Title: The effects of caloric vestibular stimulation on denial of illness and psychopathology
1The effects of caloric vestibular stimulation on
denial of illness and psychopathology
2History
3- In the last decade, the pendulum between
pharmacological and non-pharmacological
biological therapeutic interventions in severe
mental disorders seems to move slowly in the
direction of the latter interventions. - A variety of non-pharmacological neurostimulatory
techniques are being investigated with regard to
their potential diagnostic and therapeutic
effects in mental disorders.
4- These techniques included
- Transcranial magnetic stimulation
- Deep brain stimulation
- Vagal nerve stimulation and
- A current study explores the therapeutic effects
of trigeminal nerve stimulation (DeGiorgio et al,
2006).
5Are the relatively non localized brain
stimulation techniques OUT ? and the more
localized brain stimulation techniques IN ?
6Cerlleti
out
Munitz
7- The availability and spread of Neuroimaging
data is enabling the development of specific
stimulatory interventions in the fields of
psychiatry - in the same magnitude as
- the availability and spread of economical data
via internet trafficking enables the development
of novel interventions in economical systems
8- Caloric vestibular stimulation CVS is one of a
number of related techniques that have been shown
to induce brain activation of a multimodal
network. - Others include galvanic and rotational vestibular
stimulation (GVS and RVS, respectively), neck
muscle vibration (NMV via proprioceptors) and
optokinetic stimulation (OKS via visual
stimulation).
9- The use of tDCS and CVS as methods of
non-invasive brain stimulation - Gregory Been, Trung T. Ngo, Steven M. Miller and
Paul B. Fitzgerald -
- Caloric vestibular stimulation (CVS) is a
safe methods for selectively modulating cortical
excitability and activation, respectively, which
have recently received increased interest
regarding possible clinical applications. -
- CVS involves irrigating the auditory canal
with cold water which induces a temperature
gradient across the semicircular canals of the
vestibular apparatus. This has been shown in
functional brain-imaging studies to result in
activation in several contralateral cortical and
subcortical brain regions. -
- Brain Research Reviews Volume 56, Issue 2,
December 2007, Pages 346-361
10- The use of tDCS and CVS as methods of
non-invasive brain stimulation - Gregory Been, Trung T. Ngo, Steven M. Miller and
Paul B. Fitzgerald -
-
- CVS has also been shown to have effects on a
wide range of visual and cognitive phenomena, as
well as on post-stroke conditions, mania and
chronic pain states. -
- CVS has been shown to modulate a range of
brain functions, and display potential as
clinical treatment. Importantly, the procedure is
inexpensive relative to other brain stimulation
techniques such as electroconvulsive therapy
(ECT) and transcranial magnetic stimulation
(TMS). - Brain Research Reviews Volume 56, Issue 2,
December 2007, Pages 346-361
11- Caloric vestibular nerve stimulation (CVS)
usually with cold (30ºC) or warm (44ºC) water is
a common clinical procedure routinely employed
during testing of vestibulocochlear nerve
function. - A stronger stimulation may be obtained by the use
of ice water (4ºC).
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16- System of balance
- Membranous and bony labyrinth embedded in petrous
bone - 5 distinct end organs
- 3 semicircular canals superior, lateral,
posterior - 2 otolith organs utricle and saccule
17- Semicircular canals sense angular acceleration
- Otolithic organs (utricle and saccule) sense
linear acceleration
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19The use CVS as methods of non-invasive brain
stimulation - MECHANISM
- The caloric stimulation procedure involves
irrigation of the external auditory canal with
cold or warm water (or air). It has traditionally
been believed to achieve its effects by inducing
a temperature change across the semicircular
canals, thus altering the density of the
endolymphatic fluid ( Bárány, 1906). This creates
convection currents that cause cupular
deflection, leading to stimulation of the
vestibular nerve and vestibular nuclei with
elicitation of the vestibulo-ocular reflex and
resultant nystagmus. - Regardless of its peripheral mechanism of action,
CVS results in a brisk phase of nystagmus with
the direction contralateral to the ear irrigated
following cold-water irrigation.
20-
- This CVS neurostimulatory technique if
proved to carry therapeutic effects in major
mental disorders may have several advantages
including - a it is a non-invasive procedure compared with
VNS or DBS - b this simple procedure is easy to perform
without the use of sophisticated devices and thus
may be applied in a variety of settings - c it reliably affects the same brain structures
repeatedly without the need for navigators and/or
stereotactic procedures applied in TMS and DBS - d it is an inexpensive procedure that can be
used in developing countries and lower
socioieconomic status populations. - Unfortunately, for this very reason, the
private sector will probably refrain from
financing studies designed to examine the
efficacy of this "orphan" procedure.
