Monthly Archives: August 2008

Reflections on August 2008

Here’s another reflection on the month just ending, trying to make some kind of narrative sense of events.

August 2008 was the month of the Beijing Olympics when the whole world stopped for two weeks and watched the best athletes in the world compete against each other. Michael Phelp’s eight gold medals (7 world records) and Usain Bolt’s 3 gold medals (3 world records) were phenomenal achievements as were Chris Hoy’s remarkable three gold medals in the cycling. Hopefully the Olympics will inspire many people to take up healthy levels of exercise (with a careful choice of treadmill settings!). It’s important to remember that it’s not just the winning athletes that are important but all of the participating athletes and indeed the people of the world coming together to celebrate the games. This surely must be the greatest success of the games. Having said that, Great Britain were particularly proud of their athletes performance which was above expectations and the role of psychiatrist Steve Peters with the Olympic cycling team was examined in the media.

In other areas there were a lot of (sometimes complex) developments in many areas of psychiatry.

In treatment resistant depression, there were studies showing the efficacy of deep brain stimulation of the subcallosal cingulate gyrus and another study using the vagus nerve stimulating device (this also looking at Bipolar depression). Another novel approach examined was augmentation with N-Acetylcysteine. There was further validation of the concept of vascular depression in the elderly as well as evidence of changes in cognition related grey matter areas in mild cognitive impairment in the elderly also. This suggests a possible mechanism relating depression and impaired cognition that can be explored in future studies. The importance of early compliance with antidepressants was emphasised in one study and the short term efficacy of pulsed IV clomipramine combined with oral treatment was shown in another study (although there was no placebo group).

With Schizophrenia, things were more complicated yet. Research suggested that negative symptoms could be predictive of functional abilities. Furthermore there was a role for improving negative symptoms with muscarinic agonists. A role for a nicotinic receptor subtype in Alzheimer’s psychosis means that acetylcholine may be an emerging hot topic in schizophrenia research. A reduction in processing speed in first episode psychosis and altered firing activity in sophisticated combined imaging techniques means that there may be emerging neurocognitive markers of psychosis. I’m tempted to bring in another marker used in a separate context – the amyloid beta peptides which have been shown to increase with improvement in neurological status after brain injury. In other words the higher the amyloid beta peptide, the more effectively the brain is functioning under these circumstances. It would be possible to speculate that in first episode psychosis with slower processing speed, there may be a reduction in these peptides – perhaps we will see research in this area. There was other research pointing towards a neurodevelopmental aetiology – stress during pregnancy, grades in exams and enuresis in childhood. In both Alzheimer’s Diseaes and Schizophrenia there was research showing difficulties with theory of mind, a concept which is classically associated with autism. The buzz word at the moment is social cognition and research has shown that in schizophrenia, difficulties in this area may be related to a special type of memory relating to keeping track of one’s own actions. Crow’s model was also examined, which relates to asymmetry and language together with epigenetics. Intriguingly in China, more women develop Schizophrenia than men! The other interesting finding was some very strong evidence to support the role of culture in religious delusions.

The importance of dissociation in adolescence as a predictor for later dissociation was also shown which i’m sure will have implications for trauma research. Exercise was shown to be effective in countering antipsychotic-related weight gain. A curious finding was the implication that genes may be predictive of both tendency to exercise and anxiety/depression scores in twins although the exercise didn’t appear to influence the latter independently. The influence of culture in China in one paper offers a useful starting point for an examination of the impact of culture on the relationship between neurasthenia, chronic fatigue syndrome and depression.

Several books were reviewed including the Maudsley Guidelines, Humanizing Madness (with a very interesting biocognitive theory), Handbook of Psychopharmacology (Lifespan approach) and the Old Age Psychiatry Handbook. There were also several interesting blogs including the entertaining ‘Mental Nurse’, the brain-work-out ‘Neurocritic’, the marathon ‘Psychcentral’, the inspired ‘Furious Seasons’ and the political ‘The Psychiatrist’ blog.

