Monthly Archives: January 2009

Jung Podcast #5 in John Betts Series

The featured podcast is the 5th in the series by John Betts on Analytical (Jungian) Psychology. Betts starts be summarising the structures in the different levels of the psyche and the points made in previous episodes.

The persona is then discussed and Betts tells us that we often have more than one persona and that these are chosen to fulfil what we perceive are the expectations of others. Without the persona, the ego is exposed to the outside world and a weak persona can cause difficulties for a person. He uses the term ‘persona up’ in a way that suggests putting our defences up and that the development of persona in adolescence is accelerated as a person experiments with identity. Betts then discusses cultural expectations of personas, for instance in terms of professional roles. Betts also suggests that overidentification with the persona may result in the eruption of unconscious material as a form of compensation by the psyche. What I found interesting was his description of the ego, when overidentifying with the persona, focusing on the external world and not on the unconsciousness. This then necessitates dreamwork, which allows the ego to re-engage with the unconscious material. My interpretation of this is that it is a difference between focusing on the internal world and the external world. However the persona would necessarily need to partly focus on the internal world – to recall the ‘rules’ necessary for behaving in a particular situation. A further point I have at this point is that it could contribute to the debate on genes (or rather epigenetics) versus environment in influencing our behaviour.  Thus we have a choice to focus on that area which is influenced by our (epi)genetics – the unconscious (but also necessarily by the environment), or we have a choice to focus on the external environment or some combination thereof. Betts narration is clear, his explanations easy to understand and engaging. Through the series, the listener is able to gradually build a clear picture of analytic psychology.

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

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.

EMDR International Association Blog Review

The featured blog is the EMDRIA Blog (located here). EMDR stands for Eye Movement Desensitisation and Reprocessing. EMDR is a form of therapy developed by Francine Shapiro which involves the use of eye movements (although not always) to desensitise people to the distressing emotions associated with traumatic memories and followed by a ‘reprocessing’ phase which aims to reframe the memories adaptively. This is quite a new blog with the introductory article posted on January 2nd 2009. Within this short time two themes emerge – EMDR itself (including announcements on relevant organisations and aspects of practice) and information on Post-Traumatic Stress Disorder. In this article there is a discussion of the International Society for Traumatic Stress Studies (ISTSS) and their recommendation for using EMDR which received a Level A Rating (based on the Agency for Health Care Policy and Research Guidelines). In this article there is a look at research identifying an association between childhood physical abuse and impaired immune functioning. This blog will be relevant to EMDR Practitioners and those with an interest in EMDR

Conflict of Interest

I have an interest in and practice EMDR.

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

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: Pocket Atlas of Cranial Magnetic Resonance Imaging

The featured book is ‘Pocket Atlas of Cranial Magnetic Resonance Imaging’ by Atlas and Kaplan and is intended for ‘anyone interested in cranial magnetic resonance imaging’. The book has a glossy cover with rounded edges and is as the title suggests pocket sized (while it does seem a little wide, I tried it in 2 jacket pockets and it did indeed fit). The images were acquired on a 1.5T MRI Scanner. However, I wasn’t able to ascertain the characteristics of the subject(s) on whom the scans were undertaken and presume in the absence of this information that it is an adult of under 65 years (although this may be incorrect). The book is divided into five sections – the saggital brain, axial brain, coronal brain, sella coronal/sagittal and intracranial MRA. In the Sagittal sections there are corresponding coronal section insets allowing us to better gauge the location of the slides. The sagittal slides are clearly labelled and I found it easy to understand relationships between structures. The Axial brain section contained corresponding sagittal insets as does the coronal brain section of the book. The Intracranial MRA contains axial insets along with the different perspectives on the arteries and their tributaries. This is a valuable resource for those with an interest in improving their knowledge of MRI Cranial imaging.

References

Scott W Atlas and Richard Kaplan. Pocket Atlas of Cranial Magnetic Resonance Imaging. Lippincott Williams and Wilkins. Second Edition. 2001.

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.

