Monthly Archives: November 2008

Reflections on November 2008

Reflections on November 2008

November has also gone very quickly but there was a lot happening this month.

In terms of news there was found to be a relationship between lissencephaly genes and executive dysfunction in schizophrenia and bipolar disorder. This might be signal a trend towards relating genes to components of an illness (e.g. executive function, memory etc), where these components come together produce an illness and would fit with the evidence suggesting the involvement of many genes. The East London First Episode Psychosis Study found psychosis to be increased in black and ethnic minority groups compared to white british. In a study of twin pairs, the healthy twin of a sibling with schizophrenia was found to have greater whole brain volume reduction and frontal/temporal gray matter volume reduction over 5-years compared to twin pairs without schizophrenia. There was also some evidence of childhood bullying leading to an increased likelihood of psychosis.

Examining the relationship between anticholinesterase inhibitors and circadian rhythms together with polyunsaturated fats and healthy brain again were the topics of 2 review papers. A paradox which needs explaining is the finding that the risk of MCI conversion to dementia decreases as time progresses. There is evidence for Amyloid deposition in Lewy Body Dementia but not in Parkinson’s Disease(PDD) or PDD+. Delivery of a telephone-based service for carers of people with dementia was found to lead to significant improvements in caregiver burden scores. A potential marker of glial cell activity was identified in one study which found increased uptake of the compound [11C]DAA1106 in people with Alzheimer’s Disease suggesting that glial cell activity might be increased. ABeta42 levels were found to be lowest in people with Lewy Body Dementia compared to other types of dementia in one study but highest in Alzheimer’s Disease (as expected). There was some indirect evidence for a more protective role of the Val-Met form of Brain derived Neurotrophic Factor compared to the Val-Val form. A five factor model for predicting conversion from MCI to dementia was found to have 81% sensitivity and included immediate recall, functional assessment, smell test, MRI hippocampal volume and entorhinal volume. A multicentre study found a higher association between depression and dementia in the younger age group and for the most severe cases of depression.

People with Cornelia de Lange syndrome were found to have a higher rate of severe autistic phenotypes.  A Western Australian study using a database registry of 245,749 people with mental illness and intellectual disability found that 31.7% of people with intellectual disability had a concurrent mental illness.

There was also found to be a lower prevalence of borderline personality disorders in Spanish immigrants compared to the indigenous population particularly in Asia and Sub-Saharan people. Three subtypes of Narcissistic Personality Disorder are proposed on the basis of one survey of 1200 clinicians and includes the fragile subtype, malignant/grandiose subtype as well as the high-functioning and exhibitionist subtype. Overcrowding on wards was associated with staff’s use of antidepressants in another study.

An expert consensus meeting concluded that the Bipolar Disorder was more likely to be a neurodegenerative disorder than a neurodevelopmental one. One study showed a 67.1% response rate for Mirtazapine and 62.1% response rate for SSRI’s with different side-effect profiles for each. The Health in Men study found a correlation between Homocysteine levels and risk of depression. The Right Anterior Insula was activated in people with depression when anticipating depression in one study (together with the Anterior CIngulate Cortex and the Right Amygdala) perhaps suggesting a reduced ability to modify emotional responses in depression. A hydrolysed protein form of the tryptophan diet was found to have an advantage in effect on mood compared to other tryptophan diets or placebo. In an 8-week RCT of Pre-Gabalin in people with anxiety disorders there was found to be a 2-point advantage over placebo on the Hamilton Rating Scale.

Ghrelin and Obestatin secretion was found to be subtly altered in women with anorexia compared to controls. PTSD was found to influence mortality rates in people who received implantable defibrillators.

In people who had undergone CABG within the last 2 years, depression was associated with a higher rate of new cardiac events. Metabolic syndrome was associated with individual and neighbourhood socioeconomic status in women but not men while at least two pathways were found mediating a relationship between depressive symptoms and HDL-LDL levels. The Rotterdam study found that total cholesterol was positively correlated with sleep duration. The metabolic syndrome was found to be significantly associated with Beck Depression Inventory scores in one studyPaternal age was associated with impairment in social functioning if the father was less than 20 years old or over 45-years old. There was found to be an association between cognitive deficits and a number of psychiatric disorders in swedish army conscripts in one study.

