早期创伤后应激障碍的执行功能与额叶损害

目的探讨创伤后应激障碍(Post-traumatic stress disorder,PTSD)患者的执行功能损害特点以及结构性核磁共振的变化。方法收集12例病程小于1年的首发PTSD患者为PTSD组,16名健康志愿者为对照组。PTSD组应用艾司西酞普兰治疗3个月,治疗前后均使用临床应用的PTSD诊断量表(Clinician AdministeredPTSD Scale,CAPS)评估临床症状,威斯康星卡片分类测验(Wisconsin Card Sorting Test,WCST)评定PTSD组执行功能,对照组WCST只评估一次。采用基于体素的形态学分析技术比较PTSD组治疗前后及对照组的脑结构形态。结果 PTSD组治疗前、治疗后总应答数(Ra)、错误应答数(Re)及持续性错误数(Rpe)评分均差于对照组,差异有统计学意义(均P0.05);治疗前Ra、Cc、Re及Rpe评分均差于治疗后,差异有统计学意义(均P0.05)。PTSD组治疗前和治疗后CAPS得分均与执行功能(Ra、Cc、Re、Rp及Rpe)无统计学相关性(P0.05)。PTSD组治疗前额叶部分脑区灰质体积小于对照组[P0.01(uncorrected)],治疗后PTSD患者额叶部分脑区灰质体积较治疗前恢复[P0.01(uncorrected)],但仍小于对照组[P0.01(uncorrected)]。结论 PTSD患者存在明显执行功能障碍,临床症状恢复后,执行功能障碍依然存在。大脑额叶部分脑区灰质体积治疗后不能完全恢复,可能为其认知功能损害的病理基础。     

首次发病的强迫症患者的认知功能

目的探讨首次发病的强迫症患者的认知功能特点。方法采用韦氏智力测验(Wechsler adult intelligence scale,WAIS)、韦氏记忆测验(Wechsler memorys cale,WMS-R)、Stroop测验、连线测验(trail-making test,TMT)A和B、威斯康星卡片分类测验(Wisconsin card sorting test,WCST)对首次发病的强迫症患者30例和正常对照32名进行认知功能评估。结果患者组WMS-R中图片回忆、再认、联想学习等3项成绩均较正常对照组差(P0.05),而Stroop测验中的读字色测验的错误数和用时、TMT-B时间、TMTB-A时间等4项成绩也差于正常对照组(P0.05)。此外,患者组WCST中的完成分类数、正确应答数、错误应答数、持续错误数等4项成绩均较正常对照组差(P0.01)。结论首次发病的强迫症患者存在记忆、注意和执行功能损害。     

童年创伤对健康青年认知功能的影响

目的 评估童年创伤对健康青年成人认知功能的影响。方法 2012 年2 月以来3 次利用 童年创伤问卷筛查出有童年创伤以及不伴任何形式童年创伤的健康青年，分别完成威斯康星卡片分类 测验（WCST）、Stroop 测验及韦氏记忆量表（WMS）连线测验、词语流畅测验等评估。结果 伴童年创伤组 （n=90）在词语流畅性测验、WMS 视觉再生分测验以及WCST中正确应答数、错误应答数、持续错误数及 完成分类数与无童年创伤组（n=104）相比差异有统计学意义，童年创伤总分与视觉再生结果呈负相关， 与连线测验B、WCST 错误应答数呈正相关，不同童年创伤类型的数量与Stroop 测验、WCST正确应答数、 WMS 部分结果呈负相关（均P ＜ 0.05）。结论 伴童年创伤的健康青年的认知功能受损，童年创伤越严 重或不同创伤数量越多，认知功能越差。     

创伤后应激障碍患者远期认知功能损害的随访研究

目的探讨创伤后应激障碍（PTSD）患者远期认知功能损害的特点。方法选取2004年1月～2005年12月来河北医科大学第一医院精神科就诊的38例符合DsM—IV—TR诊断标准的PTSD患者（PTSD组）,同期在本院就诊的40例广泛性焦虑症患者（焦虑组）,本院常规体检的37名正常人群（健康对照组）。入组时及9年后随访分别完成汉密尔顿焦虑量表（HAMA）、汉密尔顿抑郁量表（HAMD）、威斯康星卡分类测验（WCST）、韦氏记忆测试（wPS—R）的测评。结果3组对象入组时性别、年龄、受教育年限差异均无统计学意义（P〉o．05）。入组时焦虑组患者HAMA、HAMD评分高于PTSD组及健康对照组,PTSD组HAMA、HAMD评分高于健康对照组,差异有统计学意义（P〈0．05）。9年后随访,3组间HAMA和HAMD评分差异无统计学意义（P〉0．05）。入组时和9年后随访PTSD组韦氏记忆测查成绩均低于焦虑组及健康对照组,差异有统计学意义（P〈0．01）。入组时和9年后随访PTSD组患者WCST7项目因子中的总应答数（Ra）、错误应答数（Re）显著高于焦虑组及健康对照组,差异有统计学意义（P〈0．05）,各组完成分类数（cc）、正确应答数（Rc）、持续错误数（Rpe）、非持续性错误数（nRpe）、完成第一个分类所需的应答数（Rf）的差异无统计学意义（P〉0．05）。结论PTSD患者发病时存在认知功能损害,主要表现为记忆功能和执行功能损害,且记忆及执行功能损害较广泛性焦虑症患者严重。PTSD患者9年后随访仍存在认知功能损害,提示PTSD的认知功能损害长期持续存在。     

