The blog reviewed here is ‘Movies and Mental Illness’. The blog is described as

‘A blog that Danny Wedding, Mary Ann Boyd and Ryan Niemiec will use in preparing the 4th Edition of movies and mental illness‘

While I wasn’t able to find many details in the contributors section about the authors at the time of writing, a quick google search reveals that Danny Wedding is a Professor of Psychiatry and that Ryan Niemiec has authored another book on positive psychology at the cinema. If my search results for Mary Ann Boyd are correct (I may have misattributed) then she is a prolific author of nursing books including textbooks. It thus appears that the group have produced a large and impressive body of work between them.

Appearance and Design

There is a white background with a white rectangular title section. The articles have a white background with orange text in the article title section. The main text in the article uses a black font. Articles also detail the author, comments and tags. On the right hand panel there are links to other sites of interest, previous posts and archives. I found it very easy to navigate through the archives section – the results are displayed on a single page. Further, the articles are displayed in full rather than needing the reader to click on a tab to reveal the full article (which would take up more time).

Articles

The first article in the database is a brief commentary on the 1948 film ‘The Snake Pit’. There are links within the articles to the relevant film details in the Internet Movie Database. What is interesting here as with other blogs is that the readers can contribute to the articles in the commentaries section adding different perspectives as in this post about the film ‘Off the Map‘ which explores clinical depression. I found this review of ‘Night Watch‘ to be quite interesting because Wedding writes that he is left puzzled after watching the film which seems to have no purpose. This in itself is useful as by showing us what a film shouldn’t be according to Wedding, we can work out what a film should be and this in turn gives a value to that same film. There were a number of reviews that draw attention to films with interesting subject matter and these include reviews of Mozart and the Whale on Asperger syndrome, Das Experiment which is apparently analogous to the famous Stanford prison experiment from 1971 and Grey Gardens exploring folie a deux.

Conclusions

This is an interesting blog which publishes a few articles in a month and at the time of writing there were four archived months in 2009. The articles are brief and focus on films that the author has found interesting. Some of the reviews are longer and focus on issues related to the films. This blog should appeal to those in particular who have an interest in the representation of mental illness in films.

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The audiobook reviewed here is the ‘Borderlands of Science’ written by Michael Sherman and narrated by Grover Gardner. Gardner narrates at a moderate pace and with an expression that is able to keep the listener engaged over the 13 hours of the audiobook. Sherman’s book is about the areas at the ‘edge’ or borders of science and includes a discussion of the distinction between what he considers science, non-science and nonsense. I found myself sympathetic at times to Gardner’s arguments as he employs reasoning and evidence in his investigation of various fields. I found a central theme running through the book was that of evolutionary theory be this in the discussion of Edward Wallace’s codiscovery of natural selection and interest in spiritualism or a comparison of Darwin and Freud. Sherman is rather dismissive of Freud and psychoanalysis and relatively early in the book refers to psychoanalysis as a pseudoscience and later in his comparison of Freud and Darwin paints the picture of Freud as a celebrity in passing who’s writings have not stood the test of time in contrast with Darwin as a hero who’s greatness has increased through time as the validity of his theories have become increasingly evident. The manner in which Sherman paints the endeavours of a global body of psychoanalysts with a single label ‘pseudoscience’ is in my opinion unfortunate. This contrasts with Sherman’s discussion of the works of Frank Sulloway in establishing retrospectively a relationship between the works of great scientists and birth order supported in this same retrospective analysis with commentary on their personalities. While Sherman admonishes another author for the use of ‘confirmatory bias’ he himself applies this same bias to Freud by carefully selecting those statements made by Freud along with biographical details about him which when pastiched, caricature him as a self-styled conquistador who was preoccupied with his image and mythology. Freud has written on numerous occasions with humility imploring those who study his writings to employ them with due caution and to improve upon his theory. While there is much about Freud’s writings and approach that can be criticised he was a keen observer of human nature and had conducted basic science research and studied with one of the leading neurologists of his time Charcot before developing his methods of psychoanalysis. Freud’s writings are filled with references that will be familiar to clinicians such as the exclusion of organic states when examining the cases of ‘neurosis’ along with discussion with medical colleagues about appropriate management. This suggests that his practice was not an isolated ad hoc experimental journey led from his inner fantasy life but is instead an attempt to understand the mind through a systematic analytical process by a physician who was well versed in basic research methodology and who in his practice communicated, sought the opinions of and referred through patients to his colleagues in the medical profession. Indeed Sherman could on looking closely at some of Freud’s writings (see reviews here and here) see someone with similar values to himself as when Freud writes

‘There is no authority higher than reason’

Such parallels become obvious secondary to a thorough analysis of the relevant branch of the history of science – in this case psychoanalysis.

