Psychische Erkrankungen in der Lebensspanne ... - DGPPN

Topic 12 G Bildgebung, Neurophysiologie, Neuropsychologie // Brain Imaging, neurophysiology, neuropsychology
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Multidimensionale Charakterisierung von emotionalen Dysfunktionen
und therapeutische Möglichkeiten am Beispiel der Depression
und Schizophrenie
Ute Habel (Universitätsklinik Aachen, Psychiatrie und Psychotherapie)
Einleitung: Die Evaluation psycho- wie auch pharmakotherapeutischer
Interventionen und die Variabilität in der Responsivität auf
diese Therapien stellt in der psychiatrischen Forschung nach wie
vor eine große Herausforderung dar. Die funktionelle Bildgebung
erlaubt eine Charakterisierung der zerebralen Dysfunktionen und
eine Effektivitätsprüfung verschiedener therapeutischer Verfahren
neben der üblichen Outcomevariablen und ermöglicht auch Untersuchungen
zu den differenziellen Effekten unterschiedlicher Verfahren.
Zudem besteht nach wie vor die Notwendigkeit, Therapieformen
zu entwickeln und auch zu prüfen, die spezifisch auf eine
Verbesserung der emotionalen Fähigkeiten und Fertigkeiten schizophrener
und depressiver Patienten ausgerichtet sind.
Methode: Es werden verschiedene Längsschnittstudien zu den
Effekten eines emotionalen Trainings bei schizophrenen Patienten
dargestellt wie auch pharmakologische Therapieeffekte. Bei depressiven
Patienten wird ein standardisiertes Humortraining in Bezug
auf die Humorverarbeitung und die zugrunde liegenden zerebralen
Netzwerke geprüft.
Diskussion / Ergebnisse: Die Ergebnisse zeigen vor allem in frontotemporo-parietalen
Arealen Normalisierungen der Aktivierungsmuster
bei emotionalen Anforderungen und insgesamt positive
Verhaltenseffekte der psychotherapeutischen wie auch medikamentöser
Therapien bei Schizophrenen. Die Verwendung von Humor
in der Therapie erscheint ebenfalls vielversprechend und wird von
den Patienten sehr gut akzeptiert. Auffälligkeiten in der Hirnaktivierung
in anterior cingulären, frontalen und Amygdalaarealen bilden
sich infolge der Therapie zurück und zeigen damit Normalisierungen
in für Emotionen relevanten Arealen an. Hier bietet sich
möglicherweise eine Ausweitung auch auf weitere Patientengruppen
an. Damit eignet sich die funktionelle Kernspintomographie
besonders auch für die Evaluation therapeutischer Interventionen.
Zukünftig müssen stärker auch prädiktive Aspekte unter Verwendung
bildgebender Verfahren verfolgt werden.
Donnerstag, 26. 11. 2009, 15.30 – 17.00 Uhr, Salon 13/14
S-069 Symposium
Deep brain stimulation in psychiatry: New strategies, clinical
efficacy, and deeper insight
Vorsitz: I. Vernaleken (Aachen), J. Kuhn (Köln)
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New and Different Anatomic Structures as Targets for DBS in Obsessive
Compulsive Disorder and Tourette Syndrome
Jens Kuhn (Universitätsklinikum Köln, Psychiatrische Klinik)
E.-H. Kim, D. Lenartz, V. Sturm, W. Huff, J. Klosterkötter
The first mental disorders to be treated experimentally by DBS were
obsessive compulsive disorder (OCD) and Tourette syndrome (TS)
in 1999. Since then a number of highly promising studies with
small samples of patients have been published, in which impressive
therapeutic outcomes under application of DBS in otherwise treatment-resistant
OCD and TS have been reported. As a consequence
in February 2009, the FDA enunciated a limited approval to treat
OCD by DBS. Nevertheless the most optimal target area for DBS in
OCD and TS is still being discussed. Last year four different resear-
cher groups reviewed 26 patients with OCD in which a similar bilateral
DBS approach to the internal capsule and the neighbouring
nucleus accumbens was used. In Cologne since 2002 the efficacy of
unilateral only rightsided DBS of the nucleus accumbens in OCD is
under investigation in a randomized sham controlled design. The
one year effects of the unilateral approach were nearly comparable
with previous studies presenting bilateral stimulation of the internal
capsule in treatment resistant OCD. Finally even the stimulation
of the subthalamic nucleus was efficient to treat OCD-symptoms,
although this approach was associated with a substantial risk
of serious adverse events. In TS most workgroups have targeted
thalamic structures for DBS and could achieve tic reduction rates
between 31 % and 95 %. But also other subcortical nuclei were used
as target for DBS and proved efficacy. Maybe in future deep brain
stimulation for OCD and TS has to utilize different and specific
target regions depending on individual clinical phenomenology.
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Modulation of Dopamine Transmission by DBS in Tourette‘s
Syndrome
Ingo Vernaleken (RWTH Aachen, Klinik für Psychiatrie und Psychotherapie)
Introduction: Deep brain stimulation (DBS) has proven efficacy in
therapy resistant Tourette‘s syndrome (GTS). If the symptomatology
is highly disruptive and the quality of life is massively disturbed
DBS can be considered to be ethically acceptable. However, the
choice of target areas and stimulation parameters is principally
based on empirical knowledge because the underlying physiological
principles of DBS are not entirely understood, yet. To this end,
we performed a positron-emission tomography investigation (PET)
in order to elucidate DBS-effects on dopamine transmission.
Method: Two patients suffering from treatment resistant GTS
(age: both 22 yrs.) underwent bithalamical DBS approximately six
months before the PET-scans. Both of the patients improved significantly
in their symptomatology. Two PET-scans by the use of the
high-affinity D2/3-receptor ligand [18F]fallypride (FP) have been
performed under on- as well as under off-conditions (DBS). The
scans necessarily had to be performed under anesthesia (propofol /
remifentanyl) due to head movements during the 4 hour scan procedure.
Discussion / Results: There was a significant reduction of FP-
binding-potentials (BP) in the thalamus in both of the patients in a
range between 6 to 16 %. All of the other regions showed no or only
little changes in BPs. Ligand binding under both conditions was
strongly upregulated if compared to healthy control subjects of similar
age (approximately +100 % in the thalamus). This is the first
detection of bithalamical DBS-effects on the dopamine transmission,
suggesting a strong inhibition of dopamine release caused by
DBS. The striking specify of these effects supports this interpretation.
However, an immense upregulation of FP-BPs may be a hint
towards counterregulative effects that may occur due to DBS and
may be responsible for the slow process of recurrence of symptoms.
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What can DBS teach us about Function and Dysfunction of Circuit
Processing of Affective Stimuli?
Thomas Schläpfer (Universitätsklinikum Bonn, Psychiatrie und Psychotherapie)
Introduction: Deep brain stimulation (DBS) ) is a well-established
procedure that refers to stereotactic placement of uni- or bilateral
electrodes in a given brain region with electrodes connected to
a neurostimulator implanted under the skin of the chest. It is a
FDA approved method for control of severe forms of tremor in
Parkinson’s disease, essential tremor and primary dystonia. Re-
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