Bild obsessive Compulsive Disorder

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					   Lecture 7
Psychiatric disorders
        Diagnostic difficulties
Hypomania?     Depression?      Schizophrenia?

Euphoria       Apathy           Emotional
Restlessness   Inertia          Unconcern about
                                own person/
                                personal hygiene
Impulsivity    Unconcern        Muteness
Psychiatric disorders linked
to frontal dysfunction
   Depression and mania
   Schizophrenia
   Obsessive-Compulsive Disorder (OCD)
   Phobias and other anxiety disorders
   Autism-Asperger syndrome
   Attention Deficit/Hyperactivity Disorder
Mega & Cummings, 2001
Mayberg H., 2001
Mayberg H., 2001
Mayberg’s model of depression

                         Mayberg H., 2001
Andreasen N., 2001
Hypofrontality in
   First shown by Ingvar and Franzén 1973
   Most pronounced in chronic patients with very
    long-lasting hospitalization and treatment with
    neuroleptics. Patients display predominantly
    negative symptoms.
   Unmedicated acutely ill schizophrenic patients
    show slightly decreased, normal or even
    elevated frontal (resting) blood flow levels
    dependent upon the symptoms displayed:
    positive    negative
Hypofrontality in
schizophrenia cont.
 Functional brain imaging
 during the execution of tasks
 engaging the frontal lobes
 have consistently shown
 abnormalities also in young
 unmedicated schizophrenic
rCBF differences between 12 controls and 18 schizophrenic
 patients during performance of an auditory recognition task

                    Holcomb et al., Am. J. Psychiatry, 157, 1634-1645, 2000
rCBF differences between controls and 6 schizophrenic patients
  with abnormal performance on the auditory recognition task
Reduced communication between frontal and
temporal lobes during talking in schizophrenia

                      Ford et al., Biol. Psychiatry, 51, 485-492, 2002
Reduced communication between frontal and
temporal lobes during talking in schizophrenia
       Two trends of cortical development
                                 Archicortical trend

Paleocortical trend
Mega & Cummings, 2001
 Neuropsychological, brain imaging and
 electrophysiological research have
 consistently shown a dysfunction of
 fronto-striato-thalamic pathways in
 subjects with obsessive-compulsive

 Hyperactivity of attention/executive
 control mechanisms in obsessive-
 compulsive patients?
 Mapping structural brain alterations in
   obsessive-compulsive disorder

• Structural MR in 72 outpatients with OCD and 72
  age- and sex-matched control subjects.
• The brains of patients with OCD showed
  reduced gray matter volume in the medial frontal
  gyrus, the medial orbitofrontal cortex, and the
  left insulo-opercular region. A relative increase
  in gray matter volume was observed bilaterally
  in the ventral part of the putamen and in the
  anterior cerebellum.
• Specific parts of the frontostriatal system are
  altered in patients with OCD.
                    Pujol et al., Arch Gen. Psychiatry, 61, 720-730, 2004
The Basal Ganglia


Psychiatric disorders linked
to frontal dysfunction
   Depression and mania
   Schizophrenia
   Obsessive-Compulsive Disorder (OCD)
   Phobias and other anxiety disorders
   Autism-Asperger syndrome
   Attention Deficit/Hyperactivity Disorder
Prevalence of autism

 Autism between 0.1-0.3%
 Asperger’s syndrome 0.20-0.48%

 Autism spectrum disturbance 0.1-0.6%

 Later studies show that the total
prevalence for autism spectrum
disturbances is between 0.5-0.8%
Cognitive disturbances in
Autism spectrum disorders
 Deficient mentalizing (theory of
  mind, empathy)
 Deficient central coherence

 Deficient executive functions

 Difficulties with automatization
  and generalization
10 functional brain imaging studies of mentalizing

        Frith, U. & Frith C., Phil. Trans. R. Soc. Lond. B, 358, 459-473, 2003
Asperger’s syndrome
(Gillberg & Gillberg 1989)
   1.   Severe difficulties in social interaction.
   2.   Narrow solitary interests.
   3.   Routines and rituals.
   4.   Speech and language problems.
   5.   Problems in non-verbal communication.
   6.   Motor clumsiness.
Differences between autism and
     Asperger’s syndrome?
 Autism: more severe language
 problems, often lower general
 intelligence, earlier recognition.
 Asperger’s syndrome: often
 normal intelligence, normal
 language, problems are often
 realized later.
Brain pathology in autism

   Subnormal frontal activation during
    execution of theory of mind tasks.
   Cerebellar abnormality (smaller or larger
    vermis area).
   Less activation of ”face specific” brain
   Deviant visual search in social situations;
    difficulties recognizing social meaning.
   Causes of autism spectrum
Multiple causes: Chromosomal
abnormalities, fetal disturbances
(infections, toxins).
75 - 90% of all cases of autism are
genetically determined. Probably several
co-operating genes.
Psychosocial factors do not cause autism,
but are important for the quality of life of
the patient.
  Attention Deficit/Hyperactivity
Disorder AD/HD – diagnostic criteria

 6 out of 9 criteria for attention deficit (AD).
 6 out of 9 criteria for hyperactivity/ impulsivity
 (HD) fulfilled.
 Symptoms present before the age of 7 years.
 Functional disturbances have to be present
 within at least to areas (school, home,
 relations, work).
        Attentional deficits

Seems not to listen
Does not follow instructions
Looses objects
Easily distracted
Difficulties organizing/planning
Dislikes tasks that require mental endurance
Difficulties with sustained attention to tasks
Difficulties to remain on one place
Excessive talkativeness
Running around anxiously
Leaves the place
Difficulties to perform task in a quite and
orderly way
Answers before the person asking
has finished the question
Interrupts, intrudes
Difficulties waiting for ones turn
Prevalence of AD/HD

 3-7% of all school children

 More boys than girls
Cognitive problems in AD/HD

   Short attentional span and poor working memory
   Prefers concrete thinking
   Difficulties with automatized functions
   Deficient ability to generalize
   Low level of general knowledge
   Slow learning
   Deficient awareness of time and space
   Difficulties with reading and writing
   Bad handwriting
Brain pathology in AD/HD

   Some studies: Structural changes in
    fronto-striatal networks.
   Some studies: Subnormal function in
    the prefrontal cortex and striatum.
Treatment by
central stimulants
   Amphetamine, methylphenidate (Ritaline).
   Good or very good effect in about
    70% of treated children (about 200
    controlled studies since the 1930-ies).
   Adults: A few studies, good effect in
    50 – 60%.

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