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BackgroundLow Intensity Focused Ultrasound Pulsation (LIFUP) is a noninvasive brain stimulation method that may modulate deep brain structures using ultrasonic waves. Presently there are limited studies in humans rigorously assessing behavioral effects following LIFUP sonication of deep brain nuclei. As an initial test, we investigated whether sonication of the anterior thalamus, a central relay structure of nociception, would modulate thermal pain thresholds in healthy individuals.MethodsWe enrolled 19 healthy individuals in this three-visit, double-blind, randomized, sham-controlled, crossover trial. Participants attended a first MRI screening visit to acquire anatomical scans for LIFUP targeting. They then attended two identical experimental LIFUP/MRI visits (counterbalanced by condition) at least one-week apart. Within the MRI scanner, participants received two, 10-minute sessions of either active or sham LIFUP spread 10 minutes apart to the right anterior thalamus [Fundamental frequency:650khz, pulse repetition frequency: 10 HZ, Pulse Width: 5ms, Duty Cycle: 5%, Sonication Duration: 30s, Inter-Sonication Interval: 30 s, Number of Sonications: 10, ISPTA.3 719 mW/cm2]. Each 10-minute session was delivered in a block design (30s ON, 30s OFF). The primary outcome measure was quantitative sensory thresholding (QST), measuring sensory, pain, and tolerance thresholds to a thermal stimulus applied to the left forearm before and after LIFUP. Thermal stimuli were also applied in the scanner during certain blocks, either alone, or during LIFUP.ResultsTwo 10-minute sessions of thalamic LIFUP produced a significant antinociceptive effect on pain thresholds. Temperature sensitivity increases were significantly attenuated (timeXcondition p=0.046) after active LIFUP (0.51 degree change) relative to sham stimulation (1.08 degrees). LIFUP also changed sensory and tolerance thresholds mathematically but this was not statistically significant with this sample. LIFUP delivered concurrently with thermal pain had no immediate behavioral effect.ConclusionsTwo, 10-minute sessions of anterior thalamic LIFUP has antinociceptive effects in healthy individuals. Future studies should optimize the parameter space and dose and perhaps investigate multi-session LIFUP interventions for pain disorders.

Objective: Depression among weight loss surgery (WLS) candidates is common. Anxiety in this population is less studied. Untreated anxiety persists post-surgery and is associated with poor surgical outcomes. The current study sought to explore the nature of anxiety in WLS candidates. Given shared symptoms of anxiety and obesity, we hypothesized that physiological symptoms of anxiety would be most common. Methods: In this retrospective study, the medical records of 174 pre-WLS candidates at a large medical center were reviewed. Each completed a comprehensive medical, surgical, and psychological evaluation as part of standard of care. Data from these evaluations were abstracted. One hundred forty-three candidates completed the Beck Anxiety Inventory (BAI). A Principal Components Analysis (PCA) with varimax rotation was used to identify the factor structure of the BAI. Results: The sample consisted of primarily middle-aged (46.0 ± 13.24 years), married (60.8%), Caucasian (65.7%), females (79%) with Class III obesity (Body Mass Index = 50.1 ± 10.68) and mild anxiety (8.86 ± 8.70). Forty-four percent of the sample endorsed clinically significant anxiety. PCA revealed a four-factor structure that explained 56.28% of the variance in the BAI. The four factors were: 1) cognitive-emotional distress, 2) autonomic hyperarousal, 3) neurophysiologic concerns, and 4) body temperature. Conclusions: Clinically significant anxiety is common among WLS candidates. Cognitive-emotional clustering of anxiety symptoms was more common than hypothesized. This is notable given the overlap of physiological symptoms of anxiety and obesity. Findings lend support for the utility of psychotherapeutic approaches tailored to address maladaptive thoughts to address anxiety and potentially improve WLS outcomes.