Addendum September 2nd 2008

There were also studies with large numbers of people showing statins and ACE inhibitors (v other antihypertensives) were protective against dementia (and the latter reduced morbidity quite dramatically) although the latter study still awaits publication. The study looking at altruism in 3-8 year olds was also potentially quite important.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Podcast Review

In the science podcast for the week of 29th August 2008. There is discussion of Amyloid Beta Peptides in people following head injuries. Amyloid Beta peptides role in Alzheimer’s disease interested the researchers in the role this might play in head injury. The peptide levels fell in people as their neurological status worsened which was thought to be related to neuronal activity. In other words, the Amyloid beta peptides were thought to be proportional to neuronal activity (although they didn’t measure neuronal activity directly – it was an inference). The researchers also found that Amyloid Beta 42 levels increased and decreased with overall amyloid beta peptide levels. The researchers suggest that their techniques can be used in Alzheimer’s disease research (STT2-4). Other research suggests that there were ancient tribes producing large scale civilisations in Amazon regions where it was long thought not to be possible. Incredibly, some of these civilisations may be up to 4000 years old with many societies interacting with each other. These findings may be relevant to evolutionary psychiatry as the civilisations solved the problem of developing agriculture in a hostile environment using a variety of means (STT6). Some remarkable research showed that if people believe that they have a fake hand (using a dummy hand), the temperature of the hand it ‘replaces’ actually drops!

The Nature Podcast of 29th August 2008. Research is discussed looking at whether our sense of fairness is innate or whether it is learnt. Over 200 children were entered into a game where they could choose whether to give sweets to other children. They found that the altruistic tendency didn’t exist at age 3 but developed quickly – to about 45% in children at age 8. There were strong altruistic traits to children who were ‘within-group’. The researchers also found that the youngest children in a family, in the study were less altruistic. There is also an elaboration of the extreme male brain theory in autism by referring to imprinting. The argument is that paternal gene imprinting should be predominantly expressed in the hypothalamus whilst maternal imprinting would be expressed in the cortex. Therefore any changes in imprinting would lead to structural changes in the relevant brain areas – essentially providing a theoretical structure to fit with the higher level extreme male-brain hypothesis (STT5).

Episode #170 of Shrinkrap Radio features an interview with Dr Arnold Mindell (a Jungian analyst) and Dr Amy Mindell who talk about dreamwork. Dr Arnold relates his experience with gout and how he constructed a concept of the ‘dream-body’ based on these experiences. There is also a discussion of some work with people in a coma state, Taoism and process-based work.

The Psychology Press website features an interview with Viren Swami one of the authors of ‘The Psychology of Physical Attraction’. Swami discusses physical attractiveness and how its definition has changed in cultures across time and in different parts of the world. Swami discusses some of the positive and negative connotations of being viewed as attractive as well as some of the ‘objective’ measures that have been utilised.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

News Round-Up 24-30th August 2008

Olympic Psychiatry

In an incredible Olympic performance, Great Britain returned in 4th place – well done to all the athletes! Dr Steve Peters, the coach for the olympic cycle team which achieved gold in the recent olympics has been extensively covered in the news. In this article (which however identifies him as a psychologist) Victoria Pendleton, the gold medallist in the olympic cycling sprint is quoted as describing him as “the most important person in my career”. The article also quotes Peter’s thoughts on anxiety in performance. SImilarly Chris Hoy is described as being prepared by Peters for several cyclists breaking the world record ahead of the olympics. In this article, Pendleton recounts his advice to her which she found very beneficial ‘never leave anything to chance…..never look at the outcome only the process’ (again Pendleton is quoted as referring to Peters as a psychologist). In the Daily Mail, Peters is once again a psychiatrist and some of his work with personality disordered offenders is mentioned. He is also quoted, commenting on the importance of understanding personality and psychology in order to fully understand mental illness. The Guardian’s article comments further on the training techniques with the identification of large numbers of ‘foundation stones’ – areas that the cyclists want to work on to improve their performance. He is also described as helping with relationships within the team demonstrating the importance of his many skills and talents.

Schizophrenia

‘The Truman Show’ delusion was reported on in this article – based on case studies where people believe their lives are similar to the character from the Truman show (STT2). In this film, Jim Carrey’s character is living in a television program and provides the ‘entertainment’ for television viewers following his life (unbeknown to him!). This is not the first time that a film has given rise to the label for a symptom – for instance ‘Groundhog Day Syndrome’ has previously been reported in which people misidentify time, believing that a day is repeating. The recent work done on religion and delusions in culture in Germany indicates that perhaps there is a relationship between culture and the content of delusions – a question posed in the above article. One article suggested a trend towards OCD occuring prior to schizophrenia when it was a comorbidity although the authors suggest a need for further research to examine this relationship.

Mood Disorders

A study in Biological Psychiatry showed equivalent efficacy of Vagus Nerve Stimulating devices in Unipolar and Bipolar Treatment Resistant Depression (STT3). A preliminatry study of Deep Brain Stimulation of the Subcallosal Cingulate Gyrus has shown benefit in treatment resistant depression with a 35% remission over 6 months although double-blind studies are required before firmer conclusions can be drawn (STT3). An intriguing application of N-Acetylcysteine, which is used in the treatment of paracetamol overdose, has been found to have some benefit in depression. N-Acetylcysteine is a precursor of Glutathione which is used in various cellular processes. Other research has found a reduction of Glutathione in depression although the relationship is probably far from straightforward (STT4). Research in Biological Psychiatry has further validated the concept of vascular depression in the elderly. The research showed remarkable specificity and sensitivity when using deep white matter lesions as criteria.

