Response heterogeneity: Challenges for personalised medicine and big data approaches in psychiatry and chronic pain

Response rates to available treatments for psychological and chronic pain disorders are poor, and there is a considerable burden of suffering and disability for patients, who often cycle through several rounds of ineffective treatment. As individuals presenting to the clinic with symptoms of these disorders are likely to be heterogeneous, there is considerable interest in the possibility that different constellations of signs could be used to identify subgroups of patients that might preferentially benefit from particular kinds of treatment. To this end, there has been a recent focus on the application of machine learning methods to attempt to identify sets of predictor variables (demographic, genetic, etc.) that could be used to target individuals towards treatments that are more likely to work for them in the first instance. Importantly, the training of such models generally relies on datasets where groups of individual predictor variables are labelled with a binary outcome category − usually ‘responder’ or ‘non-responder’ (to a particular treatment). However, as previously highlighted in other areas of medicine, there is a basic statistical problem in classifying individuals as ‘responding’ to a particular treatment on the basis of data from conventional randomized controlled trials. Specifically, insufficient information on the partition of variance components in individual symptom changes mean that it is inappropriate to consider data from the active treatment arm alone in this way. This may be particularly problematic in the case of psychiatric and chronic pain symptom data, where both within-subject variability and measurement error are likely to be high. Here, we outline some possible solutions to this problem in terms of dataset design and machine learning methodology, and conclude that it is important to carefully consider the kind of inferences that particular training data are able to afford, especially in arenas where the potential clinical benefit is so large

Brain mechanisms underlying sensation-seeking in humans

Sensation-seeking is a personality trait concerned with motivation for intense and unusual sensory experiences, that has been identified as risk factor for a variety of psychopathologies with high social cost; in particular gambling and substance addictions. It has previously proved difficult to tease out neural mechanisms underlying sensation-seeking in humans, due to a lack of cognitive-behavioural paradigms probing sensation-seeking-like behaviour in the lab. The first aim of this thesis was to develop such a behavioural paradigm. Within, we present evidence from this novel task and a combination of psychopharmacological, functional imaging and computational approaches to argue that sensation-seeking behaviour in humans is driven by inter-individual differences in the activation of dopaminergic approach-withdrawal tendencies, when faced with the opportunity to experience intense and unusual sensory stimulation. In a parallel research stream, we investigate the relationship between self-reported sensation-seeking, D2-type dopamine receptor function and risky decision-making, motivated by the common implication of sensation-seeking personality and D2ergic drugs in disorders involving excessive risk-taking. Together, the findings presented here may aid investigation of various psychopathologies for which more extreme sensation-seeking scores constitute a vulnerability factor. In particular, a more precise understanding of sensation-seeking behaviour might aid in the identification of at-risk individuals and the development of individualised therapies and prevention strategies

Sensation-seeking: Dopaminergic modulation and risk for psychopathology

Sensation-seeking (SS) is a personality trait that refers to individual differences in motivation for intense and unusual sensory experiences. It describes a facet of human behaviour that has direct relevance for several psychopathologies associated with high social cost. Here, we first review ways of measuring SS behaviour in both humans and animals. We then present convergent evidence that implicates dopaminergic neurotransmission (particularly via D2-type receptors) in individual differences in SS trait. Both high tonic dopamine levels and hyper-reactive midbrain dopaminergic responses to signals of forthcoming reward are evident in higher sensations-seekers. We propose that differences in the efficacy of striatal dopaminergic transmission may result in differential expression of approach-avoidance reactions to same intensity stimuli. This constitutes a quantitative trait of intensity preference for sensory stimulation that may underlie core features of the SS personality. We review the evidence that high trait SS is a vulnerability factor for psychopathologies related to changes in brain dopamine function, in particular substance and gambling addictions. Conversely, we consider the possibility that increased tolerance of high intensity stimulation may represent a protective mechanism against the development of trauma-related psychopathologies (e.g. post-traumatic stress disorder) in high sensation-seeking individuals. Further understanding of the brain mechanisms underlying SS trait might not only to shed light on the aetiology of these disorders, but also aid in developing individualised therapies and prevention strategies for psychopathologies