Food cravings are common, more prevalent in the obese, and may differ in those who pursue surgical treatment for obesity. Food craving tools are most often validated in non-clinical, non-obese samples.In this retrospective study, 227 bariatric surgery candidates at a large medical center completed the Food Cravings Questionnaire-Trait (FCQ-T). The aim was to explore the factor structure of the FCQ-T.Principal components analysis with varimax rotation revealed a seven-factor structure that explained 70.89 % of the variance. The seven factors were: (1) preoccupation with food, (2) emotional triggers, (3) environmental cues, (4) loss of control, (5) relief from negative emotions, (6) guilt, and (7) physiological response. The preoccupation with food factor accounted for 49.46 % of the variance in responses.Unlike other populations, food cravings in bariatric surgery candidates appear to be related most to preoccupations with food.

Background Pain is common and multifactorial among patients with chronic pancreatitis. Underrecognized and undertreated psychosocial comorbidity can exacerbate pain experience. Excess inpatient service utilization within this patient population prompted a performance improvement initiative at a large academic medical center. Methods An interprofessional treatment approach with programmatic medical, surgical, and psychological and psychiatric interventions was rolled-out in January 2007 and length of stay (LOS) was measured on a quarterly basis for a 2-year period. Trends in resource utilization (LOS, estimated opportunity costs) were assessed with a novel modified bootstrapping technique, Simulation Modeling Analysis (SMA). Results From January 1, 2007, through December 31, 2008, SMA revealed a linear downward trend in LOS (ρ = −0.857, p = .0170), and the interprofessional treatment approach was associated with estimated opportunity cost savings of $670,750.27. There were no associated changes in 7-, 14-, and 30-day readmission rates, p > .05. Conclusion Interprofessional care that combines behavioral approaches to pain management; behavioral contingency management for opioid medication management; psychological and psychotropic treatments for depression, anxiety, and addiction in addition to standard medical and surgical treatments for pancreatitis appears to be associated with lower healthcare costs. Future research should examine patient reported outcomes of this model.

Technical advances allowing for the analysis of functional MRI (fMRI) results in real time have led to studies exploring the ability of individuals to use neural feedback signals to modify behavior and regional brain activation. The use of real-time fMRI (rtfMRI) feedback has been explored for therapeutic benefit in a number of disease states, but to our knowledge, the potential therapeutic benefit of rtfMRI feedback in the treatment of addictive disorders has not been explored. This article will provide an overview of the development of rtfMRI and discussion of its potential uses in the treatment of addictions. We also describe a series of pilot studies that highlight some of the technical challenges in developing a rtfMRI feedback paradigm for use in addictions, specifically in nicotine dependence. Because the use of rtfMRI feedback is in its infancy, the work described is focused on establishing some of the basic parameters in optimizing the rtfMRI feedback, such as the type of feedback signal, region of interest for feedback and predicting which subjects are most likely to respond well to training. While rtfMRI feedback remains an intriguing possibility for the treatment of addictions, much work remains to be done in establishing its efficacy.

Numerous research groups are now using analysis of blood oxygen level-dependent (BOLD) functional magnetic resonance imaging (fMRI) results and relaying back information about regional activity in their brains to participants in the scanner in 'real time'. In this study, we explored the feasibility of self-regulation of frontal cortical activation using real-time fMRI (rtfMRI) neurofeedback in nicotine-dependent cigarette smokers during exposure to smoking cues. Ten cigarette smokers were shown smoking-related visual cues in a 3 Tesla MRI scanner to induce their nicotine craving. Participants were instructed to modify their craving using rtfMRI feedback with two different approaches. In a 'reduce craving' paradigm, participants were instructed to 'reduce' their craving, and decrease the anterior cingulate cortex (ACC) activity. In a separate 'increase resistance' paradigm, participants were asked to increase their resistance to craving and to increase middle prefrontal cortex (mPFC) activity. We found that participants were able to significantly reduce the BOLD signal in the ACC during the 'reduce craving' task (P=0.028). There was a significant correlation between decreased ACC activation and reduced craving ratings during the 'reduce craving' session (P=0.011). In contrast, there was no modulation of the BOLD signal in mPFC during the 'increase resistance' session. These preliminary results suggest that some smokers may be able to use neurofeedback via rtfMRI to voluntarily regulate ACC activation and temporarily reduce smoking cue-induced craving. Further research is needed to determine the optimal parameters of neurofeedback rtfMRI, and whether it might eventually become a therapeutic tool for nicotine dependence.