21Brain imaging studies
- Earlier studies measuring EEG patterns during
CVS (herewith 'CVS' indicates cold-water
stimulation, unless otherwise specified) have
suggested greater hemispheric activation
contralateral to the side of irrigation (e.g .,
Barac, 1967). - More recently, PET and functional MRI (fMRI)
studies have been more informative in identifying
the neural structures activated following CVS.
These areas include temporalparietal cortex
(superior temporal gyrus, inferior parietal lobe,
and temporalparietal junction), anterior
cingulate cortex (ACC), insular cortex, and
putamen in the basal ganglia ( Bottini et al.,
1994, Bottini et al., 1995, Bottini et al.,
2001, Emri et al., 2003, Kisely et al.,
2002, Tuohimaa et al., 1983, Vitte et al.,
1996 and Wenzel et al., 1996 Fig. 1A).
22Brain imaging studies
- Along with temporoparietal and insular
cortical areas, other CVS-activated regions such
as somatosensory area SII and the parietal
operculum have also been regarded as representing
the human homologue of monkey parietoinsular
vestibular cortex, the core region of the
multimodal network (as mentioned above Bottini
et al., 1995, Bottini et al., 2001, Blanke et
al., 2000, Duque-Parra, 2004, Eickhoff et
al., 2006, Kahane et al., 2003 and Petit and
Beauchamp, 2003).
23- Imaging studies have shown widespread though
largely contralateral hemispheric activation
following cold water CVS. PET and functional MRI
studies have identified the neural structures
activated following CVS. - These areas include among others
- a the temporalparietal cortex
- b the anterior cingulate cortex (ACC) and
- c the insular cortex
- (Been et al, 2007 Miller Ngo, 2007 Suzuki M
et al, 2001). - Ice water (4C) vestibular caloric
irrigation of the left ear may thus lead to
activation of these key areas in the
contralateral right hemisphere. - The ACC and the insula were repeatedly
suggested to be involved in major mental
disorders characterized by delusional thoughts
and lack of insight-judgment - (see Fornito et al, 2008 Nagai et al, 2007).
24INSULA A circumscribed body or patch on the skin
25Insula
26Insula
27- Eur Psychiatry. 2007 Sep22(6)387-94.
Epub 2007 Apr 9. - Insular cortex and neuropsychiatric
disorders a review of recent literature.Nagai
M, Kishi K, Kato S.Department of Internal
Medicine, Shobara Red Cross Hospital, Hiroshima,
Japan. nagai10m_at_r6.dion.ne.jp - In this article, the literature on the
relationship between the insular cortex and
neuropsychiatric disorders was summarized
following a computer search. - Recent neuroimaging data, including voxel
based morphometry, PET and fMRI, revealed that
the insular cortex was involved in various
neuropsychiatric diseases such as mood
disorders.. and schizophrenia. -
28CINGULATE Having a girdle of bands or markings
29Schizophr Bull. 2008 Apr 23. Epub ahead of
print Anatomical Abnormalities of the Anterior
Cingulate Cortex in Schizophrenia Bridging the
Gap Between Neuroimaging and Neuropathology.Forni
to A, Yücel M, Dean B, Wood SJ, Pantelis C.
- The anterior cingulate cortex (ACC) is a
functionally heterogeneous region involved in
diverse cognitive and emotional processes that
support goal-directed behaviour. - Structural magnetic resonance imaging (MRI) and
neuropathological findings over the past two
decades have converged to suggest abnormalities
in the region may represent a neurobiological
basis for many of the clinical manifestations of
schizophrenia. - In this article, we review structural
neuroimaging and neuropathological studies of the
ACC, focusing on the unique information they
provide. The available imaging data suggest grey
matter reductions in the ACC precede psychosis
onset in some categories of high-risk
individuals, show sub-regional specificity, and
may progress with illness duration.
30Psychiatry Res. 2009 Feb 22. Epub ahead of
print Creatine abnormalities in schizophrenia
and bipolar disorder.Ongür D, Prescot AP, Jensen
JE, Cohen BM, Renshaw PF.