Shared Neural Mechanisms for the Evaluation of Intense Sensory Stimulation and Economic Reward, Dependent on Stimulation-Seeking Behavior

Why are some people strongly motivated by intense sensory experiences? Here we investigated how people encode the value of an intense sensory experience compared with economic reward, and how this varies according to stimulation-seeking preference. Specifically, we used a novel behavioral task in combination with computational modeling to derive the value individuals assigned to the opportunity to experience an intense tactile stimulus (mild electric shock). We then examined functional imaging data recorded during task performance to see how the opportunity to experience the sensory stimulus was encoded in stimulation-seekers versus stimulation-avoiders. We found that for individuals who positively sought out this kind of sensory stimulation, there was common encoding of anticipated economic and sensory rewards in the ventromedial prefrontal cortex. Conversely, there was robust encoding of the modeled probability of receiving such stimulation in the insula only in stimulation-avoidant individuals. Finally, we found preliminary evidence that sensory prediction error signals may be positively signed for stimulation-seekers, but negatively signed for stimulation-avoiders, in the posterior cingulate cortex. These findings may help explain why high intensity sensory experiences are appetitive for some individuals, but not for others, and may have relevance for the increased vulnerability for some psychopathologies, but perhaps increased resilience for others, in high sensation-seeking individuals.People vary in their preference for intense sensory experiences. Here, we investigated how different individuals evaluate the prospect of an unusual sensory experience (electric shock), compared with the opportunity to gain a more traditional reward (money). We found that in a subset of individuals who sought out such unusual sensory stimulation, anticipation of the sensory outcome was encoded in the same way as that of monetary gain, in the ventromedial prefrontal cortex. Further understanding of stimulation-seeking behavior may shed light on the etiology of psychopathologies such as addiction, for which high or low sensation-seeking personality has been identified as a risk factor

Evaluation of a manualised speech and language therapy programme for children with social communication disorder: the SCIP feasibility study

Background: Children with Social (Pragmatic) Communication Disorder (SPCD) have long-3 term needs in using and processing social language and have a high risk of later mental health difficulties. A manualised speech and language therapy programme, the Social Communication Intervention Programme (SCIP) provides therapy content for SPCD. A feasibility study is required to derive more precise estimates of key parameters for a future trial of SCIP. Aims: To assess the feasibility of conducting a substantive randomized controlled trial of SCIP for children with SPCD. Methods: A questionnaire was distributed to paediatric speech and language therapists in England. Survey questions addressed number of eligible children, routine intervention provision and trial recruitment factors. In the second phase, a single-arm intervention feasibility study was completed. 15 speech and language practitioners identified 24 children aged 5-11 years with SPCD. Practitioners received training/supervision to deliver 20 SCIP therapy sessions to each child. At Time 1 parents of participating children provided three communication goals; expected steps in each goal were defined. After intervention, parents and practitioners independently rated each goal compared to baseline ability. Two research practitioners compared parent post-intervention commentaries with outcome scores to derive guidance about clinical significance. All practitioners recorded audio commentaries on therapy experiences. Post-intervention interviews were conducted with 6 practitioners and 6 parents. An expert panel completed a Delphi consultation on trial design. Results: Routine practice for SPCD varies widely. Children tend to be embedded in autism provision. Participation in a future trial was well-supported, provided resources are available to services. Outcomes analysis indicated all children except one made some progress on parent ratings; all children made progress on practitioner ratings. A power analysis for a future trial was carried out using current outcome measure as putative primary endpoint. Practitioners’ audio-diaries provided suggestions for training and adaption in a future trial. Outcomes and therapy methods were acceptable to practitioners and parents. Conclusions: The feasibility study evaluated a novel outcome measure of social communication skills in SPCD. A power calculation indicated a feasible framework for a trial within a realistic period of time. Recommendations for recruitment methods, adaptation of manual and training were 6 supported by practitioners and an expert panel

