Gruppentherapie bei Patienten und Patientinnen mit Angststörung oder somatoformem Schwindel

Nach derzeitigem Kenntnisstand ist dies die erste Studie die Personen mit einem somatoformen Schwindel mit Personen mit einer Angststörung vergleicht sowie die erste Studie, die neurobiologische Daten zu einer kognitiven Verhaltensthera-pie von Personen mit somatoformen Schwindel darlegt. Die vorliegenden psychometrischen als auch neurobiologischen Daten weisen darauf hin, dass hier von unterschiedlichen Patientenkollektiven ausgegangen werden muss. Personen mit einem somatoformen Schwindel sind somit keine klassischen Angstpatienten/-innen im engeren Sinne, weisen jedoch eine starke Angstkomponente auf. Bei-spielsweise zeigten die Personen mit einem somatoformen Schwindel vor Beginn der Behandlung ähnlich hohe Angstwerte wie die Angstgruppe, die signifikant höher lagen als die der Kontrollgruppen. Es konnte gezeigt werden, dass diese nicht alleine durch die komorbiden Angststörungen erklärt werden kann, da ers-tens nicht alle betroffenen Personen eine komorbide Angststörung hatten sowie keine Reduktion wie in der Angstgruppe stattfand. Im Gegenteil, es scheint, dass die Schwindelsymptome die Angstsymptome aufrechterhalten und von einer Kon-fundierung auszugehen ist. Zusätzlich muss von einem zeitlich überdauernden Angsttemperament (engl. trait) ausgegangen werden, wie die prä-post-Analysen zeigten. Gleichzeitig wies die Schwindelgruppe höhere Schwindelwerte (statisti-schem Trendniveau, VSS-VER Fragebogen - Subskala Schwindelsymptomstärke) als Personen mit einer Angststörung auf. Weiterhin wies auch das Angststö-rungskollektiv eine ausgeprägte Schwindelsymptomatik auf im Vergleich zur Kon-trollgruppe. Die Hypothese 1, dass sich eine Psychotherapie gleich wirksam auf beide Gruppen auswirkt, musste verworfen werden. Die Angstgruppe zeigte einen stärkeren Rückgang in Angst- und Depressionswerten als die Schwindelgruppe bei meist mittleren Effektstärken. Dennoch konnten auch Personen mit einem so-matoformen Schwindel von der Gruppentherapie profitieren, indem sich der Um-gang mit den Symptomen sowie die Lebenszufriedenheit signifikant verbesserten. Hinsichtlich der neurobiologischen Daten zeichnete sich ein Ergebnis entgegen unserer Hypothesen ab. In den Prä-Post-Messungen reduzierten sich die BOLD-Aktivierungen in den emotionalen, vestibulären und visuellen Netzwerken in allen Gruppen, wobei die größte Abnahme in der Kontrollgruppe festzustellen war, gefolgt von der Angstgruppe. Es ist davon auszugehen, dass die gesunde Kon-trollgruppe besser an die negativ emotionalen Bilder adaptierte als die Versuchs-gruppen. Im Umkehrschluss bedeutet dies, dass mit zunehmender psychischer Beeinträchtigung die negative Emotionalität der Bilder auch nach mehrmaliger Betrachtung stärker erhalten bleibt, was sich direkt proportional als neurobiolo-gisches Korrelat abzeichnet. Für diese Annahme sprechen sowohl die Fragebog-energebnisse als auch die weiteren neurobiologischen Direktvergleiche der Gruppen zum zweiten Messzeitpunkt nach der Therapie. So wies die Schwindel-gruppe eine höhere BOLD-Aktivität im Angstnetzwerk (Amygdala, IFG) und dem Schwindelnetzwerk (SMG, Lobulus parietalis inferior, Cerebellum, Precuneus und Cuneus) als die Angstgruppe auf. Somit muss auch auf neurobiologischer Ebene die Hypothese 1, dass sich eine Psychotherapie gleich wirksam auf beide Gruppen auswirkt, verworfen werden. Daraus lässt sich ableiten, dass sich durch Psycho-therapie ein größerer neurophysiologischer Effekt in der Angstgruppe als in der Schwindelgruppe erzielen ließ, da dieser Unterschied zum ersten Messzeitpunkt zwischen den Versuchsgruppen noch nicht so deutlich bestanden hatte. Unter-mauert wird dieses