Monthly Archives: March 2009

Winnicott on Anxiety Associated With Insecurity

The featured paper is a very brief one by Winnicott – ‘Anxiety Associated with Insecurity’. Winnicott wrote this paper in response to one by Dr Rycroft – ‘Some observations on a case of Vertigo’ in 1953 in which the author comments on the role of balance in maintaining posture. The latter point is focused on by Winnicott who questions a notion proposed by Rycroft that anxiety in infancy is a matter of semicircular canal physiology. Instead Winnicott suggests that there are several types of anxiety in infancy that are influenced by the relationship with the caregiver. He further suggests three types of anxiety that may result from the relationship – ‘unintegration’, ‘lack of relationship of psyche to soma’ and ‘the centre of gravity of consciousness transfers from the kernel to the shell from the individual to the care’. Winnicott then defines ‘good enough care’ in terms of the three anxieties described above. He then suggests how the different anxieties can be distinguished by additional features such as pain. While this paper is interesting in describing ‘good enough care’, Winnicott has not demonstrated this in the paper with research and it must necessarily remain in the domain of conjecture although being supported by Winnicott’s own clinical experience. Therefore Winnicott’s paper offers a structure for considering anxiety although these conclusions require an evidence base and therefore necessarily form a starting point for discussion where further work must be undertaken to test these hypotheses.

References

Donald Winnicott. Anxiety Associated with Insecurity [1952]. In ‘Through Paediatrics to Psycho-analysis’. London. The Hogarth Press and the Institute of Psycho-analysis. 1978.

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.

Anosmia In Lewy Body Dementia

The featured article is ‘Anosmia is very common in the Lewy Body Variant of Alzheimer’s Disease’ by Olichney and colleagues and freely available here. In the introduction, the authors note the difficulties that sometimes occur in distinguishing between Lewy Body Dementia and Alzheimer’s Disease and this is complicated by cases in which there is marked overlap between the two which they refer to as the ‘Lewy Body Variant of Alzheimer’s Disease’. The authors identify two clear aims in their study

1. To confirm earlier findings by McShane and colleagues who found increased anosmia in Lewy Body Dementia but not Alzheimer’s Disease

2. To see if the smell test can facilitate discrimination of Alzheimer’s Disease from Lewy Body Dementia (DLB)

The sample population consisted of people who had been assessed with an odour threshold test at the Alzheimer’s Disease Research Center (ADRC) in California and who had subsequently undergone necropsy between 1988 and 2001. The CERAD neuropathological criteria for probably/possible Alzheimer’s Disease in combination with DSM-III R criteria for dementia were used as well as consensus clinical criteria for DLB. 106 cases were identified (Alzheimer’s Disease 89; 17 Lewy Body Variant). All subjects had given written consent for this longitudinal research program. There had also been annual neurological reviews which included a detailed assessment of Parkinson’s related features. A detailed olfactory test was used with increasing concentrations of n-butyl alcohol being used if the person was unable to discriminate between this and a stimulus with no odour.

The presence or absence of anosmia or Lewy Bodies were the dependent variables and there were a number of independent variables such as severity of dementia and visual hallucinations used in the analysis. A regression model was constructed using backward and forward step regression analyses. Anosmia was present in 64.7% of cases of Lewy Body Dementia  and 22.5% of cases of Alzheimer’s Disease and this difference between the group was significant at the 0.00045 level (using a Chi Squared test)!. The odour test attained 65% sensitivity and 78% specificity for LBV. However the test was less useful in smokers because of the relationship between smoking and olfaction (see Appendix 1). Indeed the sensitivity from the consensus diagnosis of DLB had 100% specificity but a low sensitivity. Adding anosmia to the diagnostic criteria had variable effects depending on the population – smokers or non-smokers. For instance in non-smokers, addition of anosmia produced a specificity of 88/89 but a sensitivity of 7/17. Higher education, low severity scores and Lewy Bodies were the three significant independent variables identified from the regression analysis.

In conclusion, the authors of the study found that anosmia is more common in Lewy Body Dementia than in Alzheimer’s Disease although it is also moderately correlated with dementia severity and in the Alzheimer’s Group was associated with a reduced survival period. The paper is well written, being easy to understand and conveying the methodology and results unambiguously. The results are clinically relevant and the authors are cautious in their conclusions while also indicating how they can be used. Subsequently there has been the suggestion that under circumstances in Parkinson’s Disease, biopsy of the Olfactory Bulb could be warranted (Appendix 2).

Steps To Treatment

STT 4 (Replication, Meta-analysis, Incorporation into diagnostic policies if appropriate, then one further step to treatment)

References

Beach T et al. Olfactory bulb alpha-synucleinopathy has high specificity and sensitivity for Lewy Body Disorders. Acta Neuropathol. 2009. 117(2). 169-74.

Katotomichelakis M et al. The effect of smoking on the olfactory function. Rhinology. 2007. 45(4). 273-80.

Olichney J et al. Anosmia is very common in the Lewy Body variant of Alzheimer’s Disease. J Neurol Neurosurg Psychiatry. 2005. 76. 1342-1347.

Appendix 1 – Smoking and Olfaction

In a study of 65 smokers – (median smoking period of 10 years0) and 49 non-smokers a significant inverse correlation between pack-years of smoking and odour threshold, odour discrimination and odour identification were found.

Appendix 2 – Olfactory Bulb and Alpha-synucleinopathy

In a study which included 328 post-mortems of people who had known Parkinson’s Disease, there was found to be a significant correlation of Olfactory Bulb Alpha-Synucleinopathy density scores and those in other regions at necropsy including limbic cortex. There was also a significant correlation with MMSE scores antemortem and scores on the Unified Parkinson’s Disease Rating Scale.

