Monthly Archives: September 2008

Should Antisocial Behaviour Play A Role in Defining Psychopathy?

The article reviewed here is by Joel Andrade. The author begins with a historical overview of the construct of psychopathy where perhaps the turning point is the publishing of Hervey Cleckley’s book ‘The Mask of Sanity’ in which 16 personality traits central to the construct are described. Andrade then discusses he issue of whether including antisocial behaviour in the psychopathy construct is really a judgement about good and evil and does so by referring to the literature. There follows the fascinating history of how subsequent editions of DSM-IV have moved from the psychopathy construct to the antisocial personality disorder which includes antisocial behaviours as criteria. There is then a discussion of the Hare’s Psychopathy Checklist and the ability of scores on the HCL to predict recidivism and violent crime before a final conclusion. Andrade has produced an intelligent and well researched article which gives a useful overview of the issues surrounding the construct of psychopathy.

The issue’s here are quite profound and extend across clinical practice, questions of morality, behavioural versus cognitive models, prevention of violence and crime and society’s prevailing norms. Should we consider the psychopathy construct as primary and then treat behaviour as secondary to this? Or should the person’s historical behaviour be used as a psychological marker and what is the relationship of this to stigmatisation? Yet even with the implications of incorporating past antisocial behaviors into such a diagnosis we are still left with the predictive abilities of such a model which in turn produces another paradox. For if we ignore this, then perhaps we avoid the possibility of doing good or preventing harm. With such predictions, perhaps the person themselves can be given insights and with help, the option to expand the possibilities that are available to them outside of the constraints of their psyche. Perhaps another issue is the broken contract between society and the individual in cases of criminal prosecution and the conflict between what the individual may consider as their autonomy and the impact that this has on other people’s autonomy – and ultimately on society’s autonomy. In the middle of this complex manoeuvring, psychiatry continues to progress and hopefully will help to solve some of these problems, better defining psychopathy and the limits of the medical model, improving the quality of life of people with psychopathy* and if they choose help them to improve their relationships with others.

STT1

* (for example by treating concurrent pathology) (added 4.10.8)

References

Andrade Joel. The inclusion of antisocial behavior in the construct of psychopathy: A review of the research. Aggression and Violent Behavior. Volume 13. Issue 4. August-September 2008. pp 328-335.

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.

Effect of Dimebon in Mild-to-Moderate Alzheimer’s Disease

The paper reviewed here caused quite a sensation when it first came out and the reverberations are still being felt.This is the Dimebon study in mild-to-moderate Alzheimer’s Disease which took place in Russia. According to the Editorial in the same issue, in Russia there is a place for inpatient care with an emphasis on medication perhaps helping to explain the timing and location of this remarkable finding. The authors begin by referring to an open-label pilot study of Dimebon 20mg tds (over 8/52) providing sufficient evidence for the current study to take place.

In the current study, due to a limitation of resources the researchers focused on a single dosing schedule of 20mg tds in order to sufficiently power the study.  This was a multicentre study (11 centres in Russia) including patients over the age of 50 with mild-to-moderate Alzheimer’s Disease (using DSM-IV and NIND criteria). MMSE scores were 10-24 and the Hachinski Ischaemic Score was less than or equal to 4. Written consent was obtained from participants and carers or legal guardians. The primary outcome measure was the ADAS-cog, with a number of secondary outcome measures including the MMSE, NPI for behaviour and ADCS Activities of Daily Living.

180 patients were recruited to the study. This was an intention-to-treat analysis with last observation carried forward. This was a randomised placebo controlled trial. The average age of participants was 68, all participants were white and 72% of patients were women (62% of controls), with an average of 12 years in education and 5 years of symptoms. The average MMSE was roughly 18.

89 people received Dimebon with 94 receiving placebo. In the Dimebon group 11 people discontinued, 5 of whom had adverse events. On the Dimebon arm of the trial, at week 26, there was an improvement on the ADAS-cog of 1.9 points compared to baseline and this was significant at the 0.001 level. The placebo group’s peformance decreased by an average of 2.1 points compared to baseline and this was significant at the 0.002 level. Interestingly the effect of Dimebon over Placebo was significant at the 0.0001 level!