Also in November I set out the basis for a model of Insular Cortex function and although it is very simple at this stage and most likely inaccurate, it at least offers a foundation to improve upon. While at first glance this may seem a little unusual, integrating newly acquired information into a model should at the very least offer a narrative sense about complex data, should allow a person to more easily remember details of studies, to make more informed choices about what they want to learn and to integrate new information more easily. There were a number of papers which were examined which could be helpful in building a model of the Insular Cortex and these include Insular Cortex Infarction in Acute Middle Cerebral Artery Territory Stroke, the Insular Cortex and Neuropsychiatric Disorders, Pathobiology of Visceral Pain, the Relationship of Blood Pressure to Subcortical Lesions, a case of ‘neurogenic’ T-wave inversion and Interoception and the Insular Cortex.

In the podcast reviews there were references to various studies including findings that peak age for researchers in terms of papers was identified as being in the 50’s or 60’s, outcome measures for the SureStart program, health inequalities in green space areas, antipsychotic trials in early-onset schizophrenia, twin studies and bereavement, eIF2 and memory, various relationships of chromsome 17 (evolution, progressive supranuclear palsy, inversion), epigenetics with transmission of maternal RNA and fish that go without sleep. There was also a look at some videos about the Productive Ward.

There were a few books reviewed including Goffman on Stigma, Fundamentals of Adlerian Psychology, Interpreting CT scans of the Head and Hyperchondriac. There were various blogs reviewed including Bipolar Mo, Neuroscientifically Challenged, Somatosphere and MindHacks.  In terms of social psychiatry papers there was a focus on the Global Mental Health Series and a DOH policy paper about combating mental health stigma in the workplace. There was a study looking at the phenomenology of delirium, the Impact of Events Scale, Bereavement Theory and Art Therapy.

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: November 2008 5th Edition

Schizophrenia

A study of prescribing patterns of antipsychotics in inpatients with Schizophrenia has found marked variations in prescribing patterns between countries (STT5). A study of Memantine as an adjunct in the treatment of schizophrenia has found no benefit on PANSS scores (STT5). Another study has found an association between lissencephaly genes and executive dysfunction in Schizophrenia and Bipolar Disorder (STT5).

Dementia

The authors of a systematic review found that education delayed the onset of dementia (STT3). There is a discussion of the role of polyunsaturated fatty-acids in relation to aging of the brain in an article in the Journal of Nutrition. The interaction between anticholinesterase inhibitors and the circadian rhythm is discussed in a review article.

Learning Disability Psychiatry

A case-control study of 54 people with Cornelia de Lange syndrome and 46 control subjects looking at behavioural phenotypes found that severe autism (32.1% in Cornelia de Lange and 7.1% in the control group) and compulsive behaviour were significantly higher in the former group (STT3). In a postal questionnaire study of Phenylketonuria there were found to be 98 people in the survey who hadn’t been treated at birth, 50 of whom hadn’t been tried on a phenylalanine-restricted diet and the authors suggest a need for further research in this population (STT3).

Eating Disorders

There was also a South London And Maudsley randomised-control study looking at a specific self-help program for eating disorders which was CD-Rom based (although the authors point out that a web-based program has become available) in a group of people with Bulimia Nervosa or eating disorder not otherwise specified (NOS). There was found to be no significant difference in bingeing or vomiting between the self-help and waiting list groups (STT5).

Personality Disorders

86 people (with 78 followed up) with 2/9 DSM-IV criteria for Borderline Personality Disorder and 78 also (with the same criteria fulfilled) were allocated to CAT and ‘good clinical care’ respectively. While there was no difference in a number of outcome measures those with CAT attained those outcomes more quickly – the authors recommend larger studies (STT5).