Dementia

A study in Biological Study shows an association between depression and reduction in grey matter brain volume in areas related to cognition. The authors hypothesise this as a causal link between depression and cognitive impairment in elderly people (STT 4). An unfortunate case of somebody who had developed Creutzfeld Jacob Disease with Alzheimer’s Disease and Lewy Body Dementia has been reported. CJD is extremely rare but the case report highlights cases where multiple pathology contributes to dementia.

Child and Adolescent Psychiatry

An organisation working with vulnerable children, The Kids Company, are working together with the Institute of Psychiatry on research into the effects of trauma on children. In this article, there is an interesting comment on the funding that goes into supporting families with vulnerable children and the funding of superprisons, posing the question of whether it might be possible to prevent crime rather than manage it when it occurs by diverting resources.

Psychiatry and the Arts

The play Equus, starring Daniel Radcliffe, has finished in London and is now starting in Broadway, New York. The play, written by the brilliant playwright Peter Shaffer, focuses on Alan Strang, a teenager who blinds six horses and the psychiatrist who tries to understand his motives. Daniel Radcliffer is interviewed and describes how he draws an analogy with ‘A Clockwork Orange’ in preparing for his role. Dinah from Shrinkrap reviews a few novels including Run East: Flight from the Holocaust by Jack Pomerantz, Asking for Murder by Roberta Isleib (a psychologist writer), Playing for Pizza by John Grisham and Dreamland by Sarah Dessen.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Blog Review: Mental Nurse

Mental Nurse is the blog reviewed today. The blog was started by Mental Nurse, who appears to have been ‘discharged’ and is therefore no longer writing. However, there is now a rota for the writing team who produce a stream of lighthearted, entertaining articles interspersed with serious and topical issues. Reading the blog, I felt I was listening in on the typical friendly nurse banter on the ward. There are lots of writing styles and the team have a variety of interests. Here are some of the articles I liked

Writing with a black biro: Writing in a Black Biro. Why do we write in medical notes with a black biro – i’ve often wondered that myself!

In the nursing standard – article about responses to blogging

More on History of Mental Health – Reference to David Clark’s book about managing a psychiatric hospital

Lithium – Speculation on Lithium via Bill Bryson

Changing Your Mind – Evolutionary support for not skipping your meals!

Smoking and Mental Health – nice article on some consequences of stopping smoking

Confessions of a Former Anti-Psychiatrist – Zarathustra on philosophy, coffee houses and anti-anti-psychiatry

How do you solve a problem like Maria – Touching and important story about systems and individuals

Notes from the Royal Colleg of Nursing Congress – What happens at the Congress?

News Update from Psychminded – Personality disorder label news

Nurse-Patient ratios – why they matter – Insight into importance of nurse-patient ratios

Client-Centred Services

In defence of Healthcare Assistants

Is Behaviourism Scientifically Respectable – detailed discussion of behaviourism

Cut the Paperwork – On bureaucracy

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Book Review: The Old Age Psychiatry Handbook

Today’s reviewed book is ‘The Old Age Psychiatry Handbook’ by Joanne Rodda, Niall Boyce and Zuzana Walker all based at University College London at the time of writing of the book.

The book is 303 pages long and has a clear layout with tables and boxes where appropriate. The book is well thought out and as it’s title suggests is geared towards being a practical guide to old age psychiatry. Broadly speaking the book is divided into sections on assessment, diagnostic categories, treatments and legal issues.

The authors reference standard works throughout the book including ICD-10 and the NICE guidelines. Sometimes these are relevant not only to the elderly but also to the general adult population. I found the strengths of the book to lie in the chapters on dementia and physical illness which are both very important topics in the Old Age Psychiatry particularly for those with general adult experience who are new to the specialty.

Another strength of the book is that there is an abundance of information covering a multitude of clinically relevant areas. Thus information can be found quickly in one place rather than searching through several textbooks. Needless to say this can be quite useful in busy clinical situations. I would recommend this book for those starting out in Old Age Psychiatry.

References

Rodda J, Boyce N and Walker Z. The Old Age Psychiatry Handbook – A Practical Guide. Wiley. 2008

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

Were Neanderthals Smarter Than Us – Update August 27th 2008

Since yesterday, following a press release about Metin Eren’s research on Neanderthal’s use of flints, there has been widespread reporting in the media.

