remission. Data from D2 Attention Test, Verbal Fluency Test and Trial Making Test, Dissociative Experiences Scale (DES). Quality of Life Satisfaction and Enjoyment (Q-LES-Q) and M.I.N.I. (MINI-international neuropsychiatric interview were statistically analyzed. RESULTS: There are no significant correlations between applied cognitive tests and dissociation scale DES. There are no significant correlations between applied cognitive tests and dissociation scale DES. There were no differences between employed and unemployed patients in DES, pathological DES and in any of Q-.LES-Q domains. CONCLUSIONS: We need further research to explore the role of cognitive functions and dissociation in bipolar affective disorder and its relationship to cognitive functions, emotional regulation, biological factors and therapy outcome.

Transference and countertransference in cognitive behavioral therapy.

BACKGROUND: Both patients and psychotherapists can experience strong emotional reactions towards each other in what are termed transference and countertransference within therapy. In the first part of this review, we discuss transference issues. Although not usually part of the obvious language of cognitive behavioral therapy (CBT), examination of the cognitions related to the therapist, is an integral part of CBT, especially in working with difficult patients. In the second part, we cover counter-transference issues. We describe schematic issues that give rise to therapist counter-transference and explain how this interacts in different types of patient therapist encounter. We also examine ways in which the therapist can use CT to help him/her modify the countertransference and, in the process, assist the patient. METHODS: PUBMED data base was searched for articles using the key words "therapeutic relations", "transference", "countertransference", "cognitive behavioral therapy", "cognitive therapy", "schema therapy", "dialectical behavioral therapy". The search was repeated by changing the key word. No language or time constraints were applied. The lists of references of articles detected by this computer data base search were examined manually to find additional articles. We also used the original texts of A. T. Beck, J. Beck, M. Linehan, R. Leahy, J. Young and others. Basically this is a review with conclusions about how therapists can manage transference issues. RESULTS: Transference. The therapist should pay attention to negative or positive reactions towards him/ her but should not deliberately provoke or ignore them. He/she should be vigilant for signs of strong negative emotions, such as a disappointment, anger, and frustration experienced in the therapeutic relationship by the patient. Similarly he/ she should be alert to exaggerated positive emotions such as love, excessive idealization, praise or attempts to divert the attention of therapy onto the therapist. These reactions open space for understanding the patient's past and actual relations outside the therapy. Countertransference. The therapist should be aware of countertransference schemas as they apply to him/her. He/she should monitor his/her own feelings that indicate countertransference. Further, the assistance of and discussion with supervisors and colleagues is useful in regard to countertransference even in experienced therapists. Countertransference can be used as an open window into the interpersonal relations of the patient. CONCLUSIONS: Both the literature and our experience underscore the importance of careful and open examination of both transference and counter-transference issues in CBT and their necessary incorporation in the complete management of all patients undergoing CBT.

Suicidal patients.

BACKGROUND: Suicide is the eighth leading cause of death in adults and the second leading cause of death in the 15- to 24-year-old age group. Suicidal impulses and suicidal behavior result from emotionally unbearable feeling of mental suffering and cognitive narrowing that prevent resolution to experienced stress, that is, in a situation when personal coping mechanisms have failed. Suicide attempts are a frequent cause of hospital admissions, in particular to anesthesiology and resuscitation departments. RISK FACTORS: Women attempt suicide three times more often than men. Four times more men than women complete suicide. More than 90% of people who complete suicide are diagnosed with severe mental illness and 50% suffer from depression at the time of suicide. ASSESSMENT: Physicians should be aware of possible suicidal behavior in any patient with mental illness, especially if accompanied by depressive symptoms. The physician should approach the topic of suicide carefully and discreetly, only after a therapeutic relationship with the patient has been established. MANAGEMENT: Patient protection, usually in the setting of a closed psychiatric ward, is necessary if he or she has a clear plan and means to commit suicide. After the patient's safety is secured, treatment may be initiated. If the patient is treated on an outpatient basis, his/her condition must be carefully monitored.

Obsessive compulsive disorder and dissociation - comparison with healthy controls.

The aim of our study is to examine if the dissociation can influence the intensity of psychopathology in patients suffering from obsessive compulsive disorder and to compare the levels of dissociation in the groups of the patients and healthy subjects. Method. Fifty five patients suffering from obsessive compulsive disorder and 123 healthy controls were included into the study. The patients were psychiatrically assessed. The diagnosis was made using ICD-10 research criteria confirmed with structured interview MINI. The subjective intensity of anxiety and depressive symptoms was evaluated using Beck Anxiety Inventory and Beck Depression Inventory. The intensity of obsessions and compulsions was evaluated using Yale Brown Obsessive Compulsive Scale. All participants were assessed with the Dissociative Experiences Scale (DES). Results. Level of the psychological dissociation assessed with the DES was correlated with the severity of subjective anxiety (p<0.0001), depression (p<0.0001), and with the severity of obsessive-compulsive symptoms (p<0.005). Patients have significantly lower mean score on the DES than healthy controls (p<0.0001). Conclusion. Our results suggest that the level of psychological dissociation in OCD patients is lower than in healthy controls, and is associated with the severity of anxiety, depression and obsessive compulsive symptoms.

Autonomic nervous system in euthymic patients with bipolar affective disorder.

BACKGROUND: Autonomic nervous system (ANS) dysfunction and reduced heart rate variability (HRV) have been reported in a wide variety of psychiatric disorders, but have not been well characterized in bipolar patients in remission. We recorded cardiac activity and assessed HRV in bipolar outpatients in remission. AIMS: Ascertain if ANS decrease with the age of the patient; ascertain relation between activity of ANS and level of dissociation, and other components (age of patients, and age of disorder, dosage of psychotropic medication) METHODS: Autonomic nervous system (ANS) has been evaluated during orthostatic change in three positions (1 - lie down 5 minutes, 2 - stand up 5 minutes, 3 - lie down 5 minutes). The functioning of the ANS has been measured by the diagnostic systems that are using the power spectral analysis which quantifies the heart rate variability (HRV) was assessed using time domain, frequency domain, and nonlinear analyses in 23 bipolar patients in remission. RESULTS: We found highly statistically significant negative correlations between level of dissociation measured by DES (Dissociative Experience Scale) and most of parameters of ANS. We found negative correlations between the age of the patient and activity of ANS, and negative correlations between activity of ANS and duration and onset of disorder. CONCLUSIONS: Autonomic dysregulation is associated with bipolar disorder in remission and has relation to level of dissociation and probably to age of patients and age of onset and duration of disorder.