Mental Health Taskforce: An Introduction

The featured paper is ‘Mental Health Taskforce: An Introduction’ and freely available here. The mission statement for the taskforce contains many goals which are outlined within the article and which cover a number of areas including the treatment of people with mental health problems with dignity and also involving them in their care, respecting cultural and ethnic diversity, tackling discrimination, supporting carers, promoting positive mental health, making the best treatments available, responding promptly to need, focusing on safety and the necessary characteristics of the workforce including morale and skills.

The taskforce is described as one of 11 that have been established by the government to realise the objectives of the NHS Plan which in turn references the National Service Framework for Mental Health. Here the authors describe the three main goals of ‘different ways of working, ‘user-focused services’ and integrated services.

The authors then focus on commitments to the plan including 50 early intervention teams, 335 crisis resolution teams and a large number of other resources. The authors conclude by outlining how these objectives will be achieved by a number of project teams working in the five key areas identified in the National Service Framework.

The document identifies strategic objectives and combines this with a detailed outline of services which are being rolled out nationally and thereby gives the reader a useful overview of how policy will be translated into practice.

Steps To Treatment 1 (This is an outline of policy)

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

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.

Mild Cognitive Impairment: Cognitive Screening or Neuropsychological Assessment?

The featured paper is ‘Mild Cognitive Impairment: Cognitive Screening or Neuropsychological Assessment?’ by Diniz and colleagues and freely available here. The authors begin by focusing in the introduction on the definition of Mild Cognitive Impairment (MCI) and the 10% progression to dementia. The expansion of the term MCI to include non-amnestic types together with the relationship to dementia subtypes was then discussed. The authors then discuss some of the difficulties inherent in the diagnosis including the heterogeneity of the group (this might result from the focus on a restricted group of symptoms in contrast with dementia). There is an interesting point about the specificity of combining the MMSE and Clock Drawing test in multidomain MCI which increases diagnostic specificity to 75%. The authors state a number of aims

1. To characterise MCI subtypes with neuropsychological tests in comparison with controls and people with Alzheimer’s Disease

2. To examine the discriminatory properties of the MMSE and CAMCOG for the subtypes of MCI

There are potentially important benefits for practice in answering these questions.

The researchers recruited 249 people, 3/4 of them being female, with a mean age of 71.2 and a mean of 10.5 years in education. The researchers used an interesting method for recruiting which included not only volunteers but also ‘acquaintances of patients’. The study gained approval from the local Ethics Committee. The CAMDEX was used as well as the Hamilton Depression Scale. Blood tests were completed for all patients and imaging studies where appropriate. Consensus at multidisciplinary meetings was used for diagnostic purposes. As a Kolmogorov-Smirnov test had revealed distributions on test results to be normally distributed, the researchers undertook parametrical testing of mean differences utilising ANOVA.

The results showed that there was no significant difference between genders on the distribution of diagnoses. The group with Alzheimer’s Disease (AD) had greater age and higher scores on the Hachinski Ischaemic Index than the other groups. The AD group performed significantly worse than the other groups on all of the cognitive tests.

With regards to the MCI groups, there were similar performances to the control group on the Clock Drawing Test and MMSE. The MCI groups excluding multiple-domain MCI performed similarly to the controls on the CAMCOG. The non-amnestic MCI group  performed worse on the Trail B Test (a test of executive functioning). The multiple domain MCI group had impairment in praxis, memory and executive functioning. The MMSE didn’t discriminate between MCI and controls while the CAMCOG was better in this regards. With multi-domain MCI, the CAMCOG had a sensitivity of 85% and specificity of 75% in distinguishing from controls.

In their discussion the authors mention the Montreal Cognitive Assessment which has been designed specifically for assessing people with MCI. The authors also comment on the significance of multi-domain MCI in terms of progression to Alzheimer’s Disease – suggesting that when multiple domains are involved the global performance threshold is more likely to be crossed. They also consider the significance of conversion from amnestic MCI to multi-domain MCI which may become an important pathway although further research will be needed in this area.

Steps To Treatment – 3 (Further replication of results needed, if validated incorporated into screening program, then considered for local policy).

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

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.