伴轻度抑郁症状的双相障碍患者执行和注意功能对照研究

目的:探讨伴轻度抑郁症状的双相障碍患者执行功能、注意功能与健康对照者的差异。方法:40例伴轻度抑郁症状的双相障碍患者(研究组)和40名年龄、性别、受教育年限与研究组匹配的健康者(健康对照组)均采用威斯康星卡片分类测验(WCST)及持续操作测验(CPT)测试两组执行功能和注意功能。结果:两组WCST测试成绩除完成第1个分类所需应答数、非持续性错误数差异无统计学意义(P0.05)外,完成分类数、总应答数、正确应答数、错误应答数、持续性错误数、持续性错误率组间差异有统计学意义(t=-6.10~5.96,P均=0.000);CPT测验中正确数研究组明显低于健康对照组(t=-3.87,P=0.000);错误数明显高于健康对照组(t=5.21,P=0.000)。结论:伴轻度抑郁症状的双相障碍患者存在执行功能损害和注意功能损害。     

精神分裂症首次发病患者及其健康同胞认知功能的比较研究

目的 比较精神分裂症首次发病患者与健康同胞及正常对照认知功能的差异,探讨精神分裂症在认知功能领域的内表型.方法 采用目前常用的范畴流畅测验(CFT)、数字符号编码测验(DSCT)、连线测验(TMT)、韦克斯勒记忆量表第3版(WMS-Ⅲ)空间广度测验(WMS-ⅢSST)、霍普金斯词汇学习测验-修订版(HVLT-R)、简易视觉空间记忆测验-修订版(BVMT-R)、定步调听觉连续加法测验(PASAT)和威斯康星卡片分类测验-64(WCST-64)对92例精神分裂症首次发病患者(患者组)、56例健康同胞(同胞组)和62名健康对照者(对照组)的认知功能进行检测.结果 (1)患者组所有神经心理测验成绩均差于对照组,差异有统计学意义(P＜0.01).(2)同胞组的CFT、DSCT、TMT、HVLT-R即刻记忆和延迟记忆、BVMT-R即刻记忆、PASAT、WCST-64持续错误数、持续反应数和完成分类数的测验成绩差于对照组,差异有统计学意义(P＜0.05).(3)患者组与同胞组的CFT、WCST-64中的持续错误数、持续反应数和完成分类数测验成绩分别为(18.40±12.12)分比( 18.86±5.19)分、(16.48±8.19)分比(14.80±5.86)分、(18.76±10.91)分比(16.86 ±7.73)分、(1.33±2.81)分比(1.63±1.36)分,2组比较差异无统计学意义(P＞0.05),其他神经心理测验成绩比较,患者组差于同胞组,差异有统计学意义(P＜0.05).结论 精神分裂症首次发病患者存在处理速度、工作记忆、言语记忆、空间记忆、注意警觉和执行功能广泛性的认知功能损害,精神分裂症健康同胞存在处理速度、言语记忆、视觉记忆、注意警觉、执行功能的认知缺陷;语义流畅性功能和执行功能可能是精神分裂症的潜在内表型.     

精神分裂症患者面部表情认知与执行功能的相关性研究

目的:探讨精神分裂症患者面部表情认知功能和执行功能障碍的关系.方法:采用中国人面部情绪测验(CFET)和威斯康星卡片分类测验(WCST)对56例未用药精神分裂症患者进行评估,与49名正常健康者进行比较.结果:患者组CFET的总分及6种基本情绪认知评分均显著低于对照组(P＜0.01).患者组WCST显著较对照组为差.控制阳性症状量表(SAPS)和阴性症状量表(SANS)总分的偏相关分析显示.患者组CFET的惊正确分与WCST的总应答数呈正相关(r=-0.31,P＜0.05),悲正确分与CFET的错误应答数(r=-0.37,P＜0.01)、选择错误率(r=-0.38,P＜0.01)、持续性应答数(r=-0.34,P＜0.05)、持续性错误数(r=-0.48,P＜0.01)和持续性错误率(r=-0.40,P＜0.01)呈负相关,而与完成分类数(r=0.25,P＜0.05)呈正相关.结论:精神分裂症患者存在广泛的面部表情认知缺陷和执行功能障碍,患者面部表情认知功能与执行功能有相关性.     