Miscellaneous

In the British Journal of Psychiatry, there is an editorial on grief and acceptance looking at cognitive and emotional acceptance and calling for further research in this area and there is also a very interesting editorial by Peter Tyler who converts findings from some of the studies in the December issue into a series of statements with supporting arguments. This certainly helps in organising the many complex topics that are covered in each issue . The interesting question of whether acceptance should be a goal of treatment in terminal illness was also raised (STT5). A Swedish cohort study of just under 1 million male military recruits with IQ measurements at entry into the study and follow-up over 2 decades found that higher IQ was associated with lower risk of homicide even after adjusting for various confounders but the authors recommend replication studies (STT5). There is also an interview with Steve Peters psychiatrist and trainer for the British Olympic Cyclists in the Times. In a study of 11578 consecutive psychiatric admissions to a tertiary referral service in Barcelona, there was found to be significantly lower in immigrants than in indigenous people and that there was a markedly lower rate in immigrants from Asian and Sub-Saharan immigrants (STT3).

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: November 2008 5th Edition

In the Science Podcast of 28.11.08 there is a discussion with Greg Hannon (author of study) about a study investigating epigenetics and discovering evidence of transmission of RNA in addition to DNA to offspring. In the Science Podcast of 21.11.08 there is a discussion of a new DNA sequencing technique which is 30,000 times faster than current techniques and which could allow sequencing of the human genome in one hour!  In the 14.11.08 edition of the Science Podcast there is a discussion of the evolution of childhood development. Humans have longer periods of child development than other primates and the recent research in Homo Erectus is discussed. One of the ideas is that longer periods of development are required in humans to allow for the brain to achieve it’s relatively large size and consumes lots of energy in the process. By having a longer period of development energy can be allocated to other systems in the body that are also developing. In the Science Podcast of 31.10.08, there is a brief discussion of sleep in animals and the fascinating insight that there are some species of fish that actually go without sleep!

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: Neuroscientifically Challenged

Neuroscientifically Challenged is a blog about neuroscience which started in January 2008 although at the time of writing the last article was in September 2008. Marc Dingman the author writes that he is a neuroscientist and is working in a genetics lab, explaining the versatility with which he writes about topics ranging from the function of junk DNA to evolutionary fear and the neuroimaging revolution.  The articles are easy to understand and geared towards introducing neuroscience to a wider audience.  Some of the articles I found particularly interesting were a post about deep brain stimulation of the fornix resulting in feelings of deja vu as well as an article on a  condition referred to as Body Integrity Identity Disorder. In this article Dingman takes another look at some of the possible functions of dopamine. Dingman explains that there is a temporary hiatus due to other commitments but hopefully he will return with some interesting articles in the process of doing the good work of increasing the accessibility of neuroscience.

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.

Interpreting CT Head Scans

The book reviewed here is ‘Interpreting CT Head Scans. A Basic Guide to Image Analysis’ by L.Albertyn and R.Brown. Imaging studies play an increasingly important role in psychiatry as the prevalence of conditions such as dementia increases.

The book is divided into 8 chapters. Firstly the basic principles of CT scanning are introduced including scanning techniques and some basic physics including the Hounsfield Unit which is a measure of X-ray attenuation which is translated into a grey-scale contour. These principles were introduced with clear and simple descriptions which are helpful to those coming fresh to the subject. They also describe the standard protocols for creating image slices. There are also some very nice anatomical illustrations with corresponding CT scan images for comparison. I found the most useful chapter to be that on the normal scan which gives the reader a system for approaching CT scan images including paying close attention to the Scout Image, a standardised view which allows for an examination of expected features as well as orientation of other image sections. A checklist for working through the images is included and explained. There follows a lengthy and useful chapter on abnormal scans with lots of images to back up the theory, and then a chapter on extending the search pattern looking at other anatomical features such as the sinuses and middle ear before moving onto abberations in the images and concluding with some worked case examples.

The authors adopt a friendly almost informal approach throughout the book which is very engaging and the authors’ passion for their subject is evident. This is a useful introduction to the subject for those who want to learn more about this area.

References

Interpreting CT Head Scans. A Basic Guide to Image Analysis. L Albertyn and R Brown. Churchill Livingstone.

