Estrategias terapéuticas en el trastorno obsesivo-compulsivo

El trastorno obsesivo-compulsivo (TOC) es uno de los trastornos psiquiátricos que se ha beneficiado de mayores avances durante las dos últimas décadas, tanto desde el punto de vista etiopatogénico como terapéutico. Cada vez existen más estrategias terapéuticas que pueden ser útiles en el tratamiento del TOC, especialmente en los casos de TOC refractario. Se realiza una revisión crítica de las distintas estrategias terapéuticas en el TOC, especialmente la clomipramina, los inhibidores selectivos de la recaptación de serotonma y la terapia de conducta. Se describen diversas estrategias de potenciación, y algunas alternativas terapéuticas en fase todavía de experimentación, como la estimulación magnética transcraneal y la plasmaféresis. Sin embargo, al efectuar esta revisión aparecen diversas controversias: Primero: distintos artículos utilizan diferentes definiciones de refractariedad, haciendo más difícil la comparación entre los distintos estudios. Segundo: los pacientes de distintos estudios no son directamente comparables, con la posibilidad de inclusión de pacientes del espectro obsesivo, pacientes con comorbilidad con otros trastornos y también una mala diferenciación entre idea obsesiva - idea obsesivoide, y entre compulsión e impulsión. Finalmente, no existe un consenso acerca de cuál debe ser el tratamiento de primera elección, y si distintos tipos de pacientes se benefician diferencialmente de unos u otros tratamientos

Síndrome d'Acumulació Compulsiva: "M'ho guardo. No sigui cas que..."

El 50% de les persones que pateixen aquesta síndrome no presenten un quadre de Transtorn Obsessiu Compulsiu. Una dada clau per entendre més a fons una variant poc estudiada i que cal diferenciar de la síndrome de Diògenes. Es tracta de persones de qualsevol edat, majoritàriament dones, que els resulta difícil desprendre's d'objectes sense valor i amb els que, en gran part dels casos, estableixen un vincle emocional. Una situació que deriva en espais inhabitables de la llar i condiciona el dia a dia del pacient. El següent estudi, encapçalat pel Departament de Psiquiatria de l'Hospital de Bellvitge, i amb la col·laboració de l'Institute of Psychiatry de Londres, obre el camí per continuar investigant. De moment, el mes d'octubre passat, l'article va ser publicat a la revista American Journal of Psychiatry.El 50% de las personas que sufren este síndrome no presentan un cuadro de Trastorno Obsesivo Compulsivo. Un dato clave para entender más a fondo una variante poco estudiada y que hay que diferenciar del síndrome de Diógenes. Se trata de personas de cualquier edad, mayoritariamente mujeres, que les resulta difícil desprenderse de objetos sin valor y con los que, en gran parte de los casos, establecen un vínculo emocional. Una situación que deriva en espacios inhabitables del hogar y condiciona el día a día del paciente. El siguiente estudio, encabezando por el Departamento de Psiquiatría del Hospital de Bellvitge, y con la colaboración de l'Institute of Psychiatry de Londres, abre el camino para continuar investigando. De momento, el pasado mes de octubre, el artículo fue publicado en la revista American Journal of Psychiatry

Gambling in Spain: update on experience, research and policy

AIMS: To describe the current situation of gambling in Spain, sketching its history and discussing the regulations and legislation currently in force within the framework of the European Union (EU), and to review the epidemiology of gambling in Spain, the self-help groups and professional treatments available, and their potential effectiveness. METHODS: A systematic computerized search was performed in three databases (EMBASE, PubMed and PsychINFO, including articles and chapters) and the reference lists from previous reviews to obtain some of the most relevant studies published up to now on the topic of pathologic gambling in Spain. RESULTS: Similar to other EU countries, Spain has a high prevalence of pathologic gambling, focused on specific culturally bounded types of gambling. Expenditure in online gaming has risen significantly in the last few years, prompting the Spanish government to draft new legislation to regulate gaming. CONCLUSIONS: The gaming industry is expected to be one of the fastest growing sectors in Spain in the coming years owing to the rise of new technologies and the development of online gamin