There were similar trends in the MMSE, ADL measure and NPI with the Dimebon group increasing over baseline by 26 weeks and the Placebo group decreasing by this time. As an example, at 26 weeks the MMSE had increased by 1.8 points and the placebo group had decreased very slightly (0.5 points). There were some further results at 52 weeks, again with LOCF, showing that the placebo group continued to decline and also showing a slight dip in the Dimebon group scores. In the Dimebon group dry mouth was a common side effect (14% at 26 weeks) as was depressed mood (14% compared to placebo).

This is a very important study, showing that the drug Dimebon may be very important if further studies corroborate these findings. The MMSE scores in the Dimebon group were 18.7 at baseline and so even with an increase of 1.8 points there would still be impairment. Another feature of the results was the shape of the ADAS-cog improvement which showed a dip at 52 weeks. From the shape of the graph alone, the peak effect appeared to be at 39 weeks. However the study was best  suited to looking at results at 26 weeks and so perhaps further studies might be able to look at those trends. Another finding was the increase in depressed mood in the Dimebon group over the placebo group and it would be interesting to see how treatment for depression impacted on scores.

STT=3

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.

References

Rachelle Doody, Svetlana Gavrilova, Mary Sano, Ronald Thomas, Paul Aisen, Sergey Bachurin, Lynn Seely, David Hung and ‘the dimebon investigators’. Effect of dimebon on cognition, activities of daily living, behaviour, and global function in patients with mild-to-moderate Alzheimer’s disease: a randomised, double-blind, placebo-controlled study. Lancet. Volume 372. Issue 9634. 19.7.8-25.7.8. pp207-215.

News Round-Up:22nd-28th September 2008

Here is a round-up of some of the news in September. Interesting findings include the importance of the subthalamic nucleus and ventral tegmental area in verbal memory, hemispherectomy in children and language function and spontaneous eye blinking and attention.

Psychosis

In a study of Xhosa people with schizophrenia, a number of factors influencing development of abnormal involuntary movements were found including age being a risk factor and anhedonia appearing to be a protective factor (STT1).

Dementia

In a study of 35 older adults, serum Beta-Amyloid levels were correlated with worse peformance on cognitive testing (STT3). In a study of apathy (measure using the Apathy Evaluation Scale) in people with dementia, apathy was more likely if the person was living with someone other than their spouse and was also associated with irritability and functional impairment (STT1). Verbal memory and learning was correlated with integrity of the subthalamic nucleus and ventral tegmental area in this study using magnetic transfer ratios. Ageing affected these areas and the hippocampus differently (STT3).

Anxiety and Related Disorders

A study of PTSD in WWII prisoners of war found that higher IQ appeared to be a protective factor against developing PTSD and that PTSD was associated with performance on certain frontal lobe tests (STT2).

Child and Adolescent Psychiatry

A study of 100 children who were exposed to irradiation prenatally from the Chernobyl nuclear reactor revealed differences between these children and 50 controls (classmates) including left brain neurological findings, lower IQ and a number of EEG findings (STT2). In this study of language function in children who underwent hemispherectomy, there was found to be an equivalent capacity for the right and left hemispheres to develop receptive verbal vocabulary. There were a number of other interesting findings and these results may be possibly should be of interest to theories of language development (STT3).

Miscellaneous

Spontaneous eye blink rate is predictive of the ability to identify a target rapidly presented after a first one – a phenomenon referred to as attentional blink. The authors suggest that this is mediated by dopamine and involves working memory (STT4).

Appendix

STT

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.

Online Web Resources for Psychiatry

I have been kindly invited to create links to psychiatry web resources on the Psychiatry Online website which can be found here. If the reader has any links that they think should be added, please do let me know

Conflict of Interest

This article contains a reference to my work on another website.

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: 27th September 2008

In the Science Podcast of 19th September 2008, there is a discussion of how to develop trusting social networks for science on the internet. One of the ideas is that if you want to use data from people on the internet, is there any way you could test to see how trustworthy that data will be. There is discussion of other research in which people who think they are being given the ‘cold shoulder’ rate the temperature of the room as 4 degrees lower than people who don’t think this. In a similar vein, people who thought they were being excluded from a game were more likely to ask for a warm drink afterwards. This relates to a phenomenon referred to as ‘embodied cognition’. Other research is reported on in which elderly people, who underwent MRI scans on opening presents, developed a spike in dopaminergic activity but this was followed by less prefrontal cortex activation than younger people. There was discussion of how this might contribute to an understanding of why people tend to enjoy opening presents less as they get older. There is also other research in which deaf people are able to move their jaw to the correct position, when it is has been deliberately adjusted, even when their cochlear implants are turned off so as to pronounce words correctly. The inference is that speech requires other forms of feedback in addition to auditory, perhaps proprioceptive and somatosensory.

