Abnormal and Behavioural Psychology

ISSN: 2472-0496

Open Access

Volume 6, Issue 2 (2020)

Short Communication Pages: 1 - 2

Second stage development of an early screening tool for detection of vulnerability to schizophrenia, as an example of empathic action

Kate Ball

Statement of the Problem: The concept of empathy in psychiatry infers an understanding, concern or interest in a person’s emotional state or experience. The experience of psychosis that usually precedes schizophrenia is often frightening; destabilizing a person’s sense of self and confidence in reality. Empathic action calls for ways to diminish the likelihood of a person experiencing psychosis. Methodology & Theoretical Basis: The current research tests the theory that vulnerability to developing this type of psychosis can be identified by an early-screening-tool (Schizophrenia-Traits-Questionnaire, STQ) in teenage, in a second stage of development by Flourish Australia. Originally developed in a PhD by the author, it is based on the neurodynamic/ psychobiological theory of Robert Miller. Originally, 600 adults participated in the STQ to test both the theory and its power to predict whether someone would fit into the schizophrenia category or not. The current research trial is on teenagers.

Findings: The factor analysis supported the underlying theory and thirteen (13) of the items in combination, in the original sample, accurately predicted schizophrenia to 85% accuracy with no mention of psychotic symptoms. With early-detection and the appropriate education and resources, not only can the STQ potentially stop a psychotic episode from occurring, it also identifies the types of occupations to avoid, to prevent being overwhelmed by stimuli/environments that challenge.

References 1. Miller R (2008) A Neurodynamic Theory of Schizophrenia and Related Disorders. Lulu Press, Raleigh, North Carolina. 2. Fukushima J, Chiba T, Tanaka S, Yamashita I and Kato M (1988) Disturbances of voluntary control of saccadic eye movements in schizophrenic patients. Biol Psychiatry; 23: 670-677. 3. Henik A and Salo R (2004) Schizophrenia and the stroop effect. Behavioral & Cognitive Neuroscience Reviews; 3: 42-59. 4. Nieuwenstein M R, Aleman A and de Haan E H (2001) Relationship between symptom dimensions and neurocognitive functioning in schizophrenia: a meta-analysis of WCST and CPT studies. Wisconsin Card Sorting test. Continuous Performance Test. Recent focus on early detection and intervention in psychosis has renewed interest in subtle psychopathology beyond positive and negative symptoms. These are self-experienced subclinical disturbances termed basic symptoms (BS). The phenomenologies of BS and their development in the course of psychotic disorders will be described. Diagnosis, treatment, and research studies of psychosis have focused mainly on its cardinal positive and negative symptoms. However, the current attention on prodromal phases of the illness has generated renewed interest in the early subtle, self-experienced changes in mentation that have been observed and described since Kraepelin's articulation of dementia praecox. The most thorough description of these symptoms is provided within the framework of the basic symptoms (BS) concept developed by the German psychiatrist Gerd Huber. BS are subtle, subjectively experienced subclinical disturbances in drive, affect, thinking, speech, (body) perception, motor action, central vegetative functions, and stress tolerance. They can occur and have been reported in every stage of the illness, ie, in the prodrome to the first psychotic episode, in prodromes to relapse, in residual states, and even during psychotic episodes per se.

By definition, BS are different from what is considered to be one's “normal” mental self. Being subjective, they remain predominately private and apparent only to the affected person. They are rarely observable to others, although a patient's self-initiated coping strategies (including avoidance strategies and social withdrawal) in response to his/her BS may be recognizable to others. Being self-experiences, BS differ from negative symptoms as they are currently understood, ie, as functional deficits observable to others. BS is also distinct from frank psychotic symptoms that are experienced by the patient as real, normal thinking, and feeling. In contrast, BS is spontaneously and immediately recognized by the affected person as disturbances of his/her own (mental) processes. Insight that something is wrong with one's thinking is present, yet some experiences might be so new and strange that they remain nearly inexplicable. The rare, highly introspective person may be able to articulate what is happening, but any detailed description of these experiences usually requires help in the form of guided questioning. The ability to experience BS with insight and to cope with them often attenuates with progressive illness and emerging psychotic symptoms but is restored upon remission. Thus, an evaluation of BS is often hindered by acute and/or prominent psychotic symptoms.

