안정기 양극성 장애환자의 얼굴자극에 대한 주의력 유지과제에서의 결핍 특성

황성식,전덕인,조현상,김세주,박진영,전재영,석정호 大韓神經精神醫學會 2007 신경정신의학 Vol.46 No.3

Objectives : Euthymic patients with bipolar disorder have been reported to show deficits in sustained attention. This study aimed to compare the attention capacities of euthymic bipolar patients with those of control subjects using the sustained att-ention to response task (SART) and to examine the differences in the performance of SART related to the type of the stimulus. Methods : The four SART tasks were performed to measure attention capacities in 42 euthymic patients with bipolar dis-order and 28 control subjects. Happy, neutral, fearful faces and digit '3' were used as target stimuli in happy, neutral, fear and digit task conditions, respectively. The seventy of mood symptoms was assessed with 17-item Hamilton Rating Scale for De-pressive symptoms and Young Mania Rating Scale for manic symptoms. The efficiency estimate which reflects both the res-ponse accuracy and speed was used as the main outcome variable. Results : Bipolar patients showed significantly lower correct response rate than control group in all task conditions. Effi-ciency estimates of the bipolar patient group were significantly lower than those of the control group in the SART using facial stimuli, but not in the digit task condition. There was no significant difference in task performances related to the emotional categories of facial stimuli. Conclusion : Bipolar patients showed deficits in sustained attention even in the euthymic state. The attention deficits shownin the euthymic bipolar patients may be prominent in a more complex task condition with stimuli such as facial stimuli.

정신분열병의 선택적 주의력 저하의 보상 기전

최지욱,정범석,김지웅,김성윤,권준수,전덕인,김창윤 大韓神經精神醫學會 2004 신경정신의학 Vol.43 No.6

Objectives : This study investigated the compensatory neural correlate of selective attention deficit in schizophrenics Show-ing near-normal performance. Methods : A 'modified Stroop' was developed that can be used measure the response time during functional imaging. An event-related functional magnetic resonance imaging study was carried out in 10 clinically stabilized schizophrenics and 10 healthy controls during the performance of a 'modified Stroop'. In the 'modified Stroop', the subjects were required to respond with a two-button mouse to whether or not the color of a subsequent word corresponded to one of T-shirt. The significantly activated brain regions were investigated in a voxel-wise Mest of the Stroop load. Results : Schizophrenics, compared with healthy controls, showed poorer response time, but had similar accuracy. Compen-satory activation in the right inferior frontal gyms (IFG) was observed in schizophrenics. The left paracingulate sulcus was less activated in the schizophrenics than in the healthy controls. Conclusion : These results suggest that, in schizophrenics showing a normal accuracy during the Stroop, selective attention deficits might be related to the left paracingulate sulcus as well as the anterior cingulate. In addition, their deficits may be compensated with the right IFG.