Ergebnis noch zusätzlich durch die ROI-Analysen, denn ein signifikanter Rückgang der neuronalen Aktivität wurde nur in der Angstgruppe in Strukturen des Angstnetzwerks (Hippocampus, Thalamus, IFG und Insula) von T1 zu T2 festgestellt. Für einen Therapieeffekt in der Angstgruppe spricht eine Zunahme an neurona-ler Aktivität in frontalen Arealen (dlPFC, OFC), welche mit einer erhöhten kogniti-ven Kontrolle in Verbindung gebracht werden im Sinne einer verbesserten Emo-tionsregulation. Therapieeffekte in der Schwindelgruppe ließen sich deutlich schwieriger neurobiologisch einordnen. Dies hängt einerseits mit einer einge-schränkten Datenlage und andererseits mit unterschiedlichen Provokationsme-thoden der Einzelstudien zusammen. Darüber hinaus ist davon auszugehen, dass Personen mit Schwindel aufgrund einer stark physiologisch erlebten Komponente bzw. eines somatisch geprägten Krankheitsverständnisses weniger zugänglich für Psychotherapie sind. Neurobiologische Korrelate, die für eine Wirksamkeit von Psychotherapie bei Personen mit somatoformen Schwindel sprechen würden, sind ein Rückgang der neuronalen Aktivität im Cuneus, im motorischen und soma-tosensorischen Kortex (Gyrus precentralis und Gyrus postcentralis) und in visuel-len Arealen. Dieser Befund könnte auf eine Verringerung der Haltungskontrolle und visuellen Kompensation hinweisen, wie er u.a. bei Best et al. (2015) bzw. Limburg et al. (2021) nach einer Psychotherapie beschrieben wurde. Weiterhin konnte eine signifikante Abnahme der neuronalen Aktivität im STG in der Schwin-delgruppe beobachtet werden, einer Struktur, welche im Zusammenhang mit Angst-, aber auch Schwindelsymptomen steht, so dass hier von einem Therapieef-fekt ausgegangen wird. Die Fragestellung, ob es für Patienten und Patientinnen mit einem somatoformen Schwindel neue innovative Therapiekonzepte bedarf, kann mit dieser Studie nicht endgültig beantwortet werden und muss durch zukünftige Studien eruiert wer-den. Vermutlich handelte es sich bei Personen mit einem somatoformen Schwin-del um ein schwerwiegenderes bzw. chronifizierteres Krankheitsbild bzw. Patien-tenkollektiv im Vergleich zur Angstgruppe. Sicherlich bedarf es eines größeren Psychotherapiestundenkontingents in der Behandlung des somatoformen Schwindels, um psychotherapeutische Maßnahmen sicherer in den Alltag integ-rieren und aufrechterhaltende Faktoren besser eruieren zu können. Es ist auch davon auszugehen, dass eine Schwindel-Exposition weniger wirksam war als eine Angstexposition. Daher sollten weitere Provokationsmethoden hinsichtlich Schwindelsymptome zum Einsatz kommen. Denkbar wäre ein Ansatz der zusätz-lich das visuellen System berücksichtigt, da Patienten und Patientinnen mit soma-toformen Schwindel übermäßig visuell kompensieren. In zukünftigen Studien soll-te weiterhin eine größere Stichprobe, eine Katamnese, eine Posturographiemes-sung sowie ein Messdesign, welches Habituationseffekte durch Messwiederholung besser kontrolliert, Berücksichtigung finden.To the best of our knowledge, this is the first study to compare people with soma-toform vertigo to people with anxiety disorder and the first study to present neu-robiological data on cognitive behavioural therapy for people with somatoform vertigo. The available psychometric as well as neurobiological data indicate that different patient collectives must be assumed here. Patients suffering from soma-toform vertigo are therefore not classic anxiety patients in the strict sense, but they do have a strong anxiety component. For example, the patients with somato-form vertigo showed similarly high anxiety scores before the start of treatment as the anxiety group, which were significantly higher than those of the control groups. It could