In Anglo-American psychiatry, 2 researchers, James Chapman and John Varsamis, described self-experienced symptoms like BS in the 1960s and 1970s without exploring them in as much detail as Huber and colleagues. Recently, BS emphasizing anomalies of self-awareness have been described by Josef Parnas. BS is an integral part of the psychoses and can appear throughout various stages of the disorder. Currently, BS is mainly employed in the early detection and preventive intervention of psychosis. In clinical practice, the most important feature of BS is that they are experienced and reported as abnormal and burdensome by the patients themselves. As such, they are appropriate to describe in awareness and information campaigns of psychosis to promote early detection and indicated prevention. They should also be described to patients in remission from psychosis as representing early signals of a risk for relapse. BS is also important signals of the need for rehabilitation in residual, post psychotic states. They support a more complete description of the degree of remission beyond positive and negative symptoms. In this, BS can be used for titrating adequate combinations of pharmacological, psychological, and rehabilitative interventions. BS were regarded as the earliest subjectively experienced symptoms of psychosis and the most immediate symptomatic expression of the neurobiological correlates of the illness —thus the term “basic.” According to the original concept, (early) symptoms of psychosis occur in 3 developmental forms: “uncharacteristic” BS affecting mainly drive, volition, and affect, as well as concentration and memory (level 1); “characteristic”, qualitatively peculiar BS, especially of thinking, speech, (body) perception, and motor action (level 2); and psychotic symptoms

Finally, a patient's encounters with and motivations for treatment may be improved by relating therapeutic strategies to phenomena that are clearly recognized as subjectively burdensome symptoms. The BS concept can also educate patients and their families about the expressions of psychosis and support them in acquiring a deeper understanding of the expected vicissitudes of their illness, an important step in the process of stripping “madness” of some of its intractability and terror. Finally, consideration of BS may help the therapist in achieving insight into a patient's failure to master some problems that might be a reaction to BS

Short Communication Pages: 3 - 4

Dialectical behavior therapy: A new frontier in treatment of pre-adolescent children with severe emotional and behavioral dysregulation