주의력결핍 과잉운동장애 환아에서 주의력 과제와 관련된 대뇌의 기능적 국소화

신동원,송동호,전덕인,남궁기,이만홍,이홍식,민성길 大韓神經精神醫學會 1999 신경정신의학 Vol.38 No.5

연구목적 : 주의력결핍 과잉운동장애는 주의력에 결함이 있는 장애이다. 주의력에 주로 관여하는 부위는 전두엽과 두정엽으로서 이전 연구에서 주의력결핍 과잉운동장애 환자의 전두엽과 두정엽의 이상에 대하여 보고되어 왔으나, 대부분 안정상태에서 정상인과 비교한 연구들이다. 이에 본 연구는 주의력결핍 과잉운동장애 환자가 주의를 요하는 과제를 실행하는 동안 활성화되는 뇌의 양상을 정량화 뇌파를 이용하여 파악하고, 활성화 양상에 있어 정상인과의 차이점을 확인해 주의력결핍 과잉운동장애 환자의 주의력 결함과 관계된 뇌의 국소적 병태를 밝히고자 하였다. 또한 주의력결핍 과잉운동장애 환자의 주의력 결함과 관계된 뇌의 국소적 병태를 밝히고자 하였다. 또한 주의력결핍 과잉운동장애의 치료제인 methylphenidate를 주의력결핍 과잉운동장애 환자에게 투여하여 주의력 과제 중에 활성화되는 뇌 양상의 변화를 알아보고, 치료제가 주의력을 높이는 기전에 대한 이해를 넓히고자 하였다. 방 법 : 연구 대상자는 환자 20명, 정상인 20명으로 총 40명이었다. 두 군은 성별, 나이, 손잡이, 지능에 있어서 차이가 없도록 선발되었다. 정상인은 안정 상태와 주의력 과제를 실행하는 동안 정량화 뇌파를 측정하였다. 환자군은 methylphenidate를 투여한 상태와 투여하지 않은 상태에서 각각 안정 상태와 주의력 과제를 실행하는 동안 정량화 뇌파를 측정하였다. 결 과 : 본 연구의 결과는 다음과 같다. 1) 집중력 검사상, 정상대조군이 투약 전 환자군에 비해 목표자극에 대한 정반응 시간과 목표 자극에 대한 정반응 시간의 표준편차에 있어 유의하게 낮은 점수를 보여 집중력이 좋음을 알 수 있었다. 환자군은 누락 오류, 목표 자극에 대한 평균 정반응 시간, 표준편차에 있어 투약 전에 비해 투약 후에 유의하게 낮은 점수를 얻어, 투약 후 집중력이 유의하게 호전됨을 확인하였다. 정상 대조군과 투약 후 환자군 사이에 집중력 검사상 차이는 없었다. 2) 안정상태에서 얻은 정량화 뇌파의 모든 파 영역에서 환자군은 정상군에 비해 유의하게 뇌파의 전위가 증가해 있었다. 3) 정량화 뇌파의 delta 파 영역에서 뇌파를 분석한 결과, 정상 대조군의 경우, 주의력 과제 중에는 안정상태에 비하여 두정-후두엽 부위의 전위가 유의하게 증가하였으나, 환자군에서는 주의력 과제 중에 유의하게 전위가 증가하는 부위가 없어, 국소화한 뇌 활성 변화를 관찰할 수 없었다. 4) Theta 파 영역에서, 정상 대조군의 경우, 주의력 과제 중에는 안정상태에 비해 우측 전두엽, 우측 측두엽, 양측 두정-후두엽 부위에서 전위가 유의하게 증가하였다. 그러나 환자군에서 투약하기 전에는 유의하게 증가하는 부위가 없었다. 환자군에서 투약 후에는 우측 전두엽, 우측 측두엽, 양측 두정-후두엽 부위에서 유의하게 전위가 증가해, 정상 대조군과 유사한 뇌활성도의 변화 양상을 보였다. 5) Alpha 파 영역에서, 정상 대조군의 경우, 주의력 과제 중에는 안정상태와 비교해 두정-후두엽 부위만이 유의하게 뇌파가 증가하는 반면, 투약하지 않은 환자군의 경우 광범위한 부위에서 유의하게 뇌파가 증가하여 뇌 활성 변화 부위가 국소화되지 않았다. 6) Beta 파 영역에서, 정상 대조군의 경우 안정상태에 비해 주의력 과제 중에는 좌측 전두엽과 Cz 부위만이 유의하게 전위가 증가하는 반면, 투약 하지 않은 환자군의 경우 거의 모든 뇌부위에서 전위가 유의하게 증가해 뇌의 활성 변화 부위가 국소화되지 않았다. 투약한 후에는 좌측 전두엽과 양측 측두엽의 뇌파가 유의하게 증가해 국소화한 뇌 활성 변화 양상을 보였다. 결 론 : 주의력결핍 과잉운동장애 환자는 안정상태에서 정상인과 비교해 뇌파상 비정상적으로 활성화되어 있다. 정상인의 경우, 공간 자극에 관계된 주의력 과제 실행시 주로 전두엽과 두정-후두엽이 활성화되었으나 주의력결핍 과잉운동장애 환자는 국소적인 뇌활성화에 실패하였다. 주의력결핍 과잉운동장애 환자의 주의력 결함은 전두엽과 두정-후두엽 부위의 병태와 관련이 있을 것으로 사료된다. Objectives : The attentional deficit is a core symptom in attention deficit hyperactivity disorder. The major brain areas related to attention are frontal and parietal lobes. Abnormalities of frontal and parietal lobes in attention deficit hyperactivity disorder have been reported in previous researches. But, most of the researches are based on comparing patients and controls while they are in resting condition. Further research on functional changes related to performance of attentional task is needed to understand the attentional dysfunction in attention deficit hyperactivity disorder. In this study, the localized functional changes of the brains related to attentional task in patients with attention deficit hyperactivity disorder and the differences of them between patients and normal controls were examined. Also the effect of the methylphenidate on functional changes related to attentional task in patients with attention deficit hyperactivity