Steps To Treatment (STT)

STT = Steps To Treatment. An estimate of the number of steps between the results and translation into practice i.e. treatment. This is an opinion.

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.

News Round-Up: March 2009 4th Edition

In this news round-up, relapse prevention was found to be effective in first episode psychosis compared to treatment as usual in one study while late onset depression was associated with an increased prevalence of mild cognitive impairment after treatment response in a cross-sectional study.

Research in Dementia

In a prospective study of community-based people with dementia (n=48) including post-mortem, visual hallucinations were associated with a higher frequency of neocortical lewy-related pathology, abnormal posture and gait than those without visual hallucinations. However in 59% of cases the diagnosis was Alzheimer’s Disease with concurrent Lewy Body related pathology (Tsuang et al, 2009)(STT3). Iron levels were elevated in the hippocampus in 26 people with Alzheimer’s Disease compared to controls in a phase-imaging study of 26 people with Alzheimer’s Disease and 24 controls with potential diagnostic implications (Ding et al, 2009)(STT4). In a cross-sectional study looking at 109 people aged 65 years or older with depression (who had responded to treatment) and 65 controls who had never experienced depression, the depressed group had just under twice the prevalence (38% – 2/3 amnestic, 1/3 non-amnestic) of Mild Cognitive Impairment as the control group (Bhalla et al, 2009)(STT4).

In a meta-analysis of 14 studies which looked at hippocampal volume in people with Mild Cognitive Impairment and Alzheimer’s Disease compared to controls there was found to be greater atrophy in the left hippocampus in both MCI and AD groups as well as a greater degree of atrophy in AD subjects (24.2% left, 23.1% right reduction in hippocampal volume) than in MCI (12.9% left, 11.1% right reduction in hippocampal volume) with both being significantly greater than controls (Shi et al, 2009)(STT3).

In a study of 629 elderly people without dementia, vibratory threshold measured at the ankles/toes were significantly correlated with composite mobility scores (Buchman et al, 2009)(STT3). In a small case control series of Frontotemporal Dementia, 12 people with MAPT gene mutations were found to have greater grey matter loss in the frontal, parietal and anteromedial temporal lobes copared to the control group while the 12 people with PGRN gene mutations were found to have greater grey matter loss in the frontal, parietal and posterior temporal lobes than controls (Whitwell et al, 2009)(STT5). In a 5-year prospective cohort study, over 70% of people with mild behavioural impairment converted to dementia and were more likely to develop Frontotemporal Dementia than Alzheimer’s Disease and the authors suggest that MBI may be an FTD prodrome (Taragano et al, 2009).

Research In Depression

A small study (n=14) found that Verenicline, a nicotinic acetylcholine receptor partial agonist was associated with a significant improvement in mood (using a self-report measure) and 44% achieving abstinence from smoking with the authors recommending further research to confirm these findings (Philip et al, 2009)(STT5) .

Research in Psychosis

A randomised-controlled trial of treatment as usual (n=40) versus individual and family CBT relapse prevention (n=41) in people with first episode psychosis found a significantly longer time to relapse in the relapse prevention group (Gleeson et al, 2009).

News In Brief

Over 500 6-18 year-olds were scanned prospectively (using MRI) as part of the ‘NIH MRI Study of Normal Brain Development’. A significant association between cortical thickness in multimodal association areas and intelligence was found. An increase in Ghrelin and a decrease in Leptin were found in people with chronic insomnia in this study. Having extra-curricular activities at school was associated with more years of education in later life. In a test of attention, the Visual Serial Addition Test, children with ADHD were found to have similar accuracy of responses to the control group but higher variability in response times. Cortical thinning in the right hemisphere was associated with depression in a study looking at 131 people with familial depression. An association has been found between the metabotropic glutamate 5 receptor and the process of adapting to new changes in the environment. Initial results suggest that Modafanil may reduce Olanzapine associated weight gain. A study using photographic negatives has shown that contrast around the eyes is important in recognition of faces. Alpha activity was significantly higher before mistakes were made in a sustained attention task and this information has the potential to be used in jobs which require prolonged attention.

References

Bhalla R et al. Patterns of mild cognitive impairment after treatment of depression in the elderly. Am J Geriatr Psychiatry. 2009. 17(4). 308-316.

Buchman A et al. Vibratory thresholds and mobility in older persons. Muscle Nerve. 2009. Epub.

Ding B et al. Correlation of iron in the hippocampus with MMSE in patients with Alzheimer’s Disease. J Magn Res Imaging. 2009. 29(4). 793-8.

Glesson et al. A Randomised Controlled Trial of Relapse Prevention Therapy for First-Episode Psychosis Patients. J Clin Psychiatry. 2009.

Philip N et al. Varenicline augmentation in depressed smokers: An 8-week, open label study. J Clin Psychiatry. 2009.

Shi F et al. Hippocampal volume and asymmetry in mild cognitive impairment and Alzheimer’s Disease: Meta-analyses of MRI studies. Hippocampus. 2009.

Taragano F et al. Mild behavioral impairment and risk of dementia: A Prospective Cohort Study of 358 Patients. J Clin Psychiatry. 2009.

Tsuang D et al. Visual hallucinations in dementia: a prospective community-based study with autopsy. Am J Geriatr Psychiatry. 2009. 17(4). 317-23.

Whitwell J et al. Voxel-based morphometry patterns of atrophy in FTLD with mutations in MAPT or PGRN. Neurology. 2009. 72(9). 813-20.

Steps To Treatment (STT)

STT = Steps To Treatment. An estimate of the number of steps between the results and translation into practice i.e. treatment. This is an opinion.

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.