- We quantified Cr levels in 22 healthy controls,
15 acutely manic patients with bipolar disorder
and 15 acutely ill patients with schizophrenia
using (1)H MRS in the anterior cingulate cortex,
and the parieto-occipital cortex at 4 Tesla. - Patients with schizophrenia had a statistically
significant reduction in Cr levels as compared
with controls bipolar disorder patients showed
no difference in Cr as compared with controls.
31- Ice water (4C) vestibular caloric irrigation of
the left ear may lead to activation of key areas
in the contralateral right hemisphere - including
the ACC and the insular cortex.
32Vilayanur S. Ramachandran a
neurologist best known for his work in the fields
of behavioral neurology and psychophysics. He is
currently the Director of the , Professor in the
Psychology Department and Neurosciences Program
at the University of California, San Diego, and
Adjunct Professor of Biology at the Salk
Institute for Biological Studies.
- Interestingly, Ramachandran stated recently that
"evidence from neurological diseases suggests
that the right hemisphere may act on discrepant
sensory input to cause a re-evaluation of one's
world view" and this re-evaluation of one's
delusions and views about illness seems to be a
necessary step towards a more realistic
acceptance of the external world.
33- Several case reports and small studies suggest
short term and transient improvement of personal
and/or extrapersonal neglect and anosognosia
(denial of illness) following ice water
vestibular caloric irrigation of the left ear in
patients with right parieto/temporo hemispheric
infarct (Rode et al, 1992 Vallar et al, 1990
Rode et al, 1998 Schiff Pulver, 1999). - Bächtold et al (2001) suggested that unilateral
caloric stimulation leads to a selective
activation of contralateral cerebral structures
and speeds up cognitive processes mediated by
these structures.
34- Improvement of a face perception deficit via
subsensory galvanic vestibular stimulation - DAVID WILKINSON, PHILIP KO, PATRICK KILDUFF,
REGINA McGLINCHEY and WILLIAM MILBERG - Abstract
- The remediative effect of galvanic vestibular
stimulation (GVS) was investigated in a patient
who, following right hemisphere damage, is
profoundly unable to recognize faces. -
- Although our study involved only a single
case, the data provide preliminary evidence that
a deficit in perceptual face matching can be
reduced by GVS. This raises the intriguing
possibility that other unilateral visual
disorders may also respond in such a manner.
(JINS, 2005, 11, 925929.)
Geriatric Neuropsychology Laboratory, New England
Geriatric Research, Education Clinical Center,
Veterans Affairs, Boston Medical Center and
Department of Psychiatry, Harvard Medical School,
Boston, Massachusetts
35Vilayanur S. Ramachandran a
neurologist best known for his work in the fields
of behavioral neurology and psychophysics. He is
currently the Director of the , Professor in the
Psychology Department and Neurosciences Program
at the University of California, San Diego, and
Adjunct Professor of Biology at the Salk
Institute for Biological Studies.
- Ramachandran et al (2007a, 2007b) suggested that
the same procedure with ice water applied to the
left ear may alleviate thalamic pain syndrome
proposing that vestibular stimulation may
activates the posterior insula, which in turn may
inhibits the generation of pain in the anterior
cingulate.
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37Edoardo Bisiach
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???? ???? 1987 ????????? ??????? ??????? ??????,
????? ????? ?????? ?? ????? ???????. - ?????? ???? ???? ??? ??? ???? ?? ???? ?????
??????? ?? ?????......???? ????? ???? ???? ?????
???? ?????? ?????? ????? ????? ??????, ???? ?????
?????? ??? ????? ?????? ?????, ??? ??????? ????
??????? ?? ????? ????? ?? ?????? ?????? ??????
?????? ???? ??????? ???? ????? ?????? ??????. - ???????? ??? ?? ???? ?????? ??? ??? ????? ??????
????????? ??? ???? ?????? ????? ????? ??????
?????? ???????! ????? ?????? ?????? ???? ????? ??
????? ??????? ???? ?????? ?????? (?? ?? ?????)
???????? ???..........
38-
- Proc Biol Sci. 1999 Feb 22266(1417)421-3.
Does vestibular stimulation
activate thalamocortical mechanisms that
reintegrate impaired cortical regions? - Schiff ND, Pulver M.
-
-
- Neurocase. 2007 Jun13(3)185-8.
Rapid relief of thalamic
pain syndrome induced by vestibular caloric
stimulation. Ramachandran VS, McGeoch PD,
Williams L, Arcilla G.Med Hypotheses.