Similarly the field of psychoanalysis is far from an outdated model with no progress in research as suggested by Sherman but instead is supported by a variety of research studies broaching multiple disciplines (see as an example the debate (Wolpert and Fonagy, 2009)). Returning to the historical analysis by Sulloway as described by Sherman we hear of various speculations about the basis for these birth order findings. However it must be borne in mind that this is a retrospective analysis of a select group of figures. The speculation that follows can itself be considered prescience, in the sense that these speculations need to be backed up with evidence to stand on a firmer footing. These same speculations attempt to attribute a meaning that we can understand but ironically the meaning for an individual is much more likely to be afforded through the work done with an individual in therapy (depending on the objectives) than by the application of the results of group data analysis to an individual. Such group data works best at the group level but could properly be considered to offer a guide when applied to the individual because of the large number of confounders that may operate upon the relationship of interest. In addition the use of a five-factor model along with the birth-order is essentially a quantitative analysis. On the other hand an important feature of psychoanalysis which sets it up as a soft target is the use of a qualitative approach in which language and non-verbal communication aids the therapist in their role. Interestingly in communicating to the listener just what science is, Sherman is using the medium of language in a way which makes approximations and assumptions about the audience which may or may not be correct, references relationships and appeals to both reason and the emotion. In order to do so, it is reasonable to assume that Sherman values this medium sufficiently to use it as a vehicle for his message and in so doing he shares such an approach with therapists who communicate with each other through language and use language as a medium for therapy.

The end result is that Sherman espouses a view of science in which Darwin’s theory of natural selection is an example par excellence of the results of this approach. However if science is an attempt to gain a better understanding of the universe, neutral and undisturbed by our values and prejudices then our path to this understanding does not need to be constrained by a single approach – the quantitative approach generating large data sets and supported by unquestionable statistics with very small p-values. There should be a tacit acknowledgment that there are areas where the descriptive language differs – such as the languages that optimally describe the mind and the brain (see review here). Indeed it is the language of the mind that Sherman uses when he appeals to our reasoning and our emotions and which he does so adeptly. What I consider to be a hidden subtext of the validity of quantitative versus qualitative methodology is illustrated by Sherman’s quotation of an fMRI study in which the findings are used to ‘debunk’ a psychoanalytic explanation. This is done by referring to the ‘expertise’ of the neuroimaging researcher but the dangers of glossing over the many assumptions in such research have been well illustrated (see review here).

I would argue that when a subject such as psychoanalysis is reduced to a simple notion then significant elements of truth and utility get lost in the process. By this stage it is all too easy to apply the rather dubious notion of ‘pseudoscience’. As Einstein once said,

‘Everything should be made as simple as possible but not simpler’

Of note, Einstein was working as a clerk at the patent office, isolated from the scientific community when he submitted his theory of relativity for publication, a theory which would be paradigm shifting and which he no doubt recognised as such. Interestingly Sherman discusses the above characteristics but in another context in which he predicts those who do not contribute meaningfully to science.

In other parts of the book, Shermer is convincing as in his discussion of the Piltdown Man hoax and his treatment of the life of Wallace and his heretical traits. Sherman is extremely comfortable and knowledgeable in writing about Wallace and there is much to learn from the story of the cocreator of the theory of natural selection. Sherman is also comfortable in tackling controversial areas and uses his knowledge of science to convincingly address problems that do not seem to have obvious answers. Shermer’s approach polarises the subjects he explores and this can be useful in helping to make decisions that apply to those areas. At the same time, as in the case of psychoanalysis which does not adhere to Shermer’s idealised scientific method outlined above, it impacts not just on the theory but also has the potential to impact on the wider culture related to that body of theory and sensitivity is merited in any such discussion.