The prospect of and the evaluative period for transplantation can be stressful for individuals with heart failure (HF). Little is known about the impact of psychosocial factors on service utilization and health outcomes. The current study examined the impact of depression, dysthymia, and anxiety on two-yr hospitalization and mortality among 96 individuals with HF who were evaluated for transplantation. Results revealed that only a small percentage of individuals endorsed sufficient symptomatology to meet criteria for a psychiatric, Axis I disorder (3.1% = anxiety; 2.1% = depression; 1.0% = dysthymia) although a significant proportion of the sample was prescribed an antidepressant or an anxiolytic (37%). Multivariable regression analysis was conducted to examine the association between significant independent demographic, medical, and psychiatric predictors and total duration of hospitalizations; logistic regression analysis was used to examine the relation between predictors and mortality. An increase in anxious symptoms was associated with a decrease in total number of days hospitalized during the two-yr period following the initial evaluation. Similarly, as depressive symptoms increased, risk of two-yr mortality decreased. Future research should assess communication between the patient and providers to further elucidate the potential relationship between psychiatric symptoms, service utilization/hospitalization, and mortality in this patient population.

Meditation involves attentional regulation and may lead to increased activity in brain regions associated with attention such as dorsal lateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC). Using functional magnetic resonance imaging, we examined whether DLPFC and ACC were activated during meditation. Subjects who meditate were recruited and scanned on a 3.0 Tesla scanner. Subjects meditated for four sessions of 12 min and performed four sessions of a 6 min control task. Individual and group t-maps were generated of overall meditation response versus control response and late meditation response versus early meditation response for each subject and time courses were plotted. For the overall group (n= 13), and using an overall brain analysis, there were no statistically significant regional activations of interest using conservative thresholds. A region of interest analysis of the entire group time courses of DLPFC and ACC were statistically more active throughout meditation in comparison to the control task. Moreover, dividing the cohort into short (n= 8) and long-term (n= 5) practitioners (>10 years) revealed that the time courses of long-term practitioners had significantly more consistent and sustained activation in the DLPFC and the ACC during meditation versus control in comparison to short-term practitioners. The regional brain activations in the more practised subjects may correlate with better sustained attention and attentional error monitoring. In summary, brain regions associated with attention vary over the time of a meditation session and may differ between long- and short-term meditation practitioners.

Background Ventricular assist device (VAD) recipients are at high risk of depression and anxiety, and poor psychosocial functioning is associated with worse medical outcomes. Purpose We present a case of a 31-year-old depressed patient who demonstrated passive suicidal behavior through multiple episodes of noncompliance, including temporarily discontinuing warfarin (Coumadin) several months after VAD implantation. The patient's psychosocial and medical histories and outcomes are presented. Conclusions This case underscores the importance of pre-VAD as well and ongoing psychosocial evaluation and management for this unique patient population. Clinical implications Medical teams who are treating patients with cardiovascular disease who are under consideration for VAD or heart transplantation need to be aware of the multitude of ways in which patients can express depressed and suicidal mood and work with a multidisciplinary team to treat such symptoms to optimize patients' success with VAD/heart transplantation.