200769(3)486-8. Epub 2007 Feb 23. - Can vestibular caloric stimulation be used
to treat Dejerine-Roussy Syndrome? Ramachandran
VS, McGeoch PD, Williams L.Med Hypotheses.
200769(2)250-2. Epub 2007 Feb 9.
Can
vestibular caloric stimulation be used to treat
apotemnophilia? Ramachandran VS, McGeoch
P. Conscious Cogn. 1995
Mar4(1)22-51
Anosognosia in parietal lobe
syndrome.Ramachandran VS. - Center for Research on Brain and Cognition,
University of California, San Diego, La Jolla
92093-0109, USA.
39Vestibular function IN schizophrenia
40-
- Extensive research was done in the 1960's up
to the 1980's to study possible vestibular
response abnormalities in schizophrenia. - These studies were reviewed by Levy et al
(1983) who stated that the empirical findings
linking vestibular response abnormalities to
schizophrenia indicate that these data do not
unequivocally document the presence of peripheral
or central disease of the vestibular system in
any patient group.
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42- The reasons for this ambiguity include
- 1 the use of imprecise stimulation
techniques - 2 inaccurate measures of responsiveness
- 3 unreliable measures of quantification and
- 4 the absence of experimental control over
extravestibular variables. -
43- Surprisingly, none of these studies explored the
short term therapeutic effect of caloric
vestibular stimulation. - Possibly those authors did not expect any
therapeutic effect of such procedure/ - Louis Pasteur in this regard stated that. In
the field of observation, chance favors only the
prepared mind...
44Vestibular function IN depresssssion
45- Asymmetries of vestibular dysfunction in major
depression. Soza Ried AM, Aviles M.
Neuroscience. 2007 Jan 5144(1)128-34. Epub 2006
Oct 30 - we studied the vestibulo-ocular reflex (VOR) in
depressive patients who were not taking
medication and healthy control subjects, - Ocular reflex movement depends on vestibular
nuclei activity, and compared with controls we
found that at 30 degrees C stimulation the right
vestibular system in depressive patients has
approximately half the activity of the left side.
46- Asymmetries of vestibular dysfunction in major
depression. Soza Ried AM, Aviles M.
Neuroscience. 2007 Jan 5144(1)128-34. Epub 2006
Oct 30 - We also found a significant decrease in the slow
phase (16.92/-9.13 degrees/s) of the reflex in
the depressed group as compared with the control
group (43.77/-16.04 degrees/s). - The vestibular nuclei of the right and left sides
are hypoactive. Specifically, the right
vestibular nucleus is hypoactive in depressed
people and can easily be measured using VOR. - These results support the abnormal asymmetries
hypothesis of depression and suggest that these
asymmetries also exist at the level of the brain
stem or neuronal centers that are afferents to
right vestibular nuclei, like SCN or raphe
nuclei.
47There is still a lot we can find about
the effects of biological neurostimulatory
techniques on psychopathology
48- There is however preliminary data showing
immediate positive effects of left ear CVS with
ice water irrigation upon - illness denial
- cognitive processes and
- delusions.
49- In the early 1990s Bisiach et al (1991) explored
the effects of ice water vestibular stimulation
on somatoparaphrenic delusion in a patient
suffering from a fronto-temporo-parietal
infarction located in the right hemisphere. - Transitory remission of the patient's delusional
belief was consistently observed during
unilateral vestibular activation obtained by
means of cold-water irrigation of the left
(contralesional) ear. - Recently Dodson (2004) reported an improvement in
manic symptoms after ice water caloric vestibular
stimulation to the left ear in a 29 year old
woman with a 10 year history of bipolar affective
disorder.
50- Thus although implausible at first sight, it is
intriguing to explore whether ice water
vestibular stimulation may treat -
- denial of illness and alleviate delusional
thoughts in patients suffering from - schizophrenia and manic bipolar and
schizoaffective disorders.
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52- Recently, we studied 3 patients with left versus
right ear ice water (4C) CVS. - One patient, an adult male, had a chronic history
of schizoaffective disorder and recent mild left
extremity weakness following suspected right
hemispheric CVA. - The other two patients, an otherwise healthy
adult male and female, had chronic schizophrenia
with prominent delusions. - All subjects demonstrated a clinically
significant short-term transient improvement in
delusional thoughts and insight of illness with
left versus right ice water CVS. This improvement
was maintained for at least 20 minutes and then
diminished over 60 minutes.
