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Es wird der Behandlungsfall einer Patientin mit Borderline-Personlichkeitsstorung und komplexer Traumatisierung vorgestellt, bei dem ein Teil der autoaggressiven Verhaltensanteile durch temporare Episoden von Prostitution ausagiert werden. In diesem Kontext begegnet die Patientin einem »Freier«, der selbst psychotherapeutisch tatig ist und in eine laufende ambulante Behandlung massiv eingreift. Die damit verbundenen Handlungen des Therapeuten konnen als Traumareinszenierung der Patientin verstanden werden und verstosen eklatant und auf vielfaltige Weise gegen die ethischen Richtlinien jedweder Psychotherapie. Dabei zeigt sich auch, welche grosen Uberlappungsbereiche zwischen dem narzisstischen und dem sexuellen Missbrauch in der Psychotherapie bestehen.

Background Repetitive transcranial magnetic stimulation (rTMS) has shown promise as a treatment for refractory auditory hallucinations (AH) in Schizophrenia. Most previous studies have examined the effect of low frequency, left-sided stimulation (LFL) (1 Hz) to the temporoparietal cortex (TPC). Priming stimulation (6 Hz) prior to LFL stimulation (hereby simply referred to as priming) has been shown to enhance the neurophysiological effects of LFL rTMS alone and, as such, may lead to greater attenuation of AH. Objective Therefore, this study evaluated the efficacy of priming rTMS and LFL rTMS compared to sham rTMS using MRI targeting of Heschl’s gyrus (HG) within the TPC of subjects with SCZ experiencing refractory auditory hallucinations (AH). Methods Subjects between the ages of 18 and 65 were recruited from a tertiary care university hospital. Fifty-four subjects with medication resistant AH were randomized to receive LFL, priming, or sham rTMS for 20 treatments. The primary outcome was reduction of hallucinatory symptoms as indexed by response rates on the Psychotic Symptoms Rating Scale (PSYRATS). Results The response rates did not differ among the three treatment groups using an intention to treat analysis. The response rates did not differ in any of the secondary outcome measures. The treatment was well tolerated with minimal adverse effects including no changes in cognition during the study. Conclusion These findings suggest that neither priming nor LFL rTMS of Heschl’s gyrus are effective at ameliorating refractory AH in schizophrenia. ClinicalTrials.gov Identifier: NCT01386918

Background Cortical inhibition deficits have been demonstrated in several disorders with deficits in impulsive control (e.g., attention-deficit/hyperactivity disorder [ADHD], tic disorder, Tourette syndrome) by using transcranial magnetic stimulation (TMS). With borderline personality disorder (BPD), we investigated another disorder associated with high impulsivity by TMS. We hypothesized that BPD patients display decreased cortical inhibition and/or increased cortical excitation as assessed with TMS. Methods Different inhibitory and excitatory TMS parameters were investigated in 19 unmedicated female BPD patients and 19 healthy control subjects matched for sex, age, handedness, and body height. Additionally, the results were controlled for ADHD symptomatology. Results A reduced cortical silent period (CSP) duration was found in BPD patients compared with healthy control subjects in the right cortex. Even after controlling for ADHD symptoms, this result remained significant. Conclusions These findings support an association between BPD and cortical inhibition deficits as indexed through TMS. The results are discussed considering basic neurobiological mechanisms that may explain our findings of decreased intracortical inhibition in BPD patients.

Background: Dissociation is often related to previous trauma and also occurs frequently in schizophrenia. Dissociation and psychosis may reflect a posttraumatic syndrome in some patients with schizophrenia. Sampling and Methods: In total, 80 patients diagnosed with schizophrenia were investigated by means of the Childhood Trauma Questionnaire (CTQ), the Dissociative Experience Scale and the Symptom Check List 90-R. CTQ subscales and groups reporting high and low dissociation were compared using MANOVA. Results: Childhood traumatic experiences were frequent [mean CTQ total score = 45.4 ± 17.5 (SD)]. Physical neglect was clearly associated with high dissociation, whereas abuse was not. Furthermore, there was a significant association of physical neglect with psychopathological distress not fully accounted for by dissociation. Conclusions: Dissociation may be specifically linked to childhood physical neglect in patients diagnosed with schizophrenia. Dissociation alone may not explain the effects of childhood maltreatment on adult psychopathology in schizophrenia; however, conclusions from the present study are limited due to its cross-sectional design.