The prefrontal cortex may be a promising target for the use of transcranial direct current stimulation (tDCS) in the management of pain symptoms. The present study explored the effects of anodal and cathodal tDCS over the left dorsolateral prefrontal cortex on the effects of perceived pain controllability.Forty-one participants received continuous anodal or cathodal tDCS and underwent a laboratory pain task designed to manipulate the perception of pain control. Participants were told that they would be completing a reaction-time task (press keyboard button of corresponding arrow shown on computer screen with either green or red background). A thermal pain stimulus was delivered following each trial by a thermode placed on the participant's left forearm. Although pain stimuli were pseudorandomally ordered and matched for total duration between control (green) and noncontrol (red) trials, participants were told that if they responded correctly and more quickly on green trials than their average reaction times, the thermal pain stimulus duration would be decreased (ie, perceived control). Participants were told they had no control of pain stimulus duration over trials presented with the red background.There was a significant main effect for tDCS condition (anode vs. cathode) on pain unpleasantness ratings (P0.04). Specifically, individuals receiving cathodal tDCS reported higher pain unpleasantness ratings (least squares mean=69.40, SE=3.72), whereas those receiving anodal tDCS reported lower pain unpleasantness ratings (least squares mean=58.05, SE=3.81). Exploratory analysis revealed a simple main effect for tDCS group at the level of perceived controllability (P0.02). In addition, participants receiving cathodal tDCS subjectively reported feeling less control of the painful stimuli than those receiving anodal tDCS.Left dorsolateral prefrontal cortex tDCS may play a role in modulating the neurocircuitry involved with the perception of control over pain.

Objective. The present study was conducted to determine if depressive symptoms were associated with variability in pain perception and quality of life among patients with nonalcohol-related chronic pancreatitis.Methods.The research design was cross-sectional, and self-report data was collected from 692 patients with nonalcohol-related, intractable pancreatitis. The mean age of the sample was 52.6 (); 41% of the sample were male. Participants completed the MOS SF12 Quality of Life Measure, the Center for Epidemiological Studies 10-item Depression Scale (CESD), and a numeric rating scale measure of “pain on average” from the Brief Pain Inventory.Results.Depressive symptoms were significantly related to participants’ reports of increased pain and decreased quality of life. The mean CESD score of the sample was 10.6 () and 52% of the sample scored above the clinical cutoff for the presence of significant depressive symptomology. Patients scoring above the clinical cutoff on the depression screening measure rated their pain as significantly higher than those below the cutoff () and had significantly lower physical quality of life () and lower mental quality of life ().Conclusion.Although causality cannot be determined based on cross-sectional, correlational data, findings suggest that among patients with nonalcoholic pancreatitis, the presence of depressive symptoms is common and may be a risk factor associated with increased pain and decreased quality of life. Thus, routine screening for depressive symptomology among patients with nonalcoholic pancreatitis may be warranted.

Narcissistic personality disorder (NPD) is characterized by an unrealistic need for admiration, lack of empathy toward others, and feelings of superiority. NPD presents a unique and significant challenge in clinical practice, particularly in medical settings with limited provider contact time, as health professionals treat individuals who often require excessive admiration and have competing treatment needs. This practice review highlights real case examples across three distinct medically oriented clinical settings (inpatient and outpatient behavioral medicine and a Level I trauma center) to demonstrate the difficult and compromising situations that providers face when treating patients with general medical conditions and comorbid narcissistic personality features. The main goal of this article is to discuss the various challenges and obstacles associated with these cases in medical settings and discuss some strategies that may prove successful. A second goal is to bridge diverse conceptualizations of narcissism/NPD through the discussion of theoretical and empirical perspectives that can inform understanding of the clinical examples. Despite differing perspectives regarding the underlying motivation of narcissistic behavior, this practice review highlights that these paradigms can be integrated when sharing the same ultimate goal: to improve delivery of care across medically oriented clinical settings for patients with narcissistic features.

ContextNoncompliance with medical recommendations by transplant candidates and recipients carries serious consequences for morbidity and mortality. Few patient-specific, objective measures for assessing historical compliance exist.ObjectiveTo address this gap, a psychometric and exploratory analysis of an interview-based, global measure of clinician-rated judgment of historical compliance was undertaken.MethodsAll findings are based on a retrospective chart review of the medical and psychosocial evaluations of 96 consecutive potential heart transplant candidates seen at a large Southeastern academic medical center.ResultsPreliminary results demonstrated adequate interrater reliability and discriminant validity for the measure. Additionally, results from hierarchical multivariable regression analysis revealed years of education to be positively associated with clinician-rated judgment of historical compliance.ConclusionsThis study provides preliminary psychometric support for the use of a measure of historical compliance among heart transplant candidates. Findings from this study also are consistent with the literature to date and may be reflective of a psychobiological process that mediates the relationship between socioeconomic status and health outcomes.

