subscale score: 27→11, negative subscale score: 25→22, general psychopathology subscale score: 41→28). His score on the Global Assessment of Functioning increased from 42 to 55. Weekly evaluation of hallucinations confi rmed their continuous absence for 3 months.The observation in the present case provides the fi rst evidence, to our knowledge, that a long-term bilateral application of continuous theta burst stimulation can achieve a complete and long-lasting elimination of auditory hallucinations and an improvement in global function. Of note, an amelioration of delusions, anxiety, tension, and unusual thought content was also accomplished. Since auditory hallucination-associated cortical activities are not limited to the left hemisphere, we opted for bilateral stimulation to optimize effi cacy. Notably, improvement was achieved gradually, with complete remission, pointing toward a benefi t of prolonged treatment, not occurring until 6 weeks. As intended, continuous theta burst stimulation beyond remission was followed by maintenance of the effect. However, in addition to briefer treatment sessions, an advantage of continuous theta burst stimulation relative to rTMS cannot be derived from this report. Further trials are needed to disentangle the infl uence of treatment duration, laterality, and stimulation paradigm in order to determine treatment effi cacy, clinical practicability, and sustainability. References 1. Hoffmann RE, Boutros NN, Hu S, Berman RM, Krystal JH, Charney DS: Transcranial magnetic stimulation of the left temporoparietal cortex and medication-resistant auditory hallucinations. Arch Gen Psychiatry 2003; 60:49-56 2. Slotema CW, Blom JD, Hoek HW, Sommer IE: Should we expand the toolbox of psychiatric treatment methods to include repetitive transcranial magnetic stimulation (rTMS)? A meta-analysis of the effi cacy of rTMS in psychiatric disorders. J Clin Psychiatry 2010; 71:873-884 3. Huang YZ, Edwards MJ, Rounis E, Bhatia KP, Rothwell JC: Theta burst stimulation of the human motor cortex. Neuron 2005; 45:201-206TO THE EDITOR: Auditory hallucinations in patients with schizophrenia are severely distressing and increase the risk for violence and suicide. In up to 25% of patients, such hallucinations resist therapeutic efforts. Repetitive transcranial magnetic stimulation (rTMS) to the left temporoparietal cortex has been established as an effective new treatment option (1, 2). However, the effectiveness and sustainability of this treatment are still under debate. Bilateral stimulation and prolongation of the treatment course might enhance the size and maintenance of the effect. The use of continuous theta burst stimulation, a patterned form of rTMS with brief stimulation sessions, could improve clinical practicability (3). We report on the case of a patient who received continuous theta burst stimulation applied to the left and right temporoparietal cortex."Mr. C" was a 52-year-old right-handed man with a 22-year history of paranoid schizophrenia (consistent with DSM-IV criteria). The patient suffe...
Atypical antipsychotic agents are a frequently and effectively used treatment in schizophrenia and psychotic disorders. Other than conventional antipsychotics, which mainly exert their pharmacological effect in subcortical dopaminergic systems, atypical antipsychotics additionally affect partly serotonergically innervated structures within prefrontal areas, such as the anterior cingulate cortex (ACC). However, only few controlled, randomized studies have so far investigated direct and indirect effects of atypical antipsychotics on the ACC and, up until now, no clinical investigation has exclusively addressed the specific effects of quetiapine on ACC function. The present study assessed ACC function in 18 quetiapine-medicated patients and 13 flupentixol-treated patients suffering from schizophrenia by means of the error-related negativity (ERN), a neurophysiological marker of ACC function, in a pre-post design. Between-group comparisons revealed different effects of quetiapine and flupentixol on ACC function despite similar improvement in psychopathology, cognitive performance and quality of life. Whereas atypical treatment was associated with an increase in amplitudes over time, there were prolonged ERN peak latencies in patients treated with the typical agent. Moreover, treatment effects depended on baseline prefrontal cortex function in both groups. We conclude that both flupentixol and quetiapine improve prefrontal function especially in patients with weak initial ACC function which might be due to their shared affinity for serotonin receptors in frontal brain regions. However, since this affinity is more pronounced for quetiapine, patients treated with quetiapine seemed to profit more evidently concerning their prefrontal cortex function compared to patients of the flupentixol group, who exhibited a compensatory prolongation of processes.
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