Francheska Perepletchikova

Background & Aim: Chronic irritability and difficulty with self-control may negatively affect child’s emotional, social and cognitive development and are predictive of personality disorders, dysphoric mood, substance and alcohol abuse, suicidality and non-suicidal self-injury in adolescence and adulthood. Dialectical Behavior Therapy for pre-adolescent Children (DBT-C) aims to facilitate adaptive responding by teaching coping skills and encouraging caregivers to create a validating and changeready environment. Method: Two RCTs were conducted to examine feasibility and initial efficacy of DBT-C, they are: (1) In the NIMH funded RCT of DBT-C for disruptive mood dysregulation disorder, 43 children (7-12 years) were randomly assigned to DBT-C or TAU. Children were provided with 32 individual sessions that included child counseling, parent sessions and skills training. (2) In the private foundation funded RCT of DBT-C for children in residential care, 47 children (7-12 years) were randomly assigned to DBT-C or TAU. Children were provided with 34 individual sessions, 48 group skills trainings and 12 parent trainings. Results: Subjects in DBT-C attended 40.4% more sessions than subjects in TAU. No subjects dropped out of DBT-C, while 36.4% dropped from TAU. Further, 90.4% of children in DBT-C responded to treatment compared to 45.5% in TAU, on the clinical global impression scale. All changes were clinically significant and sustained at 3-months follow-up. In the residential care trial significant differences were observed on the main measure of outcome; Child Behavior Checklist (CBCL) staff report. Children in the DBT-C condition as compared to TAU had significantly greater reduction in symptoms on both internalizing and externalizing subscales. All changes were clinically significant. Results were maintained at 3- and 6-month follow-up. Conclusions: Results of both trials supported the feasibility and initial efficacy of DBT adapted for pre-adolescent children with severe emotional and behavioral dysregulation in multiple settings. Background: Dialectical Behaviour Therapy (DBT) has been used to treat adults and adolescents with suicidal and nonÔ?Ésuicidal selfÔ?Éinjury. This article describes initial progress in modifying DBT for affected preÔ?Éadolescent children. Method: Eleven children from regular education classes participated in a 6Ô?Éweek pilot DBT skills training program for children. SelfÔ?Éreport measures of children’s emotional and behavioural difficulties, social skills and coping strategies were administered at preÔ?É and postÔ?Éintervention, and indicated that the children had mild to moderate symptoms of depression, anxiety and suicidal ideation at baseline. Results: Subjects were able to understand and utilise DBT skills for children and believed that the skills were important and engaging. Parents also regarded skills as important, child friendly, comprehensible and beneficial. At postÔ?Étreatment, children reported a significant increase in adaptive coping skills and significant decreases in depressive symptoms, suicidal ideation and problematic internalising behaviours. Conclusions: These promising preliminary results suggest that continued development of DBT for children with more severe clinical impairment is warranted. Progress on adapting child individual DBT and developing a caregiver training component in behavioural modification and validation techniques is discussed. Dialectical behavior therapy (DBT) is an empirically supported treatment for borderline personality disorder (BPD) in adults, however fewer studies have examined outcomes in adolescents. This study tested the effectiveness of an intensive 1-month, residential DBT treatment for adolescent girls meeting criteria for BPD. Additionally, given well-established associations between BPD symptoms and childhood abuse, the impact of abuse on treatment outcomes was assessed. Participants were female youth (n = 53) aged 13–20 years (M = 17.00, SD = 1.89) completing a 1-month residential DBT program. At pre-treatment, participants were administered a diagnostic interview and self-report measures assessing BPD, depression, and anxiety symptom severity. Following one month of treatment, participants were re-administered the self-report instruments. Results showed significant pre- to post-


treatment reductions in both BPD and depression symptom severity with large effects. However, there was no significant change in general anxious distress or anxious arousal over time. The experience of childhood abuse (sexual, physical, or both) was tested as moderator of treatment effectiveness. Although experiencing multiple types of abuse was related to symptom severity, abuse did not moderate the effects of treatment. Collectively, results indicate that a 1-month residential DBT treatment with adolescents may result in reductions in BPD and depression severity but is less effective for anxiety. Moreover, while youth reporting abuse benefitted from treatment, they were less likely to achieve a clinically significant reduction in symptoms. Borderline personality disorder (BPD) is characterized by repetitive suicidal and non-suicidal self-injurious behaviors, extreme emotion and behavioral dysregulation, and disruptions in interpersonal relationships . Despite prior controversy around diagnosing personality disorders in youth, it has become increasingly evident that personality disorders can be reliably diagnosed in adolescents, showing good concurrent and predictive validity and similar stability as seen in adults. Among adolescents, BPD is estimated to affect approximately 3% of the general population with higher rates seen in psychiatric populations (i.e., 11% of outpatients and 50% of inpatients. Further, numerous studies have found associations between BPD symptoms in adolescence and serious psychosocial consequences later in adulthood . Accurately diagnosing and treating BPD earlier in the disease course may, therefore, help to prevent maladaptive behavior patterns from becoming ingrained and intractable to treatment later in life.In addition, youth with BPD have high rates of comorbid psychopathology, reporting an average of three additional diagnoses Mood and anxiety disorders are the most common comorbidities. However, substance use disorders and post-traumatic stress disorder (PTSD) are also common and predict worse outcomes and reduced likelihood of remission Given the clinical and public health significance of BPD, identifying effective treatments for adolescents with BPD that target both core features of the disorder and the associated sequelae of common co-occurring disorders is essential.There is strong support for the effective use of dialectical behavior therapy (DBT) in treating BPD in adult samples, including numerous randomized control trials (for review see. Subsequently, DBT was adapted for use with adolescents with promising initial results. Much of the research on DBT’s effectiveness with adolescents, however, has examined outpatient treatment whereas youth with multiple comorbid problems, serious emotion dysregulation, and impulsive


