Annotated Abstracts of Journal Articles
2014, 3rd Quarter
Annotations by Nicholas Kontos, MD
ANNOTATION (Nicholas Kontos)
The Finding: Multiple psychological constructs and associated neuroanatomical structures contribute to human decision-making. As such, different types of psychopathology can lead to impaired deciding in different ways.
Strengths and Weaknesses: As massive of an undertaking as most journals will accommodate, this paper not only synthesizes an extensive literature on the neuroscience of decision-making, but also summarizes many related psychological concepts (e.g., game theory, temporal discounting). Ultimately, they are discussed with reference to mood, anxiety, and psychotic disorders. Coverage of interventions finishes the paper and is less detailed than the rest of the content, but by that point in this lengthy piece, the reader might be grateful.
Relevance: This paper is sure to bring greater understanding and nuance to how consultation psychiatrists think about complex capacity assessments.
A commonality of patients with major psychiatric disorders is their propensity to make poor decisions, which is intimately related to poor real-life outcomes. The authors reviewed the literature on decision making as applied to severe psychiatric disorders, with particular focus on advances in cognitive neuroscience. Deficits in reward sensitivity, avoidance learning, and temporal discounting are reported in depression. Besides abnormalities in hedonic capacity, other cognitive distortions required for flexible control of behavior occur in patients with bipolar disorder and schizophrenia. A conceptual framework of abnormal decision making in mental illness could generate targeted interventions to improve quality of life and clinical outcomes.
ANNOTATION (Nicholas Kontos)
The Finding: Manualized CBT targeted at psychogenic nonepileptic seizures (PNES) can lead to reduced frequency of spells and improved functioning in selected patients.
Strengths and Weaknesses: This is the most ambitious RCT of specifically directed treatment for PNES, and the positive result is striking and encouraging. The study is profoundly limited by exclusion criteria that led to only 6.5% of the original sample making it to randomization.
Relevance: PNES tends to be an object of initial interest and eventual frustration for neurologists and psychiatrists. The possibility of there being evidence-based treatment to offer these patients offers some hope to physicians and patients alike.
Importance: There is a paucity of controlled treatment trials for the treatment of conversion disorder, seizures type, also known as psychogenic nonepileptic seizures (PNES). Psychogenic nonepileptic seizures, the most common conversion disorder, are as disabling as epilepsy and are not adequately addressed or treated by mental health clinicians.
Objective: To evaluate different PNES treatments compared with standard medical care (treatment as usual).
Design, Setting, and Participants: Pilot randomized clinical trial at 3 academic medical centers with mental health clinicians trained to administer psychotherapy or psychopharmacology to outpatients with PNES. Thirty-eight participants were randomized in a blocked schedule among 3 sites to 1 of 4 treatment arms and were followed up for 16 weeks between September 2008 and February 2012; 34 were included in the analysis.
Interventions: Medication (flexible-dose sertraline hydrochloride) only, cognitive behavioral therapy informed psychotherapy (CBT-ip) only, CBT-ip with medication (sertraline), or treatment as usual.
Main Outcomes and Measures: Seizure frequency was the primary outcome; psychosocial and functioning measures, including psychiatric symptoms, social interactions, quality of life, and global functioning, were secondary outcomes. Data were collected prospectively, weekly, and with baseline, week 2, midpoint (week 8), and exit (week 16) batteries. Within-group analyses for each arm were performed on primary (seizure frequency) and secondary outcomes from treatment-blinded raters using an intention-to-treat analysis.
Results: The psychotherapy (CBT-ip) arm showed a 51.4% seizure reduction (P = .01) and significant improvement from baseline in secondary measures including depression, anxiety, quality of life, and global functioning (P < .001). The combined arm (CBT-ip with sertraline) showed 59.3% seizure reduction (P = .008) and significant improvements in some secondary measures, including global functioning (P = .007). The sertraline-only arm did not show a reduction in seizures (P = .08). The treatment as usual group showed no significant seizure reduction or improvement in secondary outcome measures (P = .19).
Conclusions and Relevance: This pilot randomized clinical trial for PNES revealed significant seizure reduction and improved comorbid symptoms and global functioning with CBT-ip for PNES without and with sertraline. There were no improvements in the sertraline-only or treatment-as-usual arms. This study supports the use of manualized psychotherapy for PNES and successful training of mental health clinicians in the treatment. Future studies could assess larger-scale intervention dissemination.
ANNOTATION (Nicholas Kontos)
Deep-brain stimulation (DBS) has progressed to the point where its usage may be on the cusp of expansion in terms of disorders that can be targeted and patients for whom it is feasible. There are, of course, still considerable barriers to neuromodulation becoming clinically mainstreamed quickly.
Strengths and Weaknesses: This essay is less a review than a commemoration of the awarding of Benbaid & DuLong with the Lasker-Debakey Clnical Medical Research Award. Still, in so doing, the author produces a nice, succinct summary of the state of the field in DBS, and provides two very nice figures that could be useful for teaching purposes.
Relevance: The default mode network is not a new idea, but one of increasing interest in neuroscience. This paper provides an “in” for clinicians to begin to think about its importance in understanding psychopathology. Many physicians will not encounter DBS in their daily work, but the intervention has reached a point where all should be aware of its use and rationale.
Scribonius Largus, the court physician for the Roman emperor Claudius, used an electrical torpedo fish in 50 A.D. to treat headaches and gout. More than 1000 years elapsed before the idea of therapeutic brain stimulation was rekindled. In 1786, Luigi Galvani demonstrated that he could conduct electricity through the nerves in a frog’s leg. Later, Alessandro Volta conducted electrical current through wires and built crude but effective battery sources. Yet none of these experimenters could have predicted the usefulness of their technology in treating human disease by applying an electrical current within the human brain. This year’s Lasker-Debakey Clinical Medical…