老年精神分裂症患者认知功能与社会功能研究

目的探讨老年精神分裂症患者的认知功能及社会功能损害情况。方法采用一系列标准化神经心理测验工具：韦氏记忆测验（WMS）、威斯康星卡片分类测验（WCST）、简易智力状态检查（MMSE）和日常生活能力量表（ADL），测定45例老年精神分裂症患者（研究组）的认知功能和社会功能，并与42例正常老年人（对照组）作对照。结果研究组在WMS中的经历、定向、1→100、100→1、累加、再认、记图、再生、联想、触摸、理解、背数等项成绩均差于对照组（P均〈0．05或0．01）。WCST研究组总正确数和分类次数均小于对照组，而总错误数、持续错误数和持续反应数均高于对照组（P均〈0．01）。MMSE成绩研究组显著低于对照组（P〈0．05），ADL研究组显著高于对照组（P〈0．05）。结论老年精神分裂症患者存在突出的认知功能和社会功能损害。     

喹硫平及其联合丙戊酸钠治疗双相情感障碍躁狂发作认知功能损害的对照研究

目的 应用神经心理学方法 评估双相障碍躁狂发作认知损害特点,并探讨丙戊酸钠对双相躁狂认知损害的治疗作用.方法 64例双相躁狂患者随机分为两组:丙戊酸钠联合喹硫平治疗组33侧(联合治疗组),单用喹硫平治疗组31例(单药治疗组),两组于治疗前与治疗6周末均给予威斯康星卡片分类测验( WCST)、言语记忆测验(HVILT-R)、持续操作测验(CPT)、扬氏躁狂评定量表(YMRS)、临床总体疗效量表(CGI- S)评定.对照组为30名健康人.结果 (1)两个患者组治疗前WCST操作的完成分类数、错误应答数、持续应答数、持续错误数以及HVILT-R、CPT的操作分均低于对照组,差异有统计学意义(P＜0.01),两个患者组间的差异无统计学意义(P＞0.05).6周治疗后两个治疗组WCST和HVILT-R的操作分仍低于对照组,差异有统计学意义(P＜0.01).CPT的操作得分三组间差异无统计学意义(P＞0.05);(2)治疗后与治疗前比较,联合治疗组WCST的完成分类数增加,错误应答数、持续错误数减少,差异有统计学意义(P＜0.01).单一治疗组的完成分类数增加、错误应答数减少,差异有统计学意义(P＜0.01).两个治疗组的HVLT—R操作分与治疗前的差异无统计学意义(P＞0.05).CPT操作分与治疗前比较明显提高,差异有统计学意义(P＜0.01).结论 双相障碍躁狂发作时存在执行功能、学习和记忆能力、注意力等神经认知领域损害;病情稳定后,执行功能和言语记忆功能损害仍持续存在;6周的丙戊酸钠联合喹硫平或单一喹硫平治疗均能有效地改善双相躁狂患者的部分认知功能.     

首发未经治疗的强迫症患者局部脑血流变化及其与执行功能缺陷的关系

目的 检测强迫症患者大脑局部脑血流(Regional Cerebral Blood flow,rCBF),分析其与执行功能损害的关系.方法 对26例强迫症患者及20例正常对照者,在静息和激活(即执行认知活动)状态下,应用SPECT进行脑rCBF显像.采用统计参数图(Statistical Parametric Mapping,SPM)分析强迫症患者大脑rCBF变化特点.应用威斯康星卡片分类测验改良版(Modified Wisconsin Card Sorting Test,M-WCST)评价其执行功能.结果 与对照组相比,在激活状态下患者组的基底节和左枕叶rCBF增高(Z＞ 3.29,P＜ 0.001),静息状态下左顶下小叶及小脑蚓部rCBF降低(Z＞3.29,P＜0.001);患者组WCST的完成分类数(4.13±2.00)、正确应答数(67.13±10.43)、错误应答数(47.13±22.41)、持续错误数(18.10±11.33)等成绩均差于正常对照组[分别为(5.43±1.10)、(83.37±14.22)、(27.43±13.47)、(5.53±3.36)](JP＜0.05或P＜0.01).患者组WCST与左侧额叶直回、眶回CBF明显相关(Z＞ 3.29,P＜ 0.001).结论 强迫症患者存基底节、枕叶和小脑rCBF灌注异常,执行功能损伤与眶额叶功能有关；强迫症病理机制包括眶额叶-基底节循环,及枕叶和小脑功能紊乱.     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.