behaviors, likely to benefit from DBT, are frequently referred to residential treatment settings. To our knowledge, only four studies have examined the effectiveness of DBT for adolescents in residential settings. Despite this limited evidence, results are promising with reductions in overall symptom severity depression symptom severity, and number of inpatient days. However, the treatment duration assessed in these studies was quite long, ranging from four to 29 months and cannot speak to the effectiveness of residential DBT delivered in shorter time frames. The current study seeks to assess the effectiveness of a residential DBT program delivered in a single month (i.e., 28 days).Additionally, the pervasiveness of childhood abuse among individuals with BPD is well documented, with 27–81% of adults with BPD reporting some type of childhood abuse. The severity of childhood abuse, including the duration and nature of abuse, has been found to positively relate to both the severity of BPD symptoms and level of psychosocial impairment. Additionally, a history of physical and/or sexual abuse predicted poor outcomes for youth in residential treatment. Given the high prevalence of abuse among adolescents with BPD, it is critical to consider how experiences of abuse may moderate treatment effectiveness.

Short Communication Pages: 5 - 6

If you continue to raise your voice, we will have to ask you to leave! Whatever happened to compassion in mental health care?

Michael Sheehan

Despite the belief that compassion is at the essence of caring and the heart of practitioner-client relationships, it is no longer a common feature of mental health care discourse. Moreover, there continues to be a gaping imbalance of power in mental health services evidenced by a lack of tolerance for difference and the imperative to deal decisively with problematic clients. This is a result of societal concerns and priorities around the need to control risk and uncertainty and an emphasis on rationalization of services and evidence-based practice. In this paper, I will discuss about how globalization and our current political climate have led to a lack of compassion that has developed in mental health practice. I argue for the need to reintroduce and support compassionate care where it can thrive and is expected. Only through the eyes of compassion can we truly understand a person who is grappling with despair, persecuted by voices or a prisoner of their fears and assist them on their journey to recovery. Islam is a monotheistic religion based on revelations to the Prophet Muhammad 1400 years ago, which were recorded in the sacred Quran (Koran). The word Islam in Arabic means “submission,” reflecting the central core of Islam, which is the submission to the will of God. According to the statistics from new population projections by the Pew Research Center's Forum on Religion and Public Life, there are 1.65 billion Muslims worldwide and it is expected to increase by about 35% in the next 20 years, to reach 2.2 billion by 2030; making Islam the second largest religion in the world after Christianity. Islam provides Muslims with a code of behavior, ethics, and social values, which helps them in tolerating and developing adaptive coping strategies to deal with stressful life events. Islam teaches how to live in harmony with others “Seek the life to come by means of what God granted you, but do not neglect your rightful share in this world. Do good to others as God has done good to you. Do not seek to spread corruption in the land, for God does not love those who do this” (Quran, 28:77). In Islam Sharia means ‘the path’ and it refers to the path that Muslims should follow in their life. It provides the guidelines and requirements for two types of interactions: Those between humans and God (worship); and those between humans to humans (social transactions). The main sources of Sharia are the Holy Quran and Sunna. The Quran describes the way in which Allah should be worshipped. The Sunna includes all the known sayings, advices, and actions of Prophet Mohammed, his decisions, and his responses to life situations and to philosophical and legal questions, which usually derived from what's called Hadith. According to attachment theory by John Bowlby, we know that having a secure attachment has been linked to the over-all wellbeing, coping, better mental health outcomes, enhanced self-esteem, and stronger relationship functioning. Thus, having a “healthy attachment” to God would also be linked to better psychological functioning: “… And whosoever puts