Objective: Previous results indicated a facilitated transcallosal inhibition via the corpus callosum (CC) in alexithymic male students. This study investigates transcallosal inhibition in alexithymic and nonalexithymic psychiatric inpatients. Method: Transcallosal inhibition was elicited by means of transcranial magnetic stimulation (TMS) of the primary motor cortex. Seven right-handed male and 12 female psychiatric patients with Toronto Alexithymia Scale (TAS-20) scores of ≧61 and 12 patients with TAS-20 scores of Results: There was a significant effect of alexithymia on TCT (Wilks λ = 0.76; F = 4.1; d.f. = 2, 26; p = 0.027) indicating that alexithymic patients had shorter bidirectional TCTs than nonalexithymic patients. The in-between models showed a significant impact of alexithymia on both right to left TCT (F = 4.8; d.f. = 1; p = 0.038) and left to right TCT (F = 5.0; d.f. = 1; p = 0.033). Neither gender nor scores of depression (Montgomery-Asberg Depression Rating Scale) had any significant effects on TCT. Conclusion: Our results confirm and extend the previous findings of a facilitated, bidirectional transcallosal inhibition in alexithymia to male and female psychiatric inpatients. Facilitated transcallosal inhibition should be considered as a neurobiological correlate of alexithymia.

The authors investigated the hypothesis that dissociation may represent a functional dysconnectivity syndrome using a transcranial magnetic stimulation (TMS) approach. Transcranial magnetic stimulation investigations that included motor thresholds and the transcallosal conduction time (TCT) reflecting the interhemispheric transfer were performed in 74 right-handed students. All subjects completed the Dissociative Experience Scale. The high dissociators had a significantly lower left hemispheric excitability than right hemispheric excitability. They also had a significantly shorter TCT from the left to the right hemisphere than did the low dissociators. These results suggest that the neural basis of dissociation may involve a cortical asymmetry with a left hemispheric superiority or, alternatively, a lack of right hemispheric integration.

This article reviews studies carried out on the role of transcranial magnetic stimulation (TMS) as an important neurophysiological tool to assess a variety of cortical neurophysiological processes including excitability, inhibition, and plasticity. It discusses how TMS has helped to enhance the understanding of the neurobiology and the treatment of a variety of psychiatric disorders including schizophrenia (SCZ), major depressive disorder (MDD), bipolar disorder (BD), obsessive-compulsive disorder (OCD), and Tourette's disorder (TD). The findings from these studies demonstrate that TMS is a useful tool to evaluate several neurophysiological processes that may be altered in psychiatric illness. Evidence suggests that disorders including SCZ, MDD, BD, and OCD may, in part, be associated with deficient inhibition, altered cortical excitability, and disrupted neural plasticity. Evidence also suggests that psychotropic medications alter the mechanisms, often in a direction opposite to that of illness, thus reflecting on some of their therapeutic effects.

It has been previously demonstrated that unmedicated persons with schizophrenia have deficits in cortical inhibition (CI) as indexed with transcranial magnetic stimulation (TMS). This inhibition is largely mediated by cortical GABAergic mechanisms. It has also been demonstrated that these inhibitory deficits may be normalized with the use of atypical antipsychotic medications. The purpose of this study, therefore, was to examine the effects of clozapine on TMS measures of CI and to compare these effects to unmedicated persons with schizophrenia and healthy subjects. We used two TMS inhibitory paradigms: short interval intra-cortical inhibition (SICI) and the cortical silent period (CSP) to evaluate CI in 10 clozapine-treated persons with schizophrenia, 6 unmedicated persons with schizophrenia and 10 healthy subjects. Clozapine-treated persons with schizophrenia had significantly longer CSPs compared with healthy subjects and unmedicated persons with schizophrenia. There were no significant differences in SICI between groups, however, the severity of psychotic symptoms was correlated with reduced SICI across all persons with schizophrenia. Our findings suggest that clozapine treatment is associated with greater CI in persons with schizophrenia and this increase may be related to potentiation of cortical GABAergic receptor mediated inhibitory neurotransmission. Our results also confirm previous findings suggesting that deficits in CI are related to the severity of psychotic symptoms in persons with schizophrenia.