The Guardian – Reports includes a reference to their hunting abilities

BBC News – An interview with Professor Chris Stringer comments on the diversity of tools created by modern humans whilst acknowledging that many palaeoanthropologists recognise the neanderthals as capable technicians (for manufacturing flint flakes)

The Washington Post – In this article the Neanderthal’s larger brains and stockier build is discussed as well as evidence that they were using blades between 200,000-400,000 years ago. There are suggestions that they co-existed with modern humans for 10,000 years but that they may have been ‘outpopulated’ by humans eventually.

The Independent – Mentions the difficulties of colonising an Ice Age Europe and goes into the methodology of the study

Lab Notes – This article talks about the ‘experimental archaeology’ being carried out at Exeter University where Metin Eren’s 3-year research took place

Wired – This article even has a suggestion that under different circumstances the Neanderthal’s might have gone onto colonise the world!

The Scotsman – Professor Adler is quoted, saying that the Neanderthal’s were smart and dangerous and previous research suggested they were better hunters than Homo Sapiens

Here are some related articles of interest

Sequencing the Neanderthal Genome

Neanderthal’s Matured at 15 – What’s interesting in this article is that because the Neanderthal’s brains reached a larger size than ours, they had much more growing to do in the critical period of infancy. Referring back to the article on Freud’s relevance to modern psychiatry and Feeley’s model, I wonder what it meant to have a faster rate of brain growth at a younger age. Perhaps the mother’s influence on the Neanderthal may have been even greater than in humans. However, humans may have had a wider snapshot of parental behaviour before the foundations of their brains were complete. If this were so, it might have suggested a wider repertoire of social ‘tools’ than Neanderthals. This hypothesis could be tested by looking at social behaviours of mammals with varying rates of reaching brain maturity.

How did Neanderthals and Homo Sapiens Relate – Discussion of multiregionalism v Out of Africa theory

Neanderthal Speech – Short response on what speech Neanderthals might have had

Addendum (Added 1.3.9)

1.3.9 Note the performance of a chimpanzee called Ayumu on this memory task.

11.1.10 Complex make-up in use by Neanderthals 50,000 years ago. Also covered here.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

Prevalence of Schizophrenia in China

Xiang et al’s study looks at demographics and prevalence of schizophrenia in China. This is an ambitious study looking at 5926 people in Beijing. The authors note that two studies published in chinese journals noted a lifetime prevalence of schizophrenia of 0.57% in 1982 and 0.66% in 1993 (which includes the twelve region psychiatric epidemiological study work group 1986). As with any study there is selection bias of one form or another. In this study, some of the practicalities of collecting data mean that prevalence may have been underestimated. For instance being willing to participate in the study may be less likely in those with paranoid beliefs whilst the ability to cohabit with the family may be influenced by a marked psychosis. Nevertheless the large sample size and the process of approaching households is an enormous task which should not be underestimated.

The researchers used the Composite International Diagnostic Interview-Version 1.0 (CIDI 1) which produces ICD-10 codes. Whilst as many as 102 psychiatrists completed the questionnaires, the inter-rater reliability using the kappa value was 0.795 (1 is the highest possible rating for reliability and suggests equivalent scoring – thus the value here is quite high and suggests good inter-rater reliability). In addition to the ICD-10 codes, the researchers obtained demographic data. The researchers then examined the relationship between schizophrenia and each of the other variables using a multiple regression analysis to control for the remaining variables in each case.

The researchers found that the lifetime prevalence was 0.49% (0.44% for men and 0.55% for women). For rural areas the prevalence was 0.39% and in urban areas it was 0.57%. The odds ratio for each demographic was then calculated (people with schizophrenia v people without). Significant results (p<0.05) were found for marital status, family history of schizophrenia, higher income and living in rural areas. Although these factors were described as protective, the cross-sectional nature of the study mean that they should be considered as associations.

A meta-analysis of prevalence studies by Goldner in 2002 produced a figure of 0.55%. These study findings are very similar which suggests that cultural differences may be less influential for the aetiology. The earlier study on depression in China suggested a difference of several hundred fold compared to western studies – although this was later revised in the light of further studies.

Although there was a higher prevalence of schizophrenia in women, this was not-significant in this study. However the previous studies in China showed similar findings which is the reverse of those found in Western studies. This finding certainly merits further attention. The increased prevalence in Urban areas replicates findings in Western studies. Just under 10% of people with schizophrenia in this study had attempted suicide compared to 1.6% for those without. 58% of people with schizophrenia had received treatment compared to figures of 80% reported in the USA.

This is a valuable study and the authors write that it is to the best of their knowledge the first prevalence study of schizophrenia using standardised diagnostic criteria in urban and rural areas in China.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.