his trust in Allah, then He will suffice him…” [Quran, 65:3]. Despite the growing size of the Islamic community in the western countries, most western practitioners appear not to have been very well exposed to Islamic values and teachings during their educational careers. Researchers found that many Muslims are hesitant to seek help from the mental health professionals in Western countries due to the differences in their beliefs and lack of understating of the helping professionals about Islamic values in their treatment modalities. Consequently, Muslims might feel uncomfortable in seeking psychiatric help to avoid being in conflict with their religious beliefs. The aim of this review article is to highlight the role of Islam in the management of different psychiatric disorders; and provide psychiatrists especially those working in Western countries with Muslim patients or Western psychiatrists travelling to Islamic countries or to those who are not familiar with Islamic values with therapeutic modalities that are congruent with Islamic values. We think it is highly beneficial to integrate certain Islamic views in Westernized therapeutic techniques to make them more acceptable by Muslim societies. Treatment in psychiatry follows the bio-psychosocial model, and religion is considered to be one of the most important psycho-social factors in human life, especially in Muslims’ population. Hence it is imperative to recognize how Islam can modify the treatment and prevention of different mental disorders. Islam from a bio-psychosocial model perspective In Islam, religion and spirituality are not mutually exclusive as you cannot have one without the other. Other religious and spiritual traditions may see them as separate where you can have one over the other. From the biological perspective, different studies have found that being religious increases patients’ satisfaction and adherence to treatment.This can be applied to Islam in the way it helps with drug adherence through encouraging Muslims to look after their health by seeking advice and receiving treatment as health is considered a gift from God, which should be cherished. The Prophet Muhammad has reported “down a cure even as He has sent down the disease.” On the contrary to what is commonly thought among Western societies that Muslims believe that mental illnesses are due to demons or bad spirit-related, it was in fact the Europeans in the Medieval Period who viewed mental illness as demon-related, Muslim scholars of that time, including Ibn Sina (known in the West as Avicenna – the founder of Modern Medicine), rejected such concept and viewed mental disorders as conditions that were physiologically based. This led to the establishment of the first psychiatric ward in Baghdad, Iraq in 705CE by al Razi (one of the greatest Islamic physician). This was the first psychiatric hospital in the world. According to al Razi's views, mental disorders were considered medical conditions, and were treated by using psychotherapy and drug treatments.Another fact which clinicians need to be more aware of is that adherence to psychiatric medications may be affected during Muslim fasting periods as in Ramadan (in which Muslims fast from just before sunrise to sunset each day), so clinicians should adjust the dosing interval according to timing of iftar and suhoor (i.e., the Muslim fasting and eating times). This can also be achieved by using alternative dosage forms for medication during Ramadan. However, if the patient's mental condition necessitates frequent dosing, or his physical wellbeing will be adversely affected by the combined effect of fasting and psychotropics intake, which may lead to dehydration, the clinician can then advise the patients not to fast as Islam exempts them from fasting in such conditions. “And whosoever of you is sick or on a journey, let him fast the same number of other days. Allah desired for you ease; He desired not hardship for you”. (Quran 2:185). Another detrimental factor in pharmacotherapy adherence is the presence of inert ingredients in psychotropic medications, which might be derived from pork products that may pass unnoticed by the clinicians. As ingestion of pork or any of its products is totally forbidden in Islam and it may be considered as committing a sinful act. So if this issue is not identified and addressed, then patients may not only stop taking their medications, and hence leading to relapse of symptoms, increasing hospitalization rates, and increasing healthcare costs but also lead to a poor doctor-patient relationship.