be shown that this cannot be explained by a comorbid anxiety disorder alone, because firstly, not all patients had a comorbid anxiety disorder. Secondly, the patients with somatoform vertigo were not able to reduce their anx-iety symptoms as much as in the anxiety group. On the contrary, it seems that the vertigo symptoms maintain the anxiety symptoms and a confounding can be as-sumed. In addition, an anxiety trait that persists over time must be assumed, as the pre-post analyses showed. At the same time, the dizziness group had higher dizziness scores (statistical trend level, VSS-VER questionnaire - dizziness symp-tom intensity subscale) than people with an anxiety disorder. Furthermore, the anxiety group also showed a pronounced dizziness symptomatology compared to the control group. Hypothesis 1, that psychotherapy would have the same effect on both groups, had to be rejected. The anxiety group showed a stronger decrease in anxiety and de-pression scores than the dizziness group with mostly medium effect sizes. Never-theless, people with somatoform vertigo also benefited from the group therapy by significantly improving their symptom management and life satisfaction. With regard to the neurobiological data, one result emerged contrary to our hy-potheses. In the pre-post measurements, the BOLD activations in the emotional, vestibular and visual networks were reduced in all groups, with the greatest de-crease in the control group, followed by the anxiety group. It can be assumed that the healthy control group adapted better to the negative emotional images than the experimental groups. Conversely, this could mean that with increasing psy-chological impairment, the negative emotionality of the images is retained more strongly even after repeated viewing, which is directly proportional as a neurobi-ological correlate. This assumption is supported by both the questionnaire results and the further neurobiological direct comparisons of the groups at the second measurement point after the therapy. The dizziness group showed a higher BOLD activity in the fear network (amygdala, IFG) and the dizziness network (SMG, lobu-lus parietalis inferior, cerebellum, precuneus and cuneus) than the anxiety group. Thus, also on a neurobiological level, hypothesis 1, that psychotherapy has the same effect on both groups, must be rejected. It can be deduced from this that a greater neurophysiological effect could be achieved in the anxiety group than in the dizziness group through psychotherapy, as this difference had not yet existed so clearly between the experimental groups at the first measurement time point. This result is further supported by the ROI analyses, because a significant de-crease in neuronal activity was only found in the anxiety group in structures of the anxiety network (hippocampus, thalamus, IFG and insula) from T1 to T2. Fur-thermore, it can be assumed that people with vertigo are less accessible to psy-chotherapy due to a strongly physiologically experienced component or a somati-cally shaped disease model. Neurobiological correlates that would suggest an effi-cacy of psychotherapy in individuals with somatoform vertigo are a decrease in neuronal activity in the cuneus, motor and somatosensory cortex (precentral gy-rus and postcentral gyrus) and visual areas. This finding could indicate a reduc-tion in postural control and visual compensation, as described by Best et al. (2015) and Limburg et al. (2021), among others, after psychotherapy. Further-more, a significant decrease in neuronal activity in the STG could be observed in the dizziness group, a structure that is associated with anxiety, but also dizziness symptoms, so that a therapeutic effect can be assumed here