Parental phonological memory contributes to prediction of outcome of late talkers from 20 months to 4 years: a longitudinal study of precursors of specific language impairment

Background Many children who are late talkers go on to develop normal language, but others go on to have longer-term language difficulties. In this study, we considered which factors were predictive of persistent problems in late talkers. Methods Parental report of expressive vocabulary at 18 months of age was used to select 26 late talkers and 70 average talkers, who were assessed for language and cognitive ability at 20 months of age. Follow-up at 4 years of age was carried out for 24 late and 58 average talkers. A psychometric test battery was used to categorize children in terms of language status (unimpaired or impaired) and nonverbal ability (normal range or more than 1 SD below average). The vocabulary and non-word repetition skills of the accompanying parent were also assessed. Results Among the late talkers, seven (29%) met our criteria for specific language impairment (SLI) at 4 years of age, and a further two (8%) had low nonverbal ability. In the group of average talkers, eight (14%) met the criteria for SLI at 4 years, and five other children (8%) had low nonverbal ability. Family history of language problems was slightly better than late-talker status as a predictor of SLI.. The best predictors of SLI at 20 months of age were score on the receptive language scale of the Mullen Scales of Early Learning and the parent's performance on a non-word repetition task. Maternal education was not a significant predictor of outcome. Conclusions In this study, around three-quarters of late talkers did not have any language difficulties at 4 years of age, provided there was no family history of language impairment. A family history of language-literacy problems was found to be a significant predictor for persisting problems. Nevertheless, there are children with SLI for whom prediction is difficult because they did not have early language delay

A multimeasure approach to investigating affective appraisal of social information in Williams syndrome

People with Williams syndrome (WS) have been consistently described as showing heightened sociability, gregariousness, and interest in people, in conjunction with an uneven cognitive profile and mild to moderate intellectual or learning disability. To explore the mechanisms underlying this unusual social–behavioral phenotype, we investigated whether individuals with WS show an atypical appraisal style and autonomic responsiveness to emotionally laden images with social or nonsocial content. Adolescents and adults with WS were compared to chronological age-matched and nonverbal mental age-matched groups in their responses to positive and negative images with or without social content, using measures of self-selected viewing time (SSVT), autonomic arousal reflected in pupil dilation measures, and likeability ratings. The participants with WS looked significantly longer at the social images compared to images without social content and had reduced arousal to the negative social images compared to the control groups. In contrast to the comparison groups, the explicit ratings of likeability in the WS group did not correlate with their SSVT; instead, they reflected an appraisal style of more extreme ratings. This distinctive pattern of viewing interest, likeability ratings, and autonomic arousal to images with social content in the WS group suggests that their heightened social drive may be related to atypical functioning of reward-related brain systems reflected in SSVT and autonomic reactivity measures, but not in explicit ratings

Mnesic imbalance: a cognitive theory about autism spectrum disorders

Autism is characterized by impairments in social interaction, communicative capacity and behavioral flexibility. Some cognitive theories can be useful for finding a relationship between these irregularities and the biological mechanisms that may give rise to this disorder. Among such theories are mentalizing deficit, weak central coherence and executive dysfunction, but none of them has been able to explain all three diagnostic symptoms of autism. These cognitive disorders may be related among themselves by faulty learning, since several research studies have shown that the brains of autistic individuals have abnormalities in the cerebellum, which plays a role in procedural learning. In keeping with this view, one may postulate the possibility that declarative memory replaces faulty procedural memory in some of its functions, which implies making conscious efforts in order to perform actions that are normally automatic. This may disturb cognitive development, resulting in autism symptoms. Furthermore, this mnesic imbalance is probably involved in all autism spectrum disorders. In the present work, this theory is expounded, including preliminary supporting evidence