Short Communication Pages: 7 - 8

Neuroscience-informed interventions for youth with history of traumatic stress

Victor G Carrion

35% of youth living in communities of high violence will develop significant post-traumatic stress disorder symptoms. Current treatment modalities that anchor in Cognitive Behavioral Therapy (CBT) may leave 20-50% of youth without adequate symptom relieve. New treatment modalities that address executive function, memory and emotion regulation are needed and access and dissemination should be taken into consideration. This presentation will introduce Stanford’s Cue-Centered Therapy (CCT) and a school-district wide prevention effort that involves yoga and mindfulness in students’ curriculum. CCT integrates elements from CBT with other empirically validated interventions for traumatized youth (psychodynamic therapy, insight, self-efficacy, education). The prevention study focuses on health and wellness through meditation and exercise. Our research identifying key brain regions (e.g.; hippocampus, amygdala, prefrontal cortex) alterations in structure and function as related to traumatic stress informed the development of CCT. CCT demonstrated effectiveness in reducing anxiety, depression and post-traumatic stress symptoms in a randomized controlled trial. We are currently engaged in treatment outcome research to demonstrate CCT’s efficacy in improving brain function and cognitive and emotional outcomes. The presentation will focus on our imaging (sMRI and fMRI) and salivary cortisol studies that set the stage for the development of CCT. In addition, sleep was investigated in our prevention study. A curriculum of yoga and mindfulness improves sleep variables and these will be presented. New treatment modalities and dissemination plans need to be developed to address the highly heterogenous group of children that fall under the diagnostic umbrella of Post Traumatic Stress Disorder (PTSD). Approaching both prevention and treatment that are informed by neuroscience research promises to make our interventions more focused and targeted. Recent Publications 1. Klabunde M, Weems C, Raman M and Carrion V G (2016) The Moderating Effects of Sex on Insula Subdivision Structure in Youth with Post Traumatic Stress Symptoms. Depression and Anxiety; 34(1): 51-58. 2. Weems C F, Klabunde M, Russell J D, Reiss A L and Carrion V G (2015) Post-traumatic stress and age variation in amygdala volumes among youth exposed to trauma. Social Cognitive and Affective Neuroscience; 10(12): 1661-7. Traumatic experiences early in life predispose animals and humans to later cognitive-behavioral, emotional, and somatic problems. In humans, traumatic experiences are strong predictors of psychiatric illness. A growing body of research has emphasized alterations in neurological structure and function that underscore phenotypic changes following trauma. However, results are mixed and imprecise. We argue that future translation of neurological findings to clinical practice will require: (1) discovery of neurobehavioral associations within a longitudinal context, (2) dissociation of trauma types and of trauma versus chronic stress, and (3) better localization of neural sequelae considerate of the fine resolution of neural circuitry. We provide a brief overview of early brain development and highlight the role of longitudinal research in unearthing brain-behavior relations in youth. We relay an emergent framework in which dissociable trauma types are hypothesized to impact distinct, rationally-informed neural systems. In line with this, we discuss the long-standing challenge of separating effects of chronic stress and trauma, as these are often intertwined. We bring to light inconsistencies in localization of neural correlates of trauma, emphasizing results in medial prefrontal regions. We assert that more precise spatial brain localization will help to advance prevailing models of trauma pathways and inform future research.

Neuroimaging techniques have been central to characterization of normal brain development in domains of structure, function, and connectivity. Longitudinal structural magnetic imaging (MRI) studies show a linear increase with age in white matter that is most pronounced between early childhood and adolescence.  Myelination of the corpus callosum, the primary white matter tract in the brain that controls inter-hemispheric communication, occurs in a rostral-caudal sequence and continues throughout childhood into early adulthood. In contrast, gray matter follows an inverted U-shaped pattern of change, rapidly increasing until about age 10 then decreasing thereafter. This pattern presumably reflects concurrent and complementary processes of axonal myelination and synaptic pruning. Diffusion tensor imaging (DTI) and functional connectivity MRI (fcMRI) data highlight a transition from short-range to long-range wiring in the brain through adolescence, thought to reflect increasingly optimized brain neurocircuitry. In addition to the strengthening of long-range connections, increasing regional specialization and experience-dependent plasticity also play an intricate and commensurate role in brain maturation. Extended discussion of human brain developmental processes is available in prior influential works.

Drilling down deeper into brain maturation we find that brain maturation is linked to pubertal status that different structures in adjacent brain regions mature at different rates, and that neurodevelopmental connectional and structural trajectories differ between the sexes. Knowledge that the human brain varies along these multifaceted dimensions (age, region, sex) adds a level of complexity to consideration of the impacts of trauma in the early developing brain. By the nature of their early and upstream effects, disturbances affecting the brain in time-sensitive developmental periods can have lasting or widespread organizational impact. Increased vulnerability is ascribed to periods of rapid maturation, but empirical research is needed to unpack interactions between stress/adversity and sensitive periods in human development. Also, because adjacent brain structures mature at different rates, it is likely that individual neural regions and circuits have distinct windows of vulnerability to effects of traumatic stress. Thus, the developmental timing of traumatic events and sex of the victim are relevant to behavioral and neurological outcomes, compelling the need for longitudinal and sex-specific developmental research.