A cross-sectional survey of internet use among university students

The last 2~decades have seen an increase in the number of reports of excessive internet use. Therefore, this study aimed to examine internet use among university students to gain more insight into the novel phenomenon of addictive internet use (AIU). Data were collected by the means of an online questionnaire sent to 4391 students. Approximately 10% of the 4391 students could be included in the statistical analysis. Of those 483 students, almost all (99.2%) used the internet, and a quarter (24.8%) showed AIU. The students used the internet mostly for information searches, random browsing, social networking, and online shopping; however, AIU was seen most often in the areas of social networking, random browsing, information searches, gaming, and pornography. One in four of the respondents showed addictive behavior in at least one area of internet use. Students with AIU in the area of random browsing were significantly less far advanced in their studies than those without AIU, and well-being was significantly poorer across AIU groups than in those who did not show AIU. The study confirms the importance of AIU, as reflected in the high prevalence of AIU among the students and the significantly lower level of well-being in those with AIU. Undifferentiated consideration of AIU does not do justice to its various facets, and future research should consider all areas of internet use, with the aim to increase understanding of the underlying mechanisms of AIU and develop more differentiated treatment approaches

Neurofunctional differences and similarities between persistent postural-perceptual dizziness and anxiety disorder

Introduction: Persistent postural-perceptual dizziness (PPPD) (ICD-11) and anxiety disorders (ANX) share behavioural symptoms like anxiety, avoidance, social withdrawal, hyperarousal, or palpitation as well as neurological symptoms like vertigo, stance and gait disorders. Furthermore, previous studies have shown a bidirectional link between vestibulo-spatial and anxiety neural networks. So far, there have been no neuroimaging-studies comparing these groups. Objectives: The aim of this explorative study was to investigate differences and similarities of neural correlates between these two patient groups and to compare their findings with a healthy control group. Methods: 63 participants, divided in two patient groups (ANX = 20 and PPPD = 14) and two sex and age matched healthy control groups (HC-A = 16, HC-P = 13) were included. Anxiety and dizziness related pictures were shown during fMRI-measurements in a block-design in order to induce emotional responses. All subjects filled in questionnaires regarding vertigo (VSS, VHQ), anxiety (STAI), depression (BDI-II), alexithymia (TAS), and illness-perception (IPQ). After modelling the BOLD response with a standard canonical HRF, voxel-wise t-tests between conditions (emotional-negative vs neutral stimuli) were used to generate statistical contrast maps and identify relevant brain areas (pFDR 30 voxels). ROI-analyses were performed for amygdala, cingulate gyrus, hippocampus, inferior frontal gyrus, insula, supramarginal gyrus and thalamus (p ≤ 0.05). Results: Patient groups differed from both HC groups regarding anxiety, dizziness, depression and alexithymia scores; ratings of the PPPD group and the ANX group did differ significantly only in the VSS subscale ‘vertigo and related symptoms’ (VSS-VER). The PPPD group showed increased neural responses in the vestibulo-spatial network, especially in the supramarginal gyrus (SMG), and superior temporal gyrus (STG), compared to ANX and HC-P group. The PPPD group showed increased neural responses compared to the HC-P group in the anxiety network including amygdala, insula, lentiform gyrus, hippocampus, inferior frontal gyrus (IFG) and brainstem. Neuronal responses were enhanced in visual structures, e.g. fusiform gyrus, middle occipital gyrus, and in the medial orbitofrontal cortex (mOFC) in healthy controls compared to patients with ANX and PPPD, and in the ANX group compared to the PPPD group. Conclusions: These findings indicate that neuronal responses to emotional information in the PPPD and the ANX group are comparable in anxiety networks but not in vestibulo-spatial networks. Patients with PPPD revealed a stronger neuronal response especially in SMG and STG compared to the ANX and the HC group. These results might suggest higher sensitivity and poorer adaptation processes in the PPPD group to anxiety and dizziness related pictures. Stronger activation in visual processing areas in HC subjects might be due to less emotional and more visual processing strategies

Real-Time fMRI Neurofeedback in Patients With Tobacco Use Disorder During Smoking Cessation: Functional Differences and Implications of the First Training Session in Regard to Future Abstinence or Relapse

One of the most prominent symptoms in addiction disorders is the strong desire to consume a particular substance or to show a certain behavior (craving). The strong association between craving and the probability of relapse emphasizes the importance of craving in the therapeutic process. Former studies have demonstrated that neuromodulation using real-time fMRI (rtfMRI) neurofeedback (NF) can be used as a treatment modality in patients with tobacco use disorder. The aim of the present project was to determine whether it is possible to predict the outcome of NF training plus group psychotherapy at the beginning of the treatment. For that purpose, neuronal responses during the first rtfMRI NF session of patients who remained abstinent for at least 3 months were compared to those of patients with relapse. All patients were included in a certified smoke-free course and took part in three NF sessions. During the rtfMRI NF sessions tobacco-associated and neutral pictures were presented. Subjects were instructed to reduce their neuronal responses during the presentation of smoking cues in an individualized region of interest for craving [anterior cingulate cortex (ACC), insula or dorsolateral prefrontal cortex]. Patients were stratified to different groups [abstinence (N = 10) vs. relapse (N = 12)] according to their individual smoking status 3 months after the rtfMRI NF training. A direct comparison of BOLD responses during the first NF-session of patients who had remained abstinent over 3 months after the NF training and patients who had relapsed after 3 months showed that patients of the relapse group demonstrated enhanced BOLD responses, especially in the ACC, the supplementary motor area as well as dorsolateral prefrontal areas, compared to abstinent patients. These results suggest that there is a probability of estimating a successful withdrawal in patients with tobacco use disorder by analyzing the first rtfMRI NF session: a pronounced reduction of frontal responses during NF training in patients might be the functional correlate of better therapeutic success. The results of the first NF sessions could be useful as predictor whether a patient will be able to achieve success after the behavioral group therapy and NF training in quitting smoking or not

