Saturday, August 8, 2026

Opparounds

🔬Psychiatric Research Article

Intermittent Theta Burst Stimulation of the Dorsomedial Prefrontal Cortex and Expectancy-Driven Placebo Mood Effects: A Randomized Clinical Trial

Ian Snyder, Kevin Handoko, Alyssa Neppach, et al. · JAMA Psychiatry · May 2026

In this crossover trial, 50 adults completed three separate theta burst stimulation sessions — intermittent (iTBS), continuous (cTBS), and sham — targeting the dorsomedial prefrontal cortex, each followed an hour later by an antidepressant-expectancy fMRI task using cue-based sham neurofeedback.

iTBS produced significantly greater dorsomedial PFC activation than cTBS, following a monotonic gradient (iTBS > sham > cTBS). The degree of default mode network activation during the placebo task tracked with how much participants' mood improved from the expectancy manipulation alone — greater DMN engagement under iTBS predicted stronger placebo-driven mood gains, independent of any direct antidepressant effect of the stimulation itself.

💡 Why it matters

Placebo response is not just noise to subtract out of a stimulation trial — it may be a trainable neural mechanism, and existing iTBS protocols could potentially be tuned to potentiate it alongside direct antidepressant effects.

Read the paper → doi:10.1001/jamapsychiatry.2026.0647

📖Psychotherapy Research Article

Effects of Short-Term Versus Long-Term Mentalization-Based Therapy on Psychiatric Symptoms in Outpatients With Borderline Personality Disorder: Exploratory Results From a Randomized Clinical Trial

Tine S. D. Harpøth et al. · Personality and Mental Health · August 2026

This randomized trial followed 166 outpatients with subthreshold or diagnosed borderline personality disorder assigned to either 5 months of short-term mentalization-based therapy (MBT) or 14 months of long-term MBT, the parent trial's primary comparison. This exploratory analysis looked specifically at general psychiatric symptoms, measured with the SCL-90-R at baseline, 8, 16, and 24 months.

Across the primary 16-month endpoint and the 24-month follow-up, the two arms showed no significant difference in overall symptom severity or on any SCL-90-R subscale — the shorter course neither underperformed nor fell short of the extended one on this outcome, mirroring the parent trial's null finding on BPD-specific symptoms, functioning, and self-harm.

💡 Why it matters

For a treatment this labor-intensive, more months of MBT did not buy more symptom relief — a real dose-response answer for a therapy whose 12-to-18-month standard length has rarely been tested against a shorter, equally structured alternative.

Read the paper → doi:10.1002/pmh.70088

💊Psychiatric Fact

Clozapine rechallenge after myocarditis and after agranulocytosis are not the same decision

Myocarditis typically emerges within the first two to eight weeks of treatment, often during rapid titration, and behaves like a hypersensitivity reaction rather than a dose-toxic one — troponin and CRP rise, echo shows reduced EF, and it resolves with discontinuation in most cases. Because the mechanism is titration-speed-dependent rather than a fixed contraindication, rechallenge with a much slower taper (weeks instead of days) and close cardiology co-monitoring succeeds in a majority of case series, and it is often the right call when clozapine is the only agent that has controlled otherwise treatment-resistant psychosis.

Agranulocytosis is a different mechanism — immune-mediated bone marrow suppression — and rechallenge after a severe episode (ANC below 500) carries a recurrence risk high enough, and often faster and more severe on re-exposure, that many centers treat it as an effective stop unless attempted under a specialized hematology-supported protocol with daily neutrophil counts. The distinction that matters clinically: myocarditis is a titration problem you can often engineer around; agranulocytosis is a patient-specific vulnerability that re-exposure does not fix.

🛋️Psychotherapy Teaching Pearl

Working through is not an insight — it's tolerating the same person being good and disappointing, over and over

In Klein's terms, the shift from the paranoid-schizoid position to the depressive position is not a single realization but a repeated tolerance-building process. In paranoid-schizoid functioning, love and hate toward the same object can't coexist, so the object gets split into an all-good version and an all-bad version, and whichever one is dominant in the moment feels like the whole truth. The depressive position brings the capacity to hold ambivalence — to feel angry at someone you also love, without the anger annihilating the love or making you a monster for having it.

The technical implication: when a patient swings between idealizing and devaluing you, the naive move is to name the inconsistency directly — 'you hated me last week and now you're praising me' — which, delivered to someone still functioning in paranoid-schizoid mode, often lands as persecutory rather than clarifying, and can simply trigger another split. The better move holds both affects in the room without demanding the patient integrate them on your schedule: name the feeling that's present now, then gently reintroduce the other one as still there rather than as a contradiction to resolve. Working through is the accumulation of many such moments, not one interpretation that lands and fixes it.

🗒️ Vignette

A resident's patient arrives glowing, thanking her for 'finally understanding' her — one week after storming out mid-session calling her useless. The resident is tempted to name the whiplash directly. Instead she says: 'I'm glad today feels good between us. I also remember how furious you were last week — I don't think that's gone, even though right now it might not feel like it belongs in the room.'

The patient stiffens, then admits quietly that she'd assumed if she told her therapist she was furious, the therapist would want nothing more to do with her — so today's warmth was partly relief that the anger hadn't destroyed the relationship. The intervention worked not because it resolved the contradiction, but because it demonstrated that both feelings could exist in the room at once, held by the therapist, without either one erasing the other — which is the actual work of the depressive position, session after session, not a single insight session.