A growing body of research describes altered neurological structure and function in individuals that experience early emotional trauma. In this review, we present an overview of what has been learned and provide suggestions about next steps. We describe prior results in children and adolescents that support a model in which trauma early in life alters neural circuits consistently implicated in emotional health. That is, effects observed in individuals that experience trauma resemble those described in psychopathology. These are hyper-responsiveness in medial temporal components of limbic circuitry, hypo-responsiveness in medial and lateral prefrontal regions associated with regulating limbic response, and decreased engagement of components of the basal ganglia involved in reward related processing. Alterations in stress regulatory pathways including the hippocampus and hypothalamus are also frequently observed in individuals that experience trauma, and most consistently in adults affected by PTSD. Overlap between neurobiological correlates of trauma-exposure and psychopathology suggests that the brain may be a conduit for the link between early adversity and development of emotional psychology. We are not the first to highlight this inference, but more research is needed to further support this conclusion.

We emphasize three areas for advancing understanding of the neurobiological bases of trauma: (1) discovery of neurobehavioral associations within a longitudinal context, (2) dissociation of trauma types and of trauma versus chronic stress, and (3) better localization of neural sequelae considerate of the fine resolution of neural circuitry. Longitudinal research can address several current limitations in the literature. Brain networks evolve, grow and adapt to changing cognitive demands, a meaningful context in which to dissect the neurobiology of trauma. Longitudinal examination is needed to evaluate prevailing theory that neural mechanisms that undergird emotional illness may mediate correspondence between severe early adversity and emergence of emotional disorder.

Short Communication Pages: 9 - 10

Structural and functional MRI correlates of post-stroke depression

Wai Kwong Tang

Depression is common following an acute stroke. Post-Stroke Depression (PSD) has notable impacts on the function recovery and quality of life of stroke survivors. Incidence decreased across time after stroke, but prevalence of PSD tend to be stable. Many studies have explored the association between lesion location and the incidence of PSD. For example, lesions in frontal lobe, basal ganglia and deep white matter have been related with PSD. Furthermore, cerebral microbleeds and functional changes in brain networks have also been implicated in the development of PSD. In this presentation, evidences of such association between the above structural and functional brain changes and PSD will be reviewed. One in three survivors of stroke experience poststroke depression (PSD). PSD has been linked with poorer recovery of function and cognition, yet our understanding of potential mechanisms is currently limited. Alterations in resting-state functional MRI have been investigated to a limited extent. Fluctuations in low frequency signal are reported, but it is unknown if interactions are present between the level of depressive symptom score and intrinsic brain activity in varying brain regions.  A cross-sectional analysis of 63 stroke survivors who were assessed at 3 months poststroke for depression, using the Montgomery–Åsberg Depression Rating Scale (MÅDRS-SIGMA), and for brain activity using fMRI. A MÅDRS-SIGMA score of >8 was classified as high depressive symptoms. Fractional amplitude of frequency fluctuations (fALFF) data across three frequency bands (broadband, i.e., ~0.01–0.08; subbands, i.e., slow-5: ~0.01–0.027 Hz, slow-4: 0.027–0.07) was examined. Of the 63 stroke survivors, 38 were classified as “low-depressive symptoms” and 25 as “high depressive symptoms.” Six had a past history of depression. We found interaction effects across frequency bands in several brain regions that differentiated the two groups. The broadband analysis revealed interaction effects in the left insula and the left superior temporal lobe. The subband analysis showed contrasting fALFF response between the two groups in the left thalamus, right caudate, and left cerebellum. Across the three frequency bands, we found contrasting fALFF response in areas within the fronto-limbic-thalamic network and cerebellum. Post stroke, patients frequently experience motor, sensory, cognitive, and behavioural changes, all of which may impact recovery. Changes to a stroke survivor's mood are also common, with depression as the most frequently reported psychiatric disorder following ischaemic stroke. Poststroke depression (PSD) is estimated to affect approximately one-third of survivors, compared to about one-sixth of the nonstroke population. PSD is associated with poorer recovery prospects, including increased disability, worse cognitive outcomes, decreased quality of life, and increased risk of mortality. In particular, PSD negatively impacts response to rehabilitation in acute and subacute phases of recovery. However, our understanding of the potential mechanisms underlying the negative impact of depressive symptoms on recovery and rehabilitation is currently limited. Determining factors that may assist in the identification of those “at risk” of developing poststroke depression may aide in the recovery process and/or prediction of response to rehabilitation. The value of biomarkers of stroke recovery that focus on brain structure and function has recently been highlighted in consensus-based recommendations. Neuroimaging markers of depression may be used to provide new insight into neural mechanisms underlying depression, to predict the likelihood of future depressive symptoms, and/or to predict readiness to engage in treatment or treatment response. All are important reasons to identify stroke survivors with underlying vulnerabilities that may be “at risk” of developing depression.

