Quaderni Italiani di Psichiatria最新文献

Introduction

Obsessive-compulsive disorder (OCD) is a common psychiatric illness with a lifetime prevalence in the general population of 1.9%-3%. OCD has peculiar clinical and psychopathological features and is classified among the anxiety disorders. With adequate (in terms of dose and duration) drug therapy, remission of symptoms occurs in 50-60% of patients. However, in a significant proportion of cases, other therapeutic strategies are needed for optimal control of obsessive-compulsive symptoms and achievement of acceptable overall functioning. This review analyzes data in the literature regarding therapeutic strategies that can be used for patients with resistant forms of OCD.

Materials and methods

Emphasis will be placed on those strategies that have been validated in controlled, double-blind studies.

Results

Two strategies have proved to be effective in double-blind studies: augmentation with atypical antipsychotics and the addition of cognitive-behavioral therapy. Alternatives whose efficacy has been documented in open label studies include switching to another antidepressant (SSRIs, clomipramine or venlafaxine) or to intravenous administration (citalopram or clomipramine). In extremely refractory cases, alternative experimental therapies are available.

Discussion

Clinicians now have several validated strategies to choose from for the management of resistant OCD, although there are several questions that remain to be answered.

Introduction

Paliperidone, the major active metabolite of the atypical antipsychotic (AA) risperidone, is available in an oral extended-release (ER) formulation and is indicated for the acute and maintenance treatment of schizophrenia in adults.

Materials and methods

This article overviews the recommended dosing strategies for the treatment of schizophrenic patients in acute and chronic care settings. The efficacy, safety, pharmacology, pharmacokinetics, drug-drug interactions, and administration of paliperidone for schizophrenia are reviewed.

Results

Paliperidone's advanced-generation osmotic release delivery system makes it possible to avoid dosage adjustments when initiating therapy, and it may decrease the frequency of antidopaminergic effects that can occur with an immediate-release formulation. The recommended dose of paliperidone for the treatment of adults with schizophrenia is 6 mg every morning. Patients that receive daily doses ranging from 3 to 12 mg displayed generalized symptom improvement on the Positive and Negative Syndrome Scale (PANSS) and improved functioning on the Personal and Social Performance Scale.

Discussion

Paliperidone ER is a useful option in the treatment and prevention of the acute symptoms of schizophrenia. It may also be of use in patients with non-acute disease, including those previously treated unsuccessfully with other oral antipsychotics.

Introduction

Four specific therapeutic factors (previously considered non-specific) that are common to all care activities seem to be correlated with treatment outcomes. Our hypothesis is that each factor has specific neurobiological underpinnings. Using an operationalized definition of each of the four factors, we conducted a search of the Medline database for neuroimaging and neurobiological studies conducted during the past decade.

Results and conclusions

On the basis of our review, we argue that the clinician's communication style could affect activity in the mirror neuron system and in theory of mind brain areas of both the patient and therapist, based on mutual comprehension. Attention to patient history could activate the patient's episodic memory. Transformation of memories to working memory could 1) allow the patient to become aware of them; 2) render mnestic traces usually stored in a long-term memory labile and therefore available for modification; and 3) facilitate calibration of emotions by cognitive conflict-induced activation of the anterior-dorsal cingulate cortex with inhibition of the ventral one. Calibration of expectations could activate in advance the neural networks on which the expected response depends and “reward circuits,” thereby avoiding the so-called nocebo effect. The therapeutic alliance includes two interacting components: 1) cooperation, which depends on prefrontal cortex inhibition of behavior aimed at immediate reward, and 2) attachment, which might involve modulation of the anxiety and “theory of mind” networks. The neurobiological hypotheses presented above seem to support the view that each factor plays a partly specific role in the therapeutic process.

In the last 35 years, use of the in vivo brain imaging techniques PET (Positron Emission Tomography) and SPECT (Single Photon Emission Computed Tomography) for the study of psychiatric disorders has revealed several biological alterations in patients with schizophrenia. The present article describes these two imaging modalities, in terms of underlying functional principles and application strategies, and provides a synthetic review of the literature regarding their use in schizophrenia and mood disorders. Particular emphasis is placed on the contribution of SPECT and PET findings in elucidating pathophysiology of these disorders and identifying potential biomarkers of brain function that can be used to assess treatment responses.