disorder was examined. Method : Quantitative electroencephalography(QEEG) was applied to examine the fuctional changes related to attentional task. Subjects of this study consisted of 20 patients with attention deficit hyperactivity disorder and 20 controls who were matched age, sex, handedness, intelligence. QEEG was recorded on eye open resting condition, and on performing computerized attentional task. In cases of patients, after taking of methylphenidate, QEEG was recorded on both conditions. Results : 1) In attention test, normal controls had better scores in response time and variabilities of response time than those of patients with attention deficit hyperactivity disorder without taking methylphenidate. After taking medication, scores of omission, response time and variabilities of response time were significantly improved, comparing to scores without taking medication. No differences were recognized between the controls and patients with taking medication in scores of attention test. 2) In resting condition, spectral EEG revealed baseline activity levels of patients were significantly increased comparing to those of controls. 3) Analysis of delta wave revealed that amplitudes of controls were significantly elevated in parieto-occipital area during performance of attentional task. But in patients, localized activated area related to attentional task was not remarkable. 4) Theta activity of controls were significantly elevated in right frontal, right temporal, and both parieto-occipital areas during performance of attentional task. But in patients without taking medication, localized activated area related to attentional work was not remarkable. After taking medication, right frontal, right temporal, and both parieto-occipital areas were significantly activated. 5) Alpha activities of controls were significantly increased in parieto-occipital area during performance of attentional task, but those of patient without taking medication were increased in broad area. 6) Beta activities of controls were significantly increased in frontal area during attentional performance, but those of patients without taking medication were significantly increased in most of the brain areas. After taking medication, significantly increased activities related to attentional task were recognized in left frontal, and both temporal areas. Localized activated patterns similar to those of controls were recognized. Conclusion : Based on the results of this research, it is suggested that patients with attention deficit hyperactivity disorder have increased baseline brain activity. In controls, brains showed localized response to a attentional stimuli, and functional changes related to attentional stimuli were recognized in frontal, and parieto-occipital areas. But, patients failed in showing appropriate localized activated response to attentional stimuli. It is concluded that frontal and parieto-occipital areas have some deficit responsible for the attentional dysfunction of attention deficit hyperactivity disorder.