53- All patients were evaluated with the Delusions
item of the PANSS (Item P1), the total PANSS
positive symptoms subscale score (t-P-PANSS) and
the lack of insight-judgment item of the PANSS
(Item G12) to assess their clinical status at
baseline prior to the CVS stimulation of one ear,
immediately after and at 20, 60 minutes and 24
hours later. - The same procedure was repeated on the other ear
several days later.
54- In one patient the stimulation of both right
and left vestibular nerves were also validated by
videonystagmography, and a more robust effect on
the brain was reflected by quantitative
electroencephalography (QEEG) with left versus
right CVS.
55-
- The following is a case report where ice
water (4C) were administered to left ear and the
patient was followed immediately after, 20
minutes, 60 minutes and 24 hours later. - The same procedure was repeated to the right ear
4 days later. - This whole procedure to both ears will be called
a trial. - And such 3 trial were done with this patient.
56- The first one had a qualitative nature and meant
to examine whether such procedure may at all
influence the patient symptomatology and denial
of illness. - in the second trial the function of the
vestibular system was first thoroughly studied by
the use of videonystagmography then a trail with
ice water vestibular stimulation was done to both
left and right ears as described above in trial
one. Videonestgmograpy recording of the
vestibular stimulation showed a clear stimulation
of the Rt and Lt vestibular nerves by the
procedure. - In the third trial the whole procedure as
detailed in trial one was done while QEEG
recording describing the effects of such
procedure on the brainwere done.
57Videonistagmography
Videonystagmography (VNG) technologies are used
for testing inner ear and central motor
functions. VNG testing is considered the new
standard for testing inner ear functions over
Electronystagmography (ENG), because VNG measures
the movements of the eyes directly through
infrared cameras, instead of measuring the
muscles around the eyes with electrodes like the
previous ENG version.
58Videonystagmography (VNG)
- VNG testing is more accurate, more consistent,
and more comfortable for the patient. - By having the patient more comfortable and
relaxed, consistent and accurate test results are
more easily achieved.
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60- Recording of the EEG was done with Deymed
Truescan 32 system. - During measurement the impedance of all the
electrode were kept below 5K.
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63Each point in each topographical "head" reflects
one electrode according to the international
10-20 system.
64- Each topographical "head" is drawn from above
with the left ear on the left, right ear on the
right. The nose on the top represents the frontal
area. - The raw EEG was visually scanned and artifacts
were omitted and then it was subjected to Fast
Fourier transformation (FFT). - The topographical heads show the relative power
of the FFT. The values can be calculated
according to the scale below each "head". It is
in squared micro-volt units.
65LORETA
We deal here with the
66- LORETA- low resolution brain
electromagnetic tomography -
- Scalp electric potentials (EEG) arise from
neuronal post-synaptic processes. - what is the exact contributions of the
different brain parts to a given EEG signal ? - One of the solutions to this problem is the
LORETA. The LORETA could, in theory, assign a
brain location to a specific EEG pattern that is
measured over the scalp. The technical and
mathematical considerations for this algorithm is
beyond the scope of this lecture and could be
found in previous publications. - 1. Pascual-Marqui RD. Review of methods for
solving the EEG inverse problem. - International Journal of Bioelectromagnetism
1999, 1 75-86. - 2. Pascual-Marqui RD, Esslen M, Kochi K, Lehmann
D. Functional imaging with - low resolution brain electromagnetic tomography
(LORETA) review, new - comparisons, and new validation. Japanese Journal
of Clinical Neurophysiology - 2002, 3081-94.
- 3. Pascual-Marqui RD, Michel CM, Lehmann D. Low
resolution electromagnetic - tomography a new method for localizing
electrical activity in the brain. - International Journal of Psychophysiology. 1994,
1849-65.
67Formally, LORETA is a particular 3D, discrete,
distributed, linear solution to the inverse
EEG/MEG problem. Informally, LORETA is
described in the first published abstrac
68- SEE THE POSTER FOR THE CLINICAL RESULTS AS WELL
AS FOR THE QEEG AND LORETA RESUTLTS
69MECHANISM ?
70- Mast FW, Merfeld DM, Kosslyn SM. Visual mental
imagery during caloric vestibular stimulation.
Neuropsychologia. 200644(1)101-9 - We investigated high-resolution mental imagery
and mental rotation, while the participants
received caloric vestibular stimulation. - we predicted that vestibular stimulation would
disrupt high-resolution mental imagery - this prediction was confirmed. In contrast,
such stimulation did not affect performance of a
low-imagery control task.