One approach has been to investigate the relationship between lesion location and depression; however, despite a large number of studies, findings are equivocal. These findings suggest that lesion location alone is unlikely to be an informative biomarker associated with PSD. A meta-analysis of behavioural, biochemical, and neuroimaging markers of PSD found associations with reduced cerebral blood flow and regional volume reductions. In the broader literature of clinical depression, the disorder is not considered to be caused by independent, localised changes within specific brain regions but is thought to be partially due to disruption of communication between areas. Several meta-analyses of fMRI cohort studies of clinical depression have found changes in brain activation and connectivity. Findings highlight alteration of brain regions consistent with the current system-level models of depression. It may therefore be useful to examine biomarkers of PSD using resting-state methods that focus on intrinsic brain activity and whole brain. Resting-state fMRI methods focus on low frequency fluctuations (LFF) present within the blood oxygen level-dependent (BOLD) signal (0.01 to ~0.1 Hz) which in part reflect intrinsic neuronal activity. Several methods have been developed that evaluate different aspects of the signal. For example, local or regional correlations between BOLD time series are able to be examined, collectively known as functional connectivity. These functional connectivity analyses focus on temporal correlations of the BOLD signal. The spectral (frequency) characteristics of signal within individual voxels during resting-state can also be examined, typically by taking the sum amplitude of low frequency fluctuations (ALFF) or a ratio of LFF over the entire estimated spectra (fractional ALFF, fALFF). Of these two methods, fALFF has been shown to be robust against physiological artefacts and vascular effects, which are common poststroke given changes to neurovasculature post-stroke. While methods typically focus on the full LFF range, spectral measures allow the exploration of subbands, which have been suggested to be important for a scope of physiological and function processes within the brain. Wang et al. used fALFF to examine LFF and subbands of slow-5 (0.01–0.027 Hz) and slow-4 (0.027–0.07) in medication of naive participants with major depressive disorder over two studies. Both studies found similar changes in LFF measures when depressed participants were compared to controls. Wang et al.  also found areas that displayed an interaction effect between controls and those with depression and subband signal changes. Their results showed that the areas of the left ventromedial prefrontal cortex, left inferior frontal gyrus, and bilateral precuneus showed changes in amplitude in the slow-5 band, but not slow-4. This suggests that examination of subbands may be useful in identifying regions that are associated with depressive symptoms. It also highlights the value of investigating for an interaction effect in brain regions. To date, PSD studies of resting-state changes have not been widely employed, have focused on functional connectivity from specific regions, e.g., within the default mode network (DMN) and anterior cingulate, and have included participants of varying times post stroke. Results from these studies have been inconsistent. For example, Lassalle-Lagadec et al. found correlations at 10 days post stroke between the depression score and the left middle temporal cortex and precuneus and at 3 months with the neostriatum. Vicentini et al. found an association with the posterior cingulate cortex and depression score at approximately 1-month poststroke, while Liu et al.  failed to find any regional correlations of the posterior cingulate with a depression score in a cohort of chronic stroke survivors. More recently, Balaev et al. explored changes in the default mode network and found changes post treatment. Only one study, by Egorova et al., used voxelwise spectral analysis of fALFF and found mean differences between depressed and nondepressed stroke survivors in the frontal and insular regions.


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