Intranasal Administration of Acetylcholinesterase Inhibitors

The featured paper is ‘Intranasal Administration of Acetylcholinesterase Inhibitors’ by Costantino and colleagues and freely available here. This is a brief review paper. There are a few unusual points. Thus it is an unstructured 3-page review article without a stated methodology and citing 36 references. However there are 5 authors on this paper – 1.6 authors for each page and that includes one page of references! The paper does bring together a number of different disciplines and so it could be argued that different domains of expertise are required in order to lend the article authority. Another unusual point about the paper is that the authors state that there is no conflict of interest. However the stated correspondence address for the authors is given as Nastech Pharmaceutical Company Inc. A cursory examination of the company website (the company is now referred to as mdRNA inc) and other sites reveals a proprietary intranasal delivery system developed by the company with a number of derivative products also being developed. Therefore it can be argued that there is a connection between the company’s products and the current article although it could equally be argued that such an association would not influence the conclusions arrived at within the article.

With regards to the content of the article, the authors consider the benefits of intranasal delivery of drugs. The benefits include bypassing first-pass metabolism in the liver and the ‘large surface’ area. The authors state that ‘this delivery route is non-invasive’. However, after entering the nasal cavity, passing through into the blood-stream and then being conveyed to the brain where its action takes place the case for an ‘invasive’ delivery route can also be argued.

The authors discuss in vivo and in vitro studies of Galantamine. They refer to epithelial tissue preparations where the galantamine’s passage across the cell layer is facilitated by the concurrent delivery of ‘permeation enhancers’ although these are not clarified further within the article. The Galantamine is then tested in vitro with a significant reduction in GI side-effects.  The authors conclude that this is a viable delivery method and that by avoiding GI delivery, the GI side-effects can be avoided.

What I found particularly interesting about this paper is the consideration that the numerous side-effects of a medication can  be further understood by comparing the side-effects resulting from different delivery methods. In this case the evidence would support a direct effect of Galantamine on the GI system in producing the GI effects rather than being secondary to a central effect.

Steps To Treatment 3 (The IN Galantamine would need to be tested in Phase III trials, then gain regulatory approval and then be incorporated into local policy)

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: January 2008 – 4th Edition

In the 4th Edition, there is an autosomal dominant condition with similar features to Frontotemporal Dementia as well as a number of interesting pieces of miscellaneous research.

Research in Dementia

In a 6-year Swedish cohort study looking at risk of dementia and the traits of neuroticism and extraversion, there was found to be an increased risk of dementia in those with high neuroticism and high extraversion compared to those with low neuroticism and low extraversion (Hazards Ratio 0.51 (CI 95% 0.28-0.94) (STT4). An autosomal dominant condition similar to leukodystrophy has been suggested to account for a presentation similar to Frontotemporal Dementia after a series of autopsies were undertaken in affected people. What is interesting about this condition is that it sometimes doesn’t present till the eighth decade of life (STT2). After cells have differentiated, recent research suggests that the nuclear pore complex deteriorates in an age-dependent manner allowing leakage of proteins into the surrounding cytoplasm (and also the reverse). If this were found to be relevant as a contributor to dementia processes, then it would require a novel theoretical approach as the majority of nuclear pore complexes are not changed through the life of the cell and interventions would need to take place intracellularly (STT5).

Research In Psychosis

There was a recent study in the New England Journal of Medicine, looking at both typical and atypical antipsychotics and finding an increased risk of cardiovascular events which was dose dependent (STT3).

Miscellaneous

There is a technique developed which saves a considerable number of lives in surgery. In the World Health Organization’s Safe Surgery Saves Lives program, a 19-point surgery checklist reduced rate of death from 1.5% to 0.8% in 3733 non-cardiac surgical operations before the checklist was introduced and 3955 operations after the introduction of the checklist. Whilst not directly related to psychiatry (except in the case of psychosurgical operations) this research shows the important benefits of process (STT2). Ethicists are joining ward rounds over in the United States where they contribute to the decision making processes in complex cases. Also an ancient brain from approximately 6000 years ago has been discovered in a cave (it was preserved due to the dry conditions) in Armenia with evidence of intact surface vessels. Such a find is potentially very interesting as even in the space of tens of thousands of years there is evidence of evolutionary changes in the brain (STT6).

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.