정신분열증 환자의 언어성 기억과제수행

전덕인,정기립,김찬형,이홍식 大韓神經精神醫學會 1998 신경정신의학 Vol.37 No.5

목 적 : 정신분열증 환자에서 기억장애가 일관되게 보고되고 있으나 반복에 의한 언어성 기억수행의 변화에 대해서는 아직도 알려진 바가 적다. 본 연구는 정신분열증 환자에서 전산화된 기억과제를 이용하여 반복시행에 따른 언어성 기억수행과 기억전략의 변화 및 학습과 망각의 양상을 정보처리적 관점에서 알아보기 위해 시행되었다. 방 법 : 항정신병약물을 7일 이상 복용하지 않은 정신분열증 환자 26명과 나이, 성, 교육정도를 맞춘 정상대조군 22명을 연구대상으로 하였다. 전산화 기억과제 중 우선 언어성 즉각 상기과제에서는 60개의 한글단어 모음에서 30개 단어가 선택되어 차례로 3초 동안 모니터에 제시된 다음, 피험자는 제시순서에 상관없이 기억나는 단어를 대답하였다. 이후 동일한 과제를 2회 반복하여 총 3회 수행하였다. 그리고 간섭과제로서 시각성 인식과제를 수행한 다음, 상기 과제를 구성하는 60개 단어모음을 하나씩 무작위로 노출시켜 앞서 보았던 단어인지 판단하는 언어성 인식과제를 수행하였다. 마지막 과제는 30분 지연 상기과제로서 언어성 즉각 상기과제에서 보았던 30개 단어를 다시 기억하여 답하도록 하였다. 항정신병약물을 7일 이상 복용하지 않은 정신분열증 환자 26명과 나이, 성, 교육정도를 맞춘 정상대조군 22명을 연구대상으로 하였다. 전산화 기억과제는 3회의 즉각 상기과제, 간섭과제, 인식과제, 그리고 30분 지연 상기과제의 순서로 시행되었다. 결 과 : 총 3회 반복된 즉각 상기과제에서 정신분열증 환자의 수행은 정상대조군보다 유의하게 떨어졌고 (df=1, F=12.4, p=0.001), 과제가 반복되면서 두 군 모두에서 유의한 수행증가가 나타났으나(df=2, F=148.0 p=0.0001) 증가되는 정도에는 차이가 있었다 (교호작용, df=2, F=11.4 . p=0.0001). 3차 상기수행과 30분 지연 상기수행의 차이(망각정도)는 정신분열증이 정상대조군보다 컸으나 유의하진 않았다. (df=33.9, t=-1.8, p=0.08), 3회의 상기수행에서는 전혀 기억하지 못했으나 지연상기에서는 기억한 단어, 즉 늦은 상기의 양은 정신분열증 환자에서 유의하게 적었다(df=46, t=3.0, p=0.005), 전체적으로 군집화 정도와 즉각상기 수행 사이에 유의한 정적 상관관계가 있었으며, 환자군의 군집화는 상기과제에서 전체적으로 정상대조군보다 감소되어 있었다(df=1, F=6.53, p=0.01), 비록 과제가 반복되면서 정상대조군과 환자군 모두 군집화가 증가되었으나(df=2, F=36.7, p=0.0001) 두 군 사이의 군집화 차이는 점점 커졌다(교호작용, df=2, F=3.72, p=0.03). 결 론 : 상기 결과에 의하면 정신분열증 환자에서는 반복에 의해 새로 학습할 수 있는 언어성 기억기능은 저하 되어 있으나 일단 학습된 기억은 유지할 수 있는 가능성이 시사되며, 이러한 학습저하에는 기억전략의 비효율성이 밀접하게 관련되어 있다고 사료된다. 정보처리적 관점에서 정신분열증의 정교한 부호화 과정의 결함을 지지하는 소견이다. Objectives : Memory deficits in patients with schizophrenia have been well established, but it is still unclear how memory performance changes during verbal learning tasks. This study was designed to assess the pattern of verbal learning and memory performance to test the inefficiency of encoding processes in learning of schizophrenia. Method : Subjects consisted of 26 patients with schizophrenia who were unmedicated for at least seven days and 22 normal controls who were matched for age, sex, and education. Verbal memory and learning were evaluated with computerized tasks composed of three consecutive immediate recall trials, a yes/no recognition test, and a delayed recall trial of a word list. Results : The patients with schizophrenia showed significant learning deficits characterized by impaired immediate recall performance and poor learning of a word list. However, both verbal recognition performance and forgetting were comparable in both groups. Word clustering correlated significantly with recall performance. Clustering of patients decreased significantly over immediate and delayed recall tasks and showed poor increase during consecutive recall tasks. Conclusion : These findings indicate that verbal learning and mnemonic strategy are impaired but learned information appears to be preserved in patients with schizophrenia The results are consistent with the notion that a learning deficit is closely related with impaired encoding processes in schizophrenia.

정신분열병 환자에서 정신병의 비치료 기간의 임상적 관련변인

전덕인,이성희,공지은 大韓神經精神醫學會 2004 신경정신의학 Vol.43 No.4

Objectives : Number of previous studies reported poor treatment outcome of longer duration of untreated psychosis (DUP). The purpose of this study was to determine whether DUP was associated with clinical and cognitive variables in patients with schizophrenia in Korea. Methods : The data were collected from forty-five patients with DSM-IV schizophrenia who were hospitalized. Demographic data, Psychiatric family history, insight, duration of first hospitalization, age of onset, DUP, cognitive function, and premorbid functioning were assessed. Results : The mean DUP was 23.7 months. Female subjects showed longer DUP (p<0.007) independent of age of onset. No significant correlations were observed between DUP and clinical and cognitive variables except the highest Global Assessment Functioning score in past year (r=-0.35, P=0.02). Conclusion : These findings do not support the hypothesis of a psychotoxic effect of prolonged period of untreated Psychosis.

