Thursday, September 24, 2026
Two papers, a psychopharmacology pearl, a psychotherapy pearl and the news.
AI-generated content. This briefing was written by Claude Opus 5.5 and may contain errors. Please verify against the primary source before acting clinically.
| The Paper |
| New research from the psychiatric journals |
Convergent Network Localization of Brain Stimulation Targets for Trait Anxiety
Siddiqi SH, Klingbeil J, Webler R, et al. American Journal of Psychiatry. July 2026.
Using lesion-network mapping across four independent datasets — brain-lesion patients, two TMS cohorts, and subthalamic DBS-treated Parkinson's patients (n=936 total) — the authors localized a convergent anxiety circuit from each modality's naturally occurring variation in lesion or stimulation site. Anxiety-worsening lesions and anxiety-improving TMS sites mapped onto the same circuit (spatial r=0.68); in an independent cohort, connectivity to that circuit predicted TMS response, and DBS sites overlapping it predicted anxiety worsening in Parkinson's patients. The right superior frontal gyrus emerged as a candidate target.
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In practice
This gives a biologically grounded, testable target for future anxiety-focused neuromodulation trials, and helps explain why some existing DBS/TMS protocols cause anxiety as a side effect. |
Full text doi:10.1176/appi.ajp.20250198
| Outside Psychiatry |
| A general-medicine paper that ends up in our clinic |
Impact of Cortisol Circadian Rhythm on Psychological Well-Being in Treated Cushing Syndrome: A Cross-Sectional Study
Theodorou A, Tan EC, Reiner AS, et al. Journal of Clinical Endocrinology & Metabolism. June 2026.
In 90 biochemically 'cured' Cushing syndrome patients at a tertiary center, researchers measured late-night salivary cortisol and stratified patients into normal circadian rhythm, abnormal rhythm, or on long-term glucocorticoid replacement. Patients with a normalized cortisol rhythm had significantly lower anxiety and depression scores and better quality-of-life measures than those with persistently abnormal rhythms or on replacement — even though all were considered biochemically cured.
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In practice
Biochemical cure of a hormonal disorder doesn't guarantee mood recovery — residual cortisol dysrhythmia tracked independently with anxiety and depression, so any patient with a history of HPA-axis pathology deserves ongoing mood screening, not just those still on active treatment. |
Full text doi:10.1210/clinem/dgag232
| Past the Boards |
| One advanced clinical point, usually pharmacology |
Valproate Can Poison the Urea Cycle Without Ever Touching the Liver
A patient on a stable, therapeutic valproate level who becomes confused deserves an ammonia level, not just repeat LFTs — hyperammonemic encephalopathy can occur with normal transaminases and a normal serum level, because the mechanism bypasses hepatotoxicity entirely. Valproate metabolites deplete carnitine, the cofactor mitochondria need for fatty-acid beta-oxidation, while also directly inhibiting carbamoyl phosphate synthetase I and N-acetylglutamate synthase in the urea cycle itself — the result is ammonia with nowhere to go, independent of whether the liver is being injured. The fix is L-carnitine repletion plus dose reduction or discontinuation, not a work-up chasing hepatic failure. Encephalopathy that doesn't fit the LFT picture on valproate is the pattern to remember, not the exception.
| In the Room |
| A psychotherapy technique, shown in a vignette |
Affect Focus Anchors the Session Before Content Does
MBT's affect-focus technique means naming the patient's current emotional state before pursuing the narrative that produced it — asking not “what happened” but “what is happening in you, right now, telling me this.” This isn't empathic reflection for its own sake; it's a deliberate move to keep mentalizing tethered to a felt, present-tense affect rather than drifting into pseudomentalizing — fluent, plausible psychological talk that has lost contact with any actual feeling. When a patient narrates conflict or trauma with more coherence than the material should allow, the therapist interrupts the story to locate the affect first, then lets content resume from that anchor. Content pursued ahead of affect produces insight that doesn't change anything, because it was never connected to what the patient actually felt.
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Vignette
A patient recounts a breakup with impressively organized detail — dates, quotes, a clean timeline — in a flat, unvarying tone. The therapist stops the narrative: “You're telling me exactly what happened. Before we go further — what's happening in you right now, telling me this?” The patient pauses, surprised, and says, “I don't actually know.” That gap becomes the session's real work: not the breakup's facts, but the patient's disconnection from any current feeling about it, which the polished narrative had been concealing. |
| *** |
| That's the five. Go see your first patient. |