Reviews of Note

Feature |
May 14, 2014

Reviews of Note

  1. Joel Yager, MD and
  2. Jonathan Silver, MD

Tinnitus, psychiatric comorbidities with epilepsy, cognitive training, the neurocircuitry of bipolar disorder, updates on research into ECT and neurosurgery, redefining the fear response, ADHD with emotional dysregulation

  1. Joel Yager, MD and
  2. Jonathan Silver, MD

In an occasional column, NEJM Journal Watch Psychiatry editors comment briefly on review articles.

Tinnitus: A neuropsychiatric approach. These reviewers reframe tinnitus as a neuropsychiatric disorder.1 Patients with tinnitus show not only pathology in the auditory system, but also electrophysiologic and neuroimaging changes, including in the limbic system. These patients often have mood and anxiety disorders, disrupted sleep, headaches, and cognitive slowing. The authors review the appropriate methods for evaluating and managing tinnitus. Treatment includes pharmacotherapy (especially benzodiazepines), acupuncture, and cognitive-behavioral therapy. With advances in brain stimulation therapies (repetitive transcranial stimulation; transcranial direct current stimulation), these approaches may become helpful (NEJM JW Psychiatry Jun 25 2012).

Depression and anxiety in patients with epilepsy. This author succinctly reviews the problem of mood and anxiety disorders in patients with epilepsy.2 Patients with these diagnoses have been shown to have a poorer response to and tolerance of anticonvulsant drugs, a worse response to surgical treatment, and greater risk for a poor quality of life and for death by suicide and accidents. In later sections, the author reviews the use of antidepressants and the difficulty in finding qualified psychiatrists. He concludes that neurologists need to develop greater familiarity with depression, and psychiatrists with epilepsy. A subspecialty not mentioned in this essay, Behavioral Neurology & Neuropsychiatry, has practitioners specifically trained to assess and treat these patients.

Cognitive training for psychiatric disorders. Cognitive training (also known as cognitive remediation or rehabilitation) engages well-delineated cognitive and social-affective learning processes that theoretically target neuroplastic deficits associated with neuropsychological and behavioral impairments. These authors review the current status of this approach and delineate work yet to be done.3 The strategies of cognitive training have been applied alone or adjunctively to a range of neuropsychiatric symptoms subsumed under the concept of executive dysfunction, including deficits in working memory, attention bias, processing-speed difficulties, and deficits in response inhibition. These methods have been studied with variable results across a broad range of psychiatric disorders and merit additional investigation. And perhaps, approaches that have achieved respectable effect sizes for some problems merit clinical application in some disorders.

Our emerging understanding of neurocircuitry in bipolar disorder. These authors thoughtfully examine the current understanding of the complex neurocircuitry of bipolar disorder and the associated decreases in gray matter and fractional anisotropy, as determined from functional and structural neuroimaging and diffusion imaging studies.4 Identified brain regions and deficits help account for the emotional lability, mood dysregulation, and heightened reward sensitivity seen in bipolar disorder. Noting many limitations in the research, the authors propose a roadmap for future studies, in line with the contemporary Research Domain Criteria initiatives of the National Institute of Mental Health.

ECT research collaborative. From 1997 through 2011, researchers at four hospitals conducted collaborative research into initial and continuation electroconvulsive therapy (ECT) for unipolar and bipolar depressed patients. This author,5 one of the original collaborators, reviews the key study findings:

  • ECT was effective for both unipolar and bipolar depression.

  • Results were better with bilateral than with unipolar electrode placements.

  • Fixed-schedule continuation ECT and pharmacotherapy combining lithium with nortriptyline had comparable post-remission relapse rates.

The author then offers guidance on optimal patient selection and ECT techniques, such as electrode placement and seizure thresholds.

Neuropsychiatric surgery: Consensus guidelines. Despite the tarnished history of neurosurgery for refractory psychiatric disorders, several procedures, including deep brain stimulation, are currently being explored. In a proposed consensus document, this multidisciplinary group, sponsored by various professional societies, offers a set of guidelines for these interventions.6 The group notes that there is no level I evidence for any ablative procedure, but level II evidence exists for their safety and efficacy for treatment-refractory major depression and obsessive-compulsive disorder. The authors outline the necessary elements for proper conduct of these procedures — ethical review, preoperative evaluation and patient selection criteria, ability to obtain informed consent, legitimate therapeutic indications, transparency of conflicts of interest, and need for long-term follow-up. We clinicians should read this article before considering this option for any of our patients.

Reconceptualizing the fear response. In this essay, a leading researcher in elucidating the neural mechanisms of the fear response proposes a different terminology for this system to disentangle the confusion between the conscious feelings of fear and the nonconscious processes that control defense responses to threats.7 This distinction is especially important when we jump from animals' threat responses to infer what they are “feeling” and, from there, to how these apply to human behavior and feelings. In addition, the press, the public, and many scientists confuse this mechanism with conscious fear because of the imprecise language. The author proposes that fear conditioning instead be called “threat conditioning” and the associated responses be named the “defense response complex.” This thought-provoking article will help us refocus our understanding of this important literature.

Models of ADHD with emotion dysregulation. In this review, the author identifies and addresses important interfaces between emotion dysregulation and attention-deficit/hyperactivity disorder (ADHD) in adults and children.8 As these conditions frequently co-occur, investigators are examining the clinical relationships, underlying neurophysiological associations, and combined treatment approaches. Several models are presented and explored, including viewing emotion dysregulation and ADHD as correlated but separate; considering emotion dysregulation to represent a basic diagnostic feature of ADHD; and envisioning the combination as a nosologically discrete condition that can be differentiated from ADHD and emotion dysregulation as solo entities.

Editor Disclosures at Time of Publication

  • Disclosures for Joel Yager, MD at time of publication Editorial boards Journal of Neurology, Neurosurgery and Psychiatry; Journal of Neuropsychiatry and Clinical Neuroscience; UpToDate Leadership positions in professional societies North American Brain Injury Association (Board Member) Editorial Boards Journal of Neurology, Neurosurgery & Psychiatry; Journal of Neuropsychiatry and Clinical Neurosciences

  • Disclosures for Jonathan Silver, MD at time of publication Grant /research support AHRQ Editorial boards Bulletin of the Menninger Clinic; Eating Disorders: Journal of Treatment and Prevention; Eating Disorders Review (Editor-in-Chief); International Journal of Eating Disorders; UpToDate; FOCUS: The Journal of Lifelong Learning in Psychiatry Leadership positions in professional societies American Psychiatric Association (Chair, Council of Quality Care)


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Reader Comments (1)

José Melo Physician, Critical Care Medicine, Hospital Felicio Rocho, Brazil

The major problem in this case. Most antidepressants cause tinnitus!

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