References

Michael Shermer. The Borderlands of Science. Narrated by Grover Gardner. Books on Tape. 2001.

Wolpert L and Fonagy P. There is no place for the psychoanalytic case report in the British Journal of Psychiatry. In Debate. pp483-487. 2009.

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The article reviewed here is a South Korean paper on ‘Ubiquitous Healthcare Service Using Zigbee and Mobile Phone for Elderly Patients’ by Hak Jong Lee and colleagues. In the introduction the authors discuss the ever more pervasive nature of technology. While noting the focus on hospital information systems, they note the possibility of using technologies to allow communication between the hospital and patients outside of the hospital. They note that a new wireless internet protocol Zigbee has been developed which offers a number of advantages including low power consumption. Such technology is being increasingly used in consumer electronics and the researchers were interested to see how this might be applied in healthcare. They therefore looked at a specific population – older adults – and wanted to see if they could monitor glucose levels and ECG’s in the community.

The study was a small prospective study (n=29) carried out in 2005. I found it slightly amusing that the 6-page article had been initially received in June 2006 and that the revised version was received in July 2008 when it was accepted. However delays between submission and publication in journals can be due to the logistics involved. I wasn’t clear on how sample selection was achieved and this will have a bearing on the results as successful use of the technology requires that the subject is able to use several technologies effectively. 9 subjects in the study received an ECG vest which they wore and which took readings every hour. If they were symptomatic (e.g. with palpitations) they would press a button to initiate a data capture. 20 of the subjects used a glucometer – to measure blood glucose levels. The subjects were trained in the necessary skills to ensure that the data was transmitted from the equipment to the web using a web-based program. A nurse contacted patients once weekly to administer a questionnaire regarding ‘convenience and satisfaction’. The details of the questionnaire were not included in the paper, nor were details regarding the validity and reliability of this instrument. Technical data regarding the equipment such as error rates were also identified.

With regards to the glucometer readings, the researchers found that information loss between the glucometer and the web-based service occurred in 22% of recordings and that this occurred at several points along the pathway including the mobile phone and a defect of the glucometer. A problem noticed by the participants was a large difference between the new wireless enabled glucometer and readings on the previous glucometer causing several subjects to withdrawal. However overall satisfaction was rated as 8.5/10 by the subjects (which most probably represents the intuitive meaning of scoring out of 10 which is commonly used outside of the research field). In terms of the ECG monitoring, some of the subjects withdrew from this part of the study due to a

‘fear of transmission of electromagnetic waves, skin eruption at the place where the ECG line and electrode were attached to the body and troublesome problems of attaching ECG‘

Interestingly only 57.9% of the transmitted data from the ECG was considered useful. The mean satisfaction score for the ECG sensor was 5.79. Discomfort occurred as a result of the ECG being attached to the body for 24-hour periods. As there was frequent transmission of data, the battery life of the mobile phones was also an issue.

In conclusion, this was a proof of principle. The technology itself proved effective here but it must be remembered that the technology does not occur in isolation but instead must operate within the wider healthcare environment. This in turn is dependent upon cultural factors, budgets, infrastructure and an appropriate evidence-base for the relevant healthcare service. Many technologies that achieve the chosen objectives and fulfill a useful function do not pass on into the mainstream as these barriers must be overcome. The researchers note that the emphasis in this study was on the technical aspects of the technology rather than the clinical utility. The rate at which data loss occurred as well as the need for participants to use several pieces of technology and the relatively small sample size means that further studies should examine the clinical utility in more detail. Glucose and ECG monitoring are potentially useful in various services and if a successful technology is achievable then it offers an opportunity for leveraging healthcare resources. Other types of monitoring device have the potential to be utilised using the same wireless protocols although this is already occurring using a variety of other technologies also. This study illustrates some of the difficulties that a technological solution to a healthcare problem needs to overcome in order to be of clinical utility. If such barriers are consistently overcome then this would enable new services to be developed and may impact on outcome measures in services.