한국형 우울장애 약물치료 알고리듬 (Ⅳ) : 우울장애의 아형 및 부작용에 따른 항우울제의 선택과 여성우울장애에서의 치료전략

전현태,이상열,김원,민경준,박원명,서정석,석정호,송해철,전덕인,홍진표,한국형 우울장애 약물치료 알고리듬 2006 연구그룹 大韓神經精神醫學會 2007 신경정신의학 Vol.46 No.6

Objectives : In 2002, the Korean Medication Algorithm Project for Major depressive Disorder (KMAP-MD) was published, but there has been a need for a guideline about detailed issues of depressive disorder. We revised KMAP-MDD andreestablished Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) in 2006. Methods : A questionnaire had been developed by the executive committee for KMAP-DD. The review committee consisted of 101 experienced psychiatrists. From the total of 22 questions in the questionnaire, 7 questions were evaluated for these subjects . We classified the expert opinions to 3 categories according to its confidence interval; first, second and third line. Results : SSRI and venlafaxine were the first line antidepressants (AD) for atypical and melancholic depression. For dysthymic disorder and minor depressive disorder, SSRI was recommended as the first line medications. Only AD medications was a preferred initial strategy for treating premenstrual dysphoric disorder, mild to moderate and severe non-psychotic postpartum depression. In severe psychotic postpartum depression, combination therapy of AD and atypical antipsychotics was the treatment of choice. SSRI was preferred when considering sedation, anticholinergic and cardiovascular adverse effects. Also, experts recommended mirtazapine against gastrointestinal adverse effects and bupropion in avoiding sexual dysfunction. Conclusion : These results suggest that clinicians have to consider both clinical situations and drug adverse effects in the choice of antidepressant medications.

안정기 양극성 장애 I형 환자에서 정신병적 증상에 따른 기질과 성격

박동화,전재영,최혜정,김세주,조현상,석정호,이은,전덕인 大韓神經精神醫學會 2006 신경정신의학 Vol.45 No.5

Objectives : The aim of this study was to exam whether personality, i.e. temperament and character, has an association with a previous presence of psychotic features in euthymic bipolar I disorder. Methods : We recruited 25 psychotic patients with bipolar I disorder, 23 non-psychotic bipolar I patients and 48 normal controls. All sub]ects were asked to perform Temperament and Character Inventory (TCl). Euthymic state was defined in bipolar patients by scores of below 10 on the Hamilton Depression Rating Scale (HDRS) and on the Young Manic Rating Scale (YMRS). Results : Psychotic bipolar patients, compared to normal controls, showed higher harm avoidance (HA) and self-transcendence (ST). In addition, HA in psychotic bipolar patients was higher than that in non-psychotic bipolar patients. However, no significant differences on TCI were demonstrated between non-psychotic patients and normal controls. Conclusion : There are significant discrepancies in personality between psychotic and non-psychotic bipolar patients on HA and ST. These findings are consistent with the hypothesis of a continuum between bipolar disorder with psychotic features and psychotic disorders.

양극성 장애 환자의 첫 삽화에 따른 임상적 특징

김윤기,이은,전덕인,유빈,석정호,조현상,김세주 大韓神經精神醫學會 2007 신경정신의학 Vol.46 No.4

Objectives : It has been reported that first episode polarity affected the course and the prognosis ofbipolar disorder. However, there is remarkable paucity of infbrmation regarding first episode polarity in bipolar disorder. We investigated the clinical characteristics related to the first episode polarity of bipolar patients who had been hospitalized. Methods : Analyses were based on the medical documents of 520 bipolar patients who had been hospitalized in 4 hospitals. We examined clinical features of the current episode, demographics, Past treatment history, suicidal attempt history, family history and comorbidhy. Clinical characteristics were compared between manic onset and depressive onset patients. Results : The mean age of the patients was 36.7 years old : they had 2.1 number of admission history and 6.6 years of illness duration. The patients beginning with depressive onset was 39.4%, and they had more diagnosis of bipolar II disorder, more number of suicidal attempts and reported more depressive mood during index admission than manic onset patients. Conclusion : Depressive onset is a common presentation in bipolar disorder. It is necessary to give more attention to depre-ssive episode in bipolar disorder. Prospective study needs to explore the correlation of first-episode of polarity and course of the illness in the future.