In the Nature podcast of 25.9.8, there is a discussion of the sequencing of human floral bacteria and the benefits that this might present. There is also discussion of some new evidence implicating gut bacteria in the onset of Diabetes I. The evidence suggests that some bacteria drain from the gut into the pancreatic lymph nodes. When they are here, they are thought to present antigens which cause tolerance in the local T-Cells to both the bacteria and the Pancreatic cells (presumably Islet of Langerhans cells). If this model were correct then a possible next step would be to look at the introduction of these bacteria in prevention – although further research will be needed to test this. This research has possible secondary implications in psychiatry (e.g CNS autoimmune processes and diabetes modifying cerebrovascular disease risk factors).

In the Lancet podcast of 20.9.8 there is a reinforcement of a previous statement from the journal requesting that asthma is considered as a syndrome rather than a disease. There is also discussion of research examining an association between paracetamol and asthma. Within psychiatry, continuing research in this area may be of relevance in various ways. For instance pain modifying factors in relation to asthma. However the risks of NSAID’s such as aspirin exacerbating asthma are also discussed as is the continued role of paracetamol in this condition.

In the 24.9.8 NEJM podcast (you can subscribe here) an alteplase trial placebo-controlled trial in acute ischaemic stroke was reported on showing no significant difference in mortality between groups. However clinical outcomes were significantly improved if alteplase was given 3 and 4.5 hours after onset of symptoms (versus placebo). It was emphasised however that rapid treatment (i.e before the study’s 3 hour window) is optimal.

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. Clinical Psychology and Psychiatry: A Closer Look

The featured blog ‘Clinical Psychology and Psychiatry: A Closer Look’ has been running since 2006. The author provides a  critique of research carried out in the field of psychology and psychiatry and issues which impact on practice. There are some incisive analyses of papers.  A few of the most interesting articles for me include switching from first generation antipsychotics to second generation antipsychotics (with analysis), pharma funding of patient groups, preventive psychopharmacology, the role of the doctor in the therapeutic effect, lack of efficacy of alpha-2 agonists in PTSD, occupational therapy fordementia, shadow statisticians, and a discussion of subthreshold bipolar disorder. There is some overlap with the previously featured blogs Furious Seasons and the Carlat Psychiatry Blog. As with my discussion of the Carlat Psychiatry Blog, a polarised view helps to identify the important issues much more easily. This works best in the context of a discussion or argument between proponents of opposite polarised viewpoints.

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 Dementias: Crossroads Between Neurology and Psychiatry

The book reviewed here is ‘The Dementias: Crossroads Between Neurology and Psychiatry’. The book was printed in 1992 and so the reader should be wary that some or even many of the details may now have become obsolete in the light of subsequent studies. The typesetting is a little unusual in that the references are given with author and year in parentheses but with every letter of the author’s name in capitals. Otherwise there are lots of useful diagrams and the style is easy to read. Another unusual feature of the book is the content. In the first few chapters there is a focus on electrophysiology with a recurring theme of Glutamate. There are a number of the authors’ study methodologies discussed in detail but towards the end of the book there is a general discussion of neuropsychiatric conditions. Thus the book does tend to move in different directions. In the introduction this is justified by describing the book’s role as being to bridge the gap between the neurosciences and clinical practice.

Whilst each of the neuropsychiatric conditions would benefit from a book written in their own right – moving from neurotransmitter function through to gross pathology and clinical presentation – the book encourages the reader to integrate information from different areas. There was a lot of interesting information and perspectives. For instance the consideration of the Blood Brain Barrier as being composed of multiple systems for mediating transfer of compounds, the analogy between the Placenta and Blood Brain Barrier, the possibility that people may have intrinsic differences in their BBB or placenta leading to specific conditions or teratogenicity, the kindling phenomenon in epilepsy, the lower firing threshold for the Amygdala as opposed to the Hippocampus, Kainic Acid’s augmentation of Glutamate and the author’s own model of kindling.

The strength of the book lies in reminding the reader of the importance of clear dialogue between the neurosciences and the clinical sciences (or clinical practice).

References

The Dementias. Crossroads between Neurology and Psychiatry. Makram Girgis and K. Harris. Warren Green Inc. 1992.

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.