Symptomatic remission and counterfactual reasoning in schizophrenia

Counterfactual thinking (CFT) is a type of conditional reasoning involving mental representations of alternatives to past factual events that previous preliminary research has suggested to be impaired in schizophrenia. However, despite the potential impact of these deficits on the functional outcome of these patients, studies examining the role of CFT in this disorder are still few in number. The present study aimed to extent previous results by evaluating CFT in the largest sample to date of schizophrenia patients in symptomatic remission and healthy controls. The relationship with symptomatology, illness duration, and sociodemographic characteristics was also explored. Methods: Seventy-eight schizophrenia patients and 84 healthy controls completed a series of tests that examined the generation of counterfactual thoughts, the influence of the 'causal order effect,' and the ability to counterfactually derive inferences by using de Counterfactual Inference Test. Results: Compared with controls, patients generated fewer counterfactual thoughts when faced with a simulated scenario. This deficit was negatively related to scores on all dimensions of the Positive and Negative Syndrome Scale-PANNS, as well as to longer illness duration. The results also showed that schizophrenia patients deviated significantly from the normative pattern when generating inferences from CFT. Conclusions: These findings reveal CFT impairment to be present in schizophrenia even when patients are in symptomatic remission. However, symptomatology and illness duration may have a negative influence on these patients' ability to generate counterfactual thoughts. The results might support the relevance of targeting CFT in future treatment approaches, although further research is needed to better describe the relationship between CFT and both symptomatology and functional outcome

Patients with schizophrenia activate behavioural intentions facilitated by counterfactual reasoning

Previous research has associated schizophrenia with an inability to activate behavioural intentions facilitated by counterfactual thinking (CFT) as a step to improving performance. Consequently, these findings suggest that rehabilitation strategies will be entirely ineffective. To extend previous research, we evaluated the influence of CFT in the activation of behavioural intentions using a novel sequential priming paradigm in the largest sample of subjects explored to date. Method: The main variables assessed were: answer to complete a target task (wrong or correctly), and percentage gain in the reaction time (RT) to complete a target task correctly depending on whether the prime was a counterfactual or a neutral-control cue. These variables were assessed in 37 patients with schizophrenia and 37 healthy controls. Potential associations with clinical status and socio-demographic characteristics were also explored. Results: When a counterfactual prime was presented, the probability of giving an incorrect answer was lower for the entire sample than when a neutral prime was presented (OR 0.58; CI 95% 0.42 to 0.79), but the schizophrenia patients showed a higher probability than the controls of giving an incorrect answer (OR 3.89; CI 95% 2.0 to 7.6). Both the schizophrenia patients and the controls showed a similar percentage gain in RT to a correct answer of 8%. Conclusions: Challenging the results of previous research, our findings suggest a normal activation of behavioural intentions facilitated by CFT in schizophrenia. Nevertheless, the patients showed more difficulty than the controls with the task, adding support to the concept of CFT as a potential new target for consideration in future therapeutic approaches for this illness

Counterfactual reasoning deficits in schizophrenia patients

Background Counterfactual thinking is a specific type of conditional reasoning that enables the generation of mental simulations of alternatives to past factual events. Although it has been broadly studied in the general population, research on schizophrenia is still scarce. The aim of the current study was to further examine counterfactual reasoning in this illness. Methods Forty schizophrenia patients and 40 controls completed a series of tests that assessed the influence of the "causal order effect" on counterfactual thinking, and the ability to generate counterfactual thoughts and counterfactually derive inferences from a hypothetical situation. Socio-demographic and clinical characteristics, as well as neurocognitive variables, were also examined. Results Compared to controls, the schizophrenia patients generated fewer counterfactual thoughts when faced with a simulated scenario. The pattern of response when assessing the causality effect of the order was also different between the groups, with the patients being more frequently unable to attribute any ordering of events than the control subjects. Additionally, the schizophrenia patients showed more difficulties when deriving normative counterfactual inferences from hypothetical social situations. None of the counterfactual reasoning measures was associated to any of the cognitive functions or clinical and socio-demographic variables assessed. Conclusions A global impairment in counterfactual thinking characterizes schizophrenia patients. Because of the potential impact of such deficits on psychosocial functioning, targeting counterfactual reasoning for improvement might be considered in future treatment approaches

Animal models of obsessive-compulsive disorder: utility and limitations

Obsessive-compulsive disorder (OCD) is a disabling and common neuropsychiatric condition of poorly known etiology. Many attempts have been made in the last few years to develop animal models of OCD with the aim of clarifying the genetic, neurochemical, and neuroanatomical basis of the disorder, as well as of developing novel pharmacological and neurosurgical treatments that may help to improve the prognosis of the illness. The latter goal is particularly important given that around 40% of patients with OCD do not respond to currently available therapies. This article summarizes strengths and limitations of the leading animal models of OCD including genetic, pharmacologically induced, behavioral manipulation-based, and neurodevelopmental models according to their face, construct, and predictive validity. On the basis of this evaluation, we discuss that currently labeled 'animal models of OCD' should be regarded not as models of OCD but, rather, as animal models of different psychopathological processes, such as compulsivity, stereotypy, or perseverance, that are present not only in OCD but also in other psychiatric or neurological disorders. Animal models might constitute a challenging approach to study the neural and genetic mechanism of these phenomena from a trans-diagnostic perspective. Animal models are also of particular interest as tools for developing new therapeutic options for OCD, with the greatest convergence focusing on the glutamatergic system, the role of ovarian and related hormones, and the exploration of new potential targets for deep brain stimulation. Finally, future research on neurocognitive deficits associated with OCD through the use of analogous animal tasks could also provide a genuine opportunity to disentangle the complex etiology of the disorder