한국형 우울장애 약물치료 알고리듬 2006 (Ⅲ) : 정신병적 양상을 동반한 주요우울삽화

김원,박원명,서정석,민경준,석정호,전덕인,전현태,이상열,송해철,홍진표,한국형 우울장애 약물치료 알고리듬 2006 연구그룹 大韓神經精神醫學會 2007 신경정신의학 Vol.46 No.6

Objectives : Since the publication of Korean Medication Algorithm Project for Major DepressiveDisorder (KMAP-MD) in 2002, there has been a substantial need for a revision due to rapid progress in the pharmacological management of depressive disorder. We revised KMAP-MD 2002 and developed the Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) 2006. Methods : We developed a questionniare for surveying the opinion of experts on pharmacotherapy of depressive disorder. The questionnaire consisted of 4 parts ; 1) treatment of non-psychotic depressive disorder, 2) treatment of psychotic de-pressive disorder, 3) treatment according to clinical subtypes and drugs choice considering adverse effects, and 4) treatment of depressive disorder in women. The questionnaire was completed by the review committee consisting of 101 experienced Korean psychiatrists. It is composed of 22 questions, and each question includes 54 sub-items. We classified the expert opinionto 3 categories (the first-line, the second-line, or the third-line) by χ²-test. Results : For depressive disorder with psychotic features, most reviewers prefer the combination of antidepressant and atypical antipsychotics. Electroconvulsive therapy and the combination of antidepressant and typical antipsychotics were the second-line treatment. Among antidepressants, venlafaxine was the most preferred, and SSRI and mirtazapine followed. Among atypical antipsychotics, quetiapine, risperidone and olanzapine were the most preferred, in this order. In patients who have no response to the first-line treatment, many reviewers recommended switching to another antidepressant or adding another atypical antipsychotics Conclusion : For severe depressive disorder with psychotic features, the combination of antidepressant and atypical antipsy-chotics was preferred for the first-line treatment. These results suggest that the medication strategies of depressive disorder are rapidly changing and reflects the recent studies and clinical experiences.

한국형 우울장애 약물치료 알고리듬 2006 (Ⅰ)

서정석,민경준,김원,석정호,박원명,송해철,이상열,전덕인,전현태,홍진표,한국형 우울장애 약물치료 알고리듬 2006 연구그룹 大韓神經精神醫學會 2007 신경정신의학 Vol.46 No.5

Objectives : Since the publication of Korean Medication Algorithm Project for Major depressive Disorder (KMAP-MD) in 2002, there has been a substantial need for a revision due to rapid progress in the pharmacological management for depressive disorder. We revised KMAP-MD to Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) in 2006. This paper is one of the following 4 papers consisting of Korean pharmacological algorithm for depressive disorder. Methods : The questionnaire consisted of 4 parts ; initial treatment of 1) non-psychotic depressive disorder, 2) psychotic depressive disorder, 3) treatment strategy for clinical subtypes and drug choice considering adverse effects, and 4) treatment for depressive disorder in women. It was composed of 22 questions, and each question had 54 sub-items. The questionnaire was completed by the review committee consisting of 101 experienced Korean psychiatrists. We classified the expert opinion to 3 categories (the first-line, the second-line, or the third-line). Results : For non-psychotic major depression, regardless ofthe severity of an episode, the antidepressant (AD) monotherapy was the optimal first-line treatment. SSRI, venlafaxine, and mirtazapine were the 1st-line AD. In case of a partial or no response to initial strategy, adding another AD was recommended. For psychotic major depression, combination of an AD and an atypical antipsychotic (AAP) was the treatment of choice. Among AAPs, quetiapine, rispendone, olanzapine were preferred. For non-responder to initial strategy, the next step was adding or changing AD before changing AAP. For women with premenstrual dysphoric syndrome or postpartum depression without psychotic features, AD monotherapty was a preferred strategy while for psychotic postpartum depression, combination of AD and AAP was recommended. Experts recommended various ADs according to adverse effect. Conclusion : These results suggest that the medication strategies for depressive disorder are rapidly changing and reflect the recent studies and clinical experiences.