High-Frequency Neuronavigated rTMS in Auditory Verbal Hallucinations: A Pilot Double-Blind Controlled Study in Patients With Schizophrenia

INTRODUCTION

Despite extensive testing, the efficacy of low-frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) of temporo-parietal targets for the treatment of auditory verbal hallucinations (AVH) in patients with schizophrenia is still controversial, but promising results have been reported with both high-frequency and neuronavigated rTMS. Here, we report a double-blind sham-controlled study to assess the efficacy of high-frequency (20 Hz) rTMS applied over a precise anatomical site in the left temporal region using neuronavigation.

METHODS

Fifty-nine of 74 randomized patients with schizophrenia or schizoaffective disorders (DSM-IV R) were treated with rTMS or sham treatment and fully evaluated over 4 weeks. The rTMS target was determined by morphological MRI at the crossing between the projection of the ascending branch of the left lateral sulcus and the superior temporal sulcus (STS).

RESULTS

The primary outcome was response to treatment, defined as a 30% decrease of the Auditory Hallucinations Rating Scale (AHRS) frequency item, observed at 2 successive evaluations. While there was no difference in primary outcome between the treatment groups, the percentages of patients showing a decrease of more than 30% of AHRS score (secondary outcome) did differ between the active (34.6%) and sham groups (9.1%) (P = .016) at day 14.

DISCUSSION

This controlled study reports negative results on the primary outcome but demonstrates a transient effect of 20 Hz rTMS guided by neuronavigation and targeted on an accurate anatomical site for the treatment of AVHs in schizophrenia patients.

Successful treatment of pudendal neuralgia with tricolumn spinal cord stimulation: case report

BACKGROUND AND IMPORTANCE

There is large variation in the success of decompressive surgery for pudendal neuralgia (PN), the most chronic, disabling form of perineal pain. We attempt to determine whether spinal cord stimulation using new-generation multicolumn leads could form part of the treatment algorithm for refractory PN.

CLINICAL PRESENTATION

A man with PN that was unresponsive to conventional treatment demonstrated a neuropathic component and had a negative response to nerve infiltrations (so he was not indicated for decompressive surgery) and a positive response to perianal transcutaneous electrical nerve stimulation and was implanted with a 16-contact surgical lead at the level of conus medullaris, allowing multicolumn stimulation. Using transverse combinations, it was possible to obtain 100% paresthesia over the perineal area without unwanted dorsal root stimulation. Perineal and radicular pain was successfully relieved for up to 12 months (80% and 60% reduction in the visual analogue scale scores, respectively), with an improvement in all quality of life domains and a reduction in drug consumption.

CONCLUSION

Spinal cord stimulation using a 16-contact lead may be a viable therapeutic option for patients with refractory PN for whom decompressive surgery is contraindicated.

Obsessive compulsive disorder in a patient with twiddler's syndrome

Twiddler's or twist syndrome is the twisting of pulse generators around themselves. It may result from mechanical manipulation that can induce the malfunction of the device. In this case, twiddler's syndrome resulted from compulsive checking of the device. The implantable cardioverter-defibrillator (ICD) triggered the development of an obsessive compulsive disorder (OCD). Two invasive procedures were required to replace the ICD. Psychiatric intervention prevented the recurrence of twiddler's syndrome in this patient for more than 2 years. We believe that preimplant psychiatric assessment should be the rule.

Comparaison de la réadaptation psychosociale et de la qualité de vie des schizophrènes sous neuroleptique classique ou atypique

The psychosocial rehabilitation and the quality of life of schizophrenics have constituted the main concern in the taking care of these patients since their return into our society. Thus, the emergence of atypical neuroleptics allows us to imagine very interesting and important perspectives concerning these 2 concepts. The adaptation to social and professional life, and the quality of life have been rarely compared according to the antipsychotic therapeutic used (classical neuroleptics or atypical neuroleptics). As many authors underline it, there are still very few studies undertaken concerning this subject because of the diverse methodological and ethical limitations implied. That is why we established a transversal study of the psychosocial adaptation and of the quality of life of 2 stabilized schizophrenic groups. These 2 different groups are: the NC group under classical neuroleptics on the one hand, and the NA group under atypical neuroleptics on the other hand. The main target of this study is to observe the influence of the atypical neuroleptics independently of the other factors. Three evaluation scales were used: the PANSS, the psychosocial skill scale (EAPS) of G. Darcourt and the French translation by P. Martin of the Functional Statut Questionnaire (FSQ), and a collection of the clinical and therapeutic socio-demographic data. Concerning the psychosocial capacities, the total results revealed one significant difference (p-value<0.01) between the two groups. The NA group showed a better psychosocial adaptation (80 +/- 10.89 versus 72 +/- 13.39). Besides 4 key-domains are statistically different, but are always in favour of the NA group; the domains are family life (p=0.01), social life (p=0.0026), presentation (p=0.003) and housing and food (0.029). These observations incite to modify our cure. The analysis of the total score of the FSQ did not reveal a statistically significant difference between both groups but this total score seems high in both groups, conveying an important feeling of satisfaction about the quality of life of our sample of schizophrenics. Literature data also abound along the same lines. Indeed, authors underline that patients clearly prefer to live outside rather than in the hospital. Besides, this study allows to confirm the literature data while studying some domains (such as sexuality) rarely brought to light in studies. As a conclusion, we can say that our sample is representative of a population of schizophrenics, and in spite of the difficulties of methodology inherent to this type of study, we can make a comparison between our 2 groups thanks to the stu-died data. Data in which differences could be found, did not show any influence on the results of scales, thus, they cannot be considered as a confounding factor. The NA group showed a better psychosocial adaptation. Furthermore the FSQ did not reveal a difference between both groups. It seems important to remind that a prospective study, conducted for several months and with several evaluations, is essential to confirm the results obtained on both types of treatment.