Background Dissociation is often related to psychologic trauma and is also commonly correlated with posttraumatic stress disorder (PTSD). Schneiderian symptoms occur in dissociative disorder and PTSD, whereas dissociation and trauma are also frequent in patients with schizophrenia. Dissociation and schneiderian symptoms may reflect posttraumatic symptomatology in some patients diagnosed with schizophrenia who might not develop PTSD. Method Seventy-one patients completed an interview assessing symptoms of schizophrenia, depression, dissociative disorder, and PTSD. Data were collected using the Positive and Negative Syndrome Scale, the Montgomery-Asberg Depression Rating Scale, the Arbeitsgemeinschaft Methodik und Dokumentation in der Psychiatrie scale for dissociation, and a Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition –based questionnaire. Multiple analysis of covariance was used to compare psychopathologic measures between groups with or without PTSD criteria A1 and A2, PTSD, and high and low levels of dissociation, controlling for substance abuse. Result Trauma and dissociation were associated with more severe symptoms of schizophrenia. Especially high dissociation was associated with an increase in symptom load, whereas criterion A and PTSD had little or no such effect. Discussion In the present study, those with more severe schizophrenic and depressive symptoms were also characterized by high dissociation. The possible relation to trauma and schizophrenic diathesis is discussed along with the limitations of the study.

Several lines of evidence suggest that schizophrenia (SCZ) is associated with disrupted plasticity in the cortex. However, there is little direct neurophysiological evidence of aberrant long-term potentiation (LTP)-like plasticity in SCZ and little human evidence to establish a link between LTP to learning and memory. LTP was evaluated using a neurophysiological paradigm referred to as paired associative stimulation (PAS). PAS involves pairing of median nerve electric stimulation with transcranial magnetic stimulation (TMS) over the contralateral motor cortex (for abductor pollicis brevis muscle activation) delivered at 25-ms interstimulus interval. This pairing was delivered at a frequency of 0.1 Hz for 30 min. LTP was reflected by the change in motor evoked potentials (MEPs) before and after PAS. In addition, motor skill learning was assessed using the rotary pursuit task. Compared with healthy subjects, patients with SCZ demonstrated significant MEP facilitation deficits following PAS and impaired rotary-pursuit motor learning. Across all subjects there was a significant association between LTP and motor skill learning. These data provide evidence for disrupted LTP in SCZ, whereas the association between LTP with motor skill learning suggests that the deficits in learning and memory in SCZ may be mediated through disordered LTP.

Deficient inhibitory neurotransmission has been demonstrated in schizophrenia through electroencephalography (e.g. P50 suppression) and transcranial magnetic stimulation (e.g. short-interval cortical inhibition and the cortical silent period). It is not known whether these inhibitory paradigms are related despite evidence suggesting that both are coordinated through gamma-aminobutyric acid inhibitory neurotransmission. We explored the relationship between P50 suppression, short-interval cortical inhibition and the cortical silent period in 21 healthy participants using previously published methods. P50 suppression was significantly correlated with cortical silent period (r=-0.49, P=0.02) but not with short-interval cortical inhibition. As both P50 suppression and the cortical silent period have been linked to gamma-aminobutyric acidB receptor-mediated inhibitory neurotransmission, these data highlight the importance of this receptor subtype in the pathophysiology of schizophrenia.

Objective: This study investigates the hypothesis that alexithymia is associated with an interhemispheric transfer deficit via the corpus callosum (CC). Method: The transcallosal inhibition paradigm was used to assess interhemispheric transfer. Transcranial magnetic stimulation (TMS) and peripheral electromyographic recordings were performed in 10 right-handed male and 10 female students with Toronto Alexithymia Scale (TAS-20) scores of ≧61 and controls (TAS-20 scores of Results: There was a significant interaction between gender and alexithymia (Wilks λ = 0.89; F = 3.4; d.f. = 2, 57; p = 0.04) indicating that alexithymic males had shorter bidirectional TCTs than controls and a significantly shorter left to right TCT than controls (p = 0.002). However, the left to right TCT was not significantly different from the right to left TCT in alexithymic males (p = 0.39). Alexithymic females were not different from controls. Conclusion: Our results clearly stand in contrast to the hypothesis of a transfer deficit due to a dysfunction of the CC in alexithymia. Facilitated, bidirectional transcallosal inhibition of the contralateral motor activity is associated with alexithymia in males. Facilitated cortical inhibition may be a neurobiological correlate of alexithymia.