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.

Action On Stigma

After reviewing Goffman’s work on Stigma and having finished reviewing the Global Mental Health Series, I thought it would be interesting to look at some of the Department of Health’s social and health policies related to mental health starting with this one on stigma in the workplace – ‘Action on Stigma’. The author(s) begin by referencing an estimate of £9 billion in costs from not addressing workplace mental health issues. There is then a shocking estimate that 40% of employers would not consider employing a person with mental health problems. The documents sets out 6 principles:- demonstrating promoting mental health, mental health awareness for employees, promoting ‘a culture of respect and dignity for everyone’, ensuring there is no employment discrimination, adapting the environment as necessary and accessibility.

While many of the principles were admirable, it would have been interesting to see how these higher level goals are translated into practice and ultimately culture. The authors then focus on some case studies of organisations that have focused on mental health issues in employment. BT for instance has a ‘mental well-being strategy’ with three strands which is reported to have resulted in many benefits. For instance, the company works with people who are off work with mental illness to help them get back into work. Similarly Oxleas NHS Foundation Trust is referenced for it’s work in employing people who have experienced mental illness as part of a strategy against stigmatisation.

This document sets out principles for overcoming discrimination against people with mental illness in the workplace and places an emphasis on values. There is a corresponding SHIFT website which gives details of the work being undertaken by SHIFT – the organisation set up by the government to overcome discrimination and stigma against those with mental health problems. This is a great idea for an organisation and it will be interesting to follow their work.

STT2

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.

Phenomenology in Delirium

The featured paper is ‘Phenomenology of delirium. Assessment of 100 adult cases using standardised measures’ by D Meagher and colleagues.  One of the authors is employed by Eli Lilly as stated in the declaration of interests section although I couldn’t immediately see any stated pharmacological connections with the area of study. The authors start by discussing the lack of research into the phenomenology of delirium with validated instruments as well as discussing two such instruments –  ‘The Cognitive Test for Delirium’ and ‘The Delirium Rating Scale Revised 98′. What was interesting about the DRS-R98 was that it can apparently distinguish between delirium and dementia.

The aim of the study was to characterise the phenomenology in delirium and particularly examine the ‘primacy of inattention’. The authors selected patients from Palliative care over 2 years and looked at their symptoms at one point in time – thus this is a cross-sectional study. Cases for inclusion were identified by the treating team. There may have been some selection bias towards those who were disorientated. DSM-V criteria were wused with ‘acceptable interperson reliability’ of the assessors (although we don’t know what this is). Patients were then administered the RS-R98 followed by the CTD. One interesting feature of the study was that consent was gained from relatives or carers in people who lacked capacity. People recruited into the study were administered the two delirium rating scales. Scores of severity were obtained by using the gradings on the CTD scale.

50% of the sample were men and the average age was 70. In comparing those with delirium alone and delirium plus dementia the average CTD score was much lower in the latter group but the large standard deviation meant that the populations overlapped for CTD scores. Similarly there was population overlap on the DRS-R98 severity scores where this time the latter group had an average score which was higher. I wasn’t convinced from these figures of a pragmatic utility in distinguishing between these diagnostic categories.

However, the authors drew up an interesting table in which they compared severity of scores with the individual items on the DRS-R98 scale. At any severity, sleep-wake cycle disturbance was present in 97% of the sample. A key finding was that disorientation was present at any level of severity in 76% of the sample and in only 42% of cases was it moderate-to-severe.  50% of people had perceptual disturbances including hallucinations at any level of severity. There was also a remarkable finding showing that the level of inattention on the CTD was significantly correlated with a number of items on the DRS-R98 with the implication that inattention is an explanation for many of the features of delirium.

The authors argue that in delirium therefore, the main feature is not disorientation but inattention and suggest this as a consideration for future diagnostic revisions. Another interesting finding was that motor symptoms (classically considered to be agitated versus hypoactive delirium) did not predict psychosis – in other words the quiet withdrawn people with delirium were just as likely to be experiencing psychosis.

This is a neat study with some very interesting findings in delirium.

STT3

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.