Opparounds

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.

Read the paper →  doi:10.1176/appi.ajp.20250198

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.

Read the paper →  doi:10.1210/clinem/dgag232

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.

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.