Electrocortical activity is increasingly being used to study emotion regulation and the impact of cognitive control on neural response to visual stimuli. In the current study, we used direct epidural cortical stimulation (EpCS) to examine regional specificity of PFC stimulation on the parietally-maximal late positive potential (LPP), an event-related potential (ERP) biomarker of visual attention to salient stimuli. Five patients with treatment-resistant mood disorders were stereotactically implanted with stimulating paddles over frontopolar (FP) and dorsolateral (DL) prefrontal cortex bilaterally. On their first day of activation, patients underwent sham-controlled EpCS coupled with 64-channel electroencephalograph (EEG) recordings and passive viewing of aversive and neutral images. In addition to sham, patients had either FP or DL prefrontal cortex stimulated at 2 or 4 V while they viewed neutral and aversive pictures. As expected during the sham condition, LPP was larger for aversive compared to neutral stimuli (F(1,4)=232.07, P

Background Repetitive transcranial magnetic stimulation (rTMS) is a novel, noninvasive method of stimulating selected regions of the brain that has both research applications and potential clinical utility, particularly for depression. To conduct high-quality clinical studies of rTMS, it is necessary to have a convincing placebo (or sham) treatment. Prefrontal rTMS causes cutaneous discomfort and muscle twitching; therefore, an optimal control condition, ie, sham condition, would mimic the cutaneous sensation and muscular discomfort of rTMS without stimulating the brain. Ideally, the quality and intensity of the sham condition would feel identical to the quality and intensity of the rTMS condition, except that the sham would have no effect on cortical activity. We designed and built a focal electrical stimulation system as a sham rTMS condition. Although this electrical sham system is superior to methods used in previous studies, little is known about how the new electrical sham system compares with active rTMS in terms of the level of discomfort and type of sensation it produces. Methods We hypothesized that the electrical sham system may not mirror the experimental condition sufficiently. We studied this hypothesis under single-blind conditions in 15 healthy adults by administering either the real or sham rTMS at high and low intensities while subjects, who were unaware of condition, rated subjective qualities of the stimulation (such as tingling, pinching, and piercing), the scalp location of the perception, and the painfulness of the stimuli. Results At low-intensity stimulation, the two techniques (active and sham) differ with respect to the subjective quality of the sensation. The differences between real and sham rTMS were less dramatic at higher intensities. The best sham condition that most closely mimics real prefrontal rTMS requires individual titration of the intensity of electrical stimulation across a broad range. Performing this titration without unblinding patients is likely possible, but technically challenging. We propose a new approach to do this. Conclusion We conclude that it is possible to create a truly indistinguishable sham condition (with appropriate acoustic masking as well), but more work is needed beyond these initial attempts.

Sub-clinical hepatic encephalopathy is a commonly recognized cognitive sequelae of cirrhosis. Cognitive slowing and impairments in executive functioning are frequently noted; however, there is debate in the literature regarding the degree of memory dysfunction in patients with sub-clinical hepatic encephalopathy. This study aimed to evaluate memory functioning in patients with sub-clinical hepatic encephalopathy. Compared to normative data, individuals with cirrhosis performed significantly worse than their healthy peers across neuropsychological measures of verbal memory functioning. Individuals with alcohol-induced cirrhosis performed significantly worse than individuals with non-alcohol/non-hepatitis C-induced cirrhosis on a specific measure of learning and memory. It appears that cirrhosis is associated with impaired memory functioning regardless of underlying liver disease etiology and that sustained periods of excessive alcohol consumption result in greater impairments in memory functioning than hepatic insufficiency alone. Impairments in memory functioning among individuals with cirrhosis have the potential to negatively affect receipt of medical information.