Mapping Cortical and Subcortical Asymmetry in Obsessive-Compulsive Disorder: Findings From the ENIGMA Consortium

Background: Lateralized dysfunction has been suggested in obsessive-compulsive disorder (OCD). However, it is currently unclear whether OCD is characterized by abnormal patterns of brain structural asymmetry. Here we carried out what is by far the largest study of brain structural asymmetry in OCD. Methods: We studied a collection of 16 pediatric datasets (501 patients with OCD and 439 healthy control subjects), as well as 30 adult datasets (1777 patients and 1654 control subjects) from the OCD Working Group within the ENIGMA (Enhancing Neuro Imaging Genetics through Meta Analysis) Consortium. Asymmetries of the volumes of subcortical structures, and of measures of regional cortical thickness and surface areas, were assessed based on T1-weighted magnetic resonance imaging scans, using harmonized image analysis and quality control protocols. We investigated possible alterations of brain asymmetry in patients with OCD. We also explored potential associations of asymmetry with specific aspects of the disorder and medication status. Results: In the pediatric datasets, the largest case-control differences were observed for volume asymmetry of the thalamus (more leftward; Cohen's d = 0.19) and the pallidum (less leftward; d = -0.21). Additional analyses suggested putative links between these asymmetry patterns and medication status, OCD severity, or anxiety and depression comorbidities. No significant case-control differences were found in the adult datasets. Conclusions: The results suggest subtle changes of the average asymmetry of subcortical structures in pediatric OCD, which are not detectable in adults with the disorder. These findings may reflect altered neurodevelopmental processes in OCD

Neural Network Alterations Across Eating Disorders: A Narrative Review of fMRI Studies

Background: Functional magnetic resonance imaging (fMRI) has provided insight on how neural abnormalities are related to the symptomatology of the eating disorders (EDs): anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). More specifically, an increasingly growing number of brain imaging studies has shed light on how functionally connected brain networks contribute not only to disturbed eating behavior, but also to transdiagnostic alterations in body/interoceptive perception, reward processing and executive functioning. Methods: This narrative review aims to summarize recent advances in fMRI studies of patients with EDs by highlighting studies investigating network alterations that are shared across EDs. Results and Conclusion: Findings on reward processing in both AN and BN patients point to the presence of altered sensitivity to salient food stimuli in striatal regions and to the possibility of hypothalamic inputs being overridden by top-down emotional-cognitive control regions. Additionally, innovative new lines of research suggest that increased activations in fronto-striatal circuits are strongly associated with the maintenance of restrictive eating habits in AN patients. Although significantly fewer studies have been carried out in patients with BN and BED, aberrant neural responses to both food cues and anticipated food receipt appear to occur in these populations. These altered responses, coupled with diminished recruitment of prefrontal cognitive control circuitry, are believed to contribute to the binge eating of palatable foods. Results from functional network connectivity studies are diverse, but findings tend to converge on indicating disrupted resting-state connectivity in executive networks, the default-mode network and the salience network across EDs

Brain Changes Induced by Electroconvulsive Therapy Are Broadly Distributed

BACKGROUND: Electroconvulsive therapy (ECT) is associated with volumetric enlargements of corticolimbic brain regions. However, the pattern of whole-brain structural alterations following ECT remains unresolved. Here, we examined the longitudinal effects of ECT on global and local variations in gray matter, white matter, and ventricle volumes in patients with major depressive disorder as well as predictors of ECT-related clinical response. METHODS: Longitudinal magnetic resonance imaging and clinical data from the Global ECT-MRI Research Collaboration (GEMRIC) were used to investigate changes in white matter, gray matter, and ventricle volumes before and after ECT in 328 patients experiencing a major depressive episode. In addition, 95 nondepressed control subjects were scanned twice. We performed a mega-analysis of single subject data from 14 independent GEMRIC sites. RESULTS: Volumetric increases occurred in 79 of 84 gray matter regions of interest. In total, the cortical volume increased by mean +/- SD of 1.04 +/- 1.03% (Cohen's d = 1.01, p < .001) and the subcortical gray matter volume increased by 1.47 +/- 1.05% (d = 1.40, p < .001) in patients. The subcortical gray matter increase was negatively associated with total ventricle volume (Spearman's rank correlation rho = -.44, p < .001), while total white matter volume remained unchanged (d = -0.05, p = .41). The changes were modulated by number of ECTs and mode of electrode placements. However, the gray matter volumetric enlargements were not associated with clinical outcome. CONCLUSIONS: The findings suggest that ECT induces gray matter volumetric increases that are broadly distributed. However, gross volumetric increases of specific anatomically defined regions may not serve as feasible biomarkers of clinical response