References

Lee H J, Lee S H, Ha K-S, Jang H C, Chung W-Y, Kim J Y, Change Y-S and Yoo D H. Ubiquitous healthcare service using Zigbee and mobile phone for elderly patients. International Journal of Medical Informatics. 78. 2009. 193-198.

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The paper reviewed here is ‘Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking’ by Bonnewyn and colleagues. In the conclusion to the abstract the authors write that

‘(Painful physical symptoms) were more likely in people with a 12-month major depressive episode (MDE) than in those without (OR=2.0)‘

In the introduction, the authors cite research showing a prevalence of pain in older adults of between 25 and 88%. The authors then briefly discuss the pain-depression dyad explaining the antecedent and consequence hypotheses which expand on the nature of the dyad. The aims of the study are clearly outlined and include an evaluation of the relationship between pain and depression in a community-dwelling sample of older adults (65 years and older) as well as the interactions with the use of mental health services and benzodiazepine use.

The data was obtained from the European Study on the Epidemiology of Mental Disorders (ESEMeD) a study which was initiated by the World Health Organisation. Data was obtained from 6 countries – France, Germany, Italy, Belgium, Holland and Spain. The researchers write that some of the specifics of the sampling process have been described in another paper. I wasn’t clear on the details of the sampling method as a result and the researchers note that

‘a stratified, multistage, clustered area, probability sample was used‘

59.4% of the sample were female and 38.4% were age 75 and over. 36.3% of the sample lived in rural areas compared to 26.6% that lived in urban areas. The majority of the sample (52%) had 0-11 years of education. Participants were interviewed using the Composite International Diagnostic Interview with major depressive disorder diagnosed using DSM-IV criteria and a list of questions used to detect the presence of painful symptoms specifying within the last 12 months in some of these questions. They were also asked if they had one of a number of chronic medical conditions some of which are common medical conditiosn (e.g. asthma and diabetes). They were also asked about antidepressant and benzodiazepine use. Their estimated point prevalence of painful physical symptoms in the sample was 31.8% and although they were calculated as more common in men there was no confidence intervals for this comparison. PPS were significantly more likely in females with major depressive episode than those without. Using depression as the dependent variable, the researchers ran a multvariate analysis which identified female gender and pain as predictors of depression. Without major depression, the likelihood of antidepressant use was three times greater in those with painful physical symptoms compared to those without. For participants with depression, there was no significant difference between those with and without painful physical symptoms in the use of antidepressant medication. There was a doubling in the use of benzodiazepines in those without major depression but with painful physical symptoms (PPS) compared to those with major depression but without PPS. Major depression was also found to be signficantly associated with benzodiazepine use.

In the discussion, the authors note that from their results somatic conditions mediated the relationship between depression and pain. The authors also  comment on the two-fold increase in PPS with major depressive episode and the increased prevalence of PPS with female gender. Whilst these latter two findings were consistent with previous literature, like the researchers I found the results for antidepressant and benzodiazepine use interesting. Firstly antidepressant use was found to be higher in those without major depression but with pain. The use of benzodiazepines was increased in those with major depression also. I wasn’t clear if there was a prominent anxiety component in those using benzodiazepines but given that only 20% of those with depression were receiving antidepressants a different pattern of prescribing could be explored. This however would depend on local guidelines particularly as the sample is taken from 6 countries.

In conclusion, I thought there were some interesting findings here particularly the use of antidepressants in those with pain but not major depression. It could be that the depression had been previously treated and was in remission. Alternatively it could mean that the subject or the prescriber had intended for the antidepressants to be used for the pain. It would be interesting to see how factors such as pain duration and intensity impact on antidepressant use. The paper provides valuable insights into the relationship between pain and depression in older adults and I would be interested to see in particular if there are any follow-up studies examining the use or underprescribing of antidepressants as well as benzodiazepine in the same or other regions.

References

Bonnewyn A, Katona C, Bruffaerts R, Haro J M, de Graaf R, Alonso J and Demyttenaere K. Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking. Journal of Affective Disorders. 117. 193-196. 2009.