Weniger is(s)t mehr : fasten mit Ausblick auf Psychotherapie

Maximilian MaywaldZsfass. in engl. SpracheKlagenfurt, Alpen-Adria-Univ., Dipl.-Arb., 2011(VLID)241592

Functional and clinical outcomes of FMRI-based neurofeedback training in patients with alcohol dependence: a pilot study

Identifying treatment options for patients with alcohol dependence is challenging. This study investigates the application of real-time functional MRI (rtfMRI) neurofeedback (NF) to foster resistance towards craving-related neural activation in alcohol dependence. We report a double-blind, placebo-controlled rtfMRI study with three NF sessions using alcohol-associated cues as an add-on therapy to the standard treatment. Fifty-two patients (45 male; 7 female) diagnosed with alcohol dependence were recruited in Munich, Germany. RtfMRI data were acquired in three sessions and clinical abstinence was evaluated 3 months after the last NF session. Before the NF training, BOLD responses and clinical data did not differ between groups, apart from anger and impulsiveness. During NF training, BOLD responses of the active group were decreased in medial frontal areas/caudate nucleus, and increased, e.g. in the cuneus/precuneus and occipital cortex. Within the active group, the down-regulation of neuronal responses was more pronounced in patients who remained abstinent for at least 3 months after the intervention compared to patients with a relapse. As BOLD responses were comparable between groups before the NF training, functional variations during NF cannot be attributed to preexisting distinctions. We could not demonstrate that rtfMRI as an add-on treatment in patients with alcohol dependence leads to clinically superior abstinence for the active NF group after 3 months. However, the study provides evidence for a targeted modulation of addiction-associated brain responses in alcohol dependence using rtfMRI

Individual- and Connectivity-Based Real-Time fMRI Neurofeedback to Modulate Emotion-Related Brain Responses in Patients with Depression: A Pilot Study

Introduction: Individual real-time functional magnetic resonance imaging neurofeedback (rtfMRI NF) might be a promising adjuvant in treating depressive symptoms. Further studies showed functional variations and connectivity-related changes in the dorsolateral prefrontal cortex (dlPFC) and the insular cortex. Objectives: The aim of this pilot study was to investigate whether individualized connectivity-based rtfMRI NF training can improve symptoms in depressed patients as an adjunct to a psychotherapeutic programme. The novel strategy chosen for this was to increase connectivity between individualized regions of interest, namely the insula and the dlPFC. Methods: Sixteen patients diagnosed with major depressive disorder (MDD, ICD-10) and 19 matched healthy controls (HC) participated in a rtfMRI NF training consisting of two sessions with three runs each, within an interval of one week. RtfMRI NF was applied during a sequence of negative emotional pictures to modulate the connectivity between the dlPFC and the insula. The MDD REAL group was divided into a Responder and a Non-Responder group. Patients with an increased connectivity during the second NF session or during both the first and the second NF session were identified as “MDD REAL Responder” (N = 6). Patients that did not show any increase in connectivity and/or a decreased connectivity were identified as “MDD REAL Non-Responder” (N = 7). Results: Before the rtfMRI sessions, patients with MDD showed higher neural activation levels in ventromedial PFC and the insula than HC; by contrast, HC revealed increased hemodynamic activity in visual processing areas (primary visual cortex and visual association cortex) compared to patients with MDD. The comparison of hemodynamic responses during the first compared to during the last NF session demonstrated significantly increased BOLD-activation in the medial orbitofrontal cortex (mOFC) in patients and HC, and additionally in the lateral OFC in patients with MDD. These findings were particularly due to the MDD Responder group, as the MDD Non-Responder group showed no increase in this region during the last NF run. There was a decrease of neural activation in emotional processing brain regions in both groups in the last NF run compared to the first: HC showed differences in the insula, parahippocampal gyrus, basal ganglia, and cingulate gyrus. Patients with MDD demonstrated deceased responses in the parahippocampal gyrus. There was no significant reduction of BDI scores after NF training in patients. Conclusions: Increased neural activation in the insula and vmPFC in MDD suggests an increased emotional reaction in patients with MDD. The activation of the mOFC could be associated with improved control-strategies and association-learning processes. The increased lOFC activation could indicate a stronger sensitivity to failed NF attempts in MDD. A stronger involvement of visual processing areas in HC may indicate better adaptation to negative emotional stimuli after repeated presentation. Overall, the rtfMRI NF had an impact on neurobiological mechanisms, but not on psychometric measures in patients with MDD