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The paper reviewed here is ‘Predicting Age-Specific Dosing of Antipsychotics’ by Uchida and colleagues. This is an opinion piece rather than a systematic review or research study which thus affords it more flexibility in the approach to the subject although firmer conclusions can be expected in other types of article in the evidence-base hierarchy. The authors consider the interaction between age and the loading dose for antipsychotics which the authors point out is especially important given the recent studies and reports on antipsychotics in specific populations (see here for example)*.

The authors argue citing evidence in the process, that with increasing age there is a loss both of the clearance of a drug (specific example given) and a decrease in the number of D2 receptors available for binding, a figure which decreases linearly with each passing decade. They also argue that surveys of prescribing data show age associated changes in the prescribed dose of antipsychotics for people with schizophrenia which supports the hypothesis that lower doses of antipsychotics should be prescribed in older age. This in turn is in keeping with various expert consensus guidelines. However there are obvious cultural factors that influence such prescribing and the authors note these confounders. The authors then outline a strategy for making predictions of D2 occupancy based on the plasma levels of an antipsychotic and to ensure this is applied across the lifespan. They have further studies in preparation.

Having such data is obviously extremely important and would imply that plasma levels would become clinically meaningful. There are several complexities that occur in this regards however. In older adults, polypharmacy is common relative to the population of younger adults which has the potential to influence plasma drug levels. While it can be argued that if there is a linear relationship between D2 occupancy and plasma drug levels the measured values still give useful information, such interactions may produce fluctuations in these drug levels which in turn would be expected to influence D2 occupancy. Nevertheless this argument would need supporting data. Another complexity here is that the drug clearance is influenced both by renal pathology and a number of other factors. This leads onto the point that with increasing age, comorbidity and polypharmacy may lead to an increasingly heterogenous population. This in turn may make it difficult to utilise a single model effectively and may necessitate solutions which organise this complexity in ways which facilitate prediction. This speculation also is in need of supporting data. Finally, particularly with the atypical antipsychotics, the actions have been argued to be effected not just at the D2 receptors but at a range of other receptors including other dopamine receptor subtypes, serotonin receptors, histamine receptors and so on. Thus it could be argued that an investigation of the same relationship between occupancy status and plasma drug levels could provide data contributing to more complex and realistic models.

The approach to studying lifespan changes in loading dose of antipsychotics is encouraging and it will be interesting to see the development of comprehensive age-related pharmacodynamic and pharmacokinetic models which are of clinical relevance and which can be combined with changes in practice to improve outcomes.

* The authors declare a potential conflicts of interests which include financial support from several pharmaceutical companies.

References

Uchida H, Pollock B G, Bies R R and Mamo D C. Predicting Age-Specific Dosing of Antipsychotics. Clinical Pharmacology and Therapeutics. Vol 86. Number 4. October 2009. 360-362.

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Miscellaneous

Using data from the National Epidemiological Survey on Alcohol and Related Conditions, an american study involving data on 43,000 people, older adults (over the age of 60 in this study) with alcohol dependence consumed an average of 40 alcoholic drinks per week compared to ‘between 25 and 35 drinks a week’ in the younger group. An american study is looking at whether PTSD can be predicted by incorporating a number of biological markers. The Lean Healthcare Academy recently had an awards ceremony and a hospital which implemented the Productive Ward was the recipient of an award. The Productive Ward and related Productive Series involve a systematic process to enable improvements in outcome measures such as efficiency (see review here). It is interesting to see how American and Japanese culture and technology is being used to improve care for patients in the NHS in an ever more connected world. The Productive Ward series is covered at the National Institute for Technology here. The series also includes approaches to improve outcomes in community care as well as other types of service.

News Round-Ups

Over at the Clinical Cases and Images blog there is a summary of recent news tweets. Alz Forum have got coverage of the recent Clinical Trials in Alzheimer’s Disease conference in Las Vegas here. They look at the Wisconsin Registry for Alzheimer’s Prevention study, the Memory Capacity Test and research on the CogState test amongst others. The Schizophrenia Research Forum have coverage of a recent murine study showing an association between mutations in the dysregulin gene (which has been associated with schizophrenia in genome wide association studies) and the function of fast-spiking interneurons.  Mind Hacks has coverage of a number of studies including one in which sounds presented during sleep were associated with improved learning on spatial tasks.

Psychiatry 2.0

The Google Wave tool which has been recently rolled out enables live collaboration using a number of tools and in this article Leah Betancourt discusses some of the ways this is being used in the creation, dissemination and discussion of news. Conventional methods for disseminating scientific/clinical information including conferences, journals and books are now in the process of being transformed by such tools. Another development which has the potential to have a profound impact on society, Government 2.0 was discussed at a recent conference. The idea here is that citizens can both engage with and contribute to the decision-making process of government. As an example this may impact on the way in which different segments of society are represented and this in turn could impact on health and illness on a number of levels. The American Association for the Advancement of Science has set up an expert lab to help government engage with citizens using technology and enabling them to tap into ‘crowd expertise’. There is a video on the expert lab here. In an american survey by Manhattan Research, 39% of doctors stated that they had communicated with patients online although the insurance-based nature of the healthcare system may influence such relationships. An article here looks at how doctors are using technologies such as twitter and the iPhone in their practice.  Meanwhile the Danish Government is intending to go paperless by 2010.

It is a privilege for the TAWOP blog to have been included in a list of 100 blogs for psychology students and there are many interesting blogs included in this list.

Appendix

Researchers at the Universities of Warwick and Manchester compared a course of therapy costing £800 with the effects of an increase in salary or lottery winnings. Their findings apparently showed that the £800 course of therapy produced an increase in a measure of well-being that was  equivalent to that produced by a pay rise or winnings of £25,000 causing the researchers to conclude that therapy was ‘32 times more cost-effective at increasing happiness than money’ (quote from news report).  However I wasn’t able to find the study (perhaps its preprint) and wasn’t clear on what the outcome measures were and the details of the therapy. In a press release from the company producing the devices a study (n=7) provided preliminary evidence that Deep Transcranial Magnetic Stimulation could improve scoreson measures of auditory hallucinations and psychosis. However these were described as interim results and from the limited information in the press release it looks as though a further 13 patients are to be included and so it will be interesting to further review these results when the study has been completed and submitted for publication.

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On a visit to Sandeep Gautam’s Mousetrap blog I came across this video and Gautam takes the opportunity to further discuss the contrasting Eastern and Western values in terms of illnesses such as psychosis. The video that Gautam refers to consists of a presentation by Dr Devdutt Pattanaik who describes himself as a medical doctor who has gone on to advise businesses on ideas, mythology and beliefs. I found this video interesting for a number of reasons. Firstly Pattanik gives an extraordinairy performance – a showcase for just how good a presentation can be. He weaves a narrative into his presentation with the meeting of Eastern and Western cultures. He uses some slides, but these really fade into the background because he carries the presentation through his charismatic performance. It is almost as though he is negotiating with the audience at each point. Secondly the content of the presentation is very interesting also in that he contrasts Eastern and Western lifestyle approaches. It can be argued that there is no single Western or Eastern approach, making contrasts difficult. Nevertheless Pattanaik considers beliefs about the many idealised approaches in Eastern culture, the recognition of the sheer magnitude of possibilities that are available in life and the person’s place in the greater scheme of things with a western approach which is closely aligned to success, goal setting and a single life in which to achieve all that is necessary. Pattaniak suggests that where Eastern and Western civilisations meet and these differences are not understood it will result in difficulties. Pattanaik focuses on the example of western businesses that need to adjust when operating in the East. However if such arguments are valid they have applications elsewhere. For instance with migration from East to West or West to East, families will have to adapt to these new values and this process of adaptation can influence health which is an area that has been studied extensively e.g. in transcultural psychiatry. The implication that health can be influenced indirectly by cultural mythology is on reflection quite profound. The adjustments that families make when moving between civilisations has been explored in literature and film also. Nevertheless even when there are such differences there are also many similarities. Education is assessed in both the East and West and the outcome of this goal-orientated process influences lives in both cultures. From an evolutionary perspective, competition features in a number of ways and this can itself be considered a goal-orientated process which is found in both Western and Eastern cultures whether implicit or explicit in various settings. Pattanaik’s presentation is a useful starting point for discussing cultural differences.

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The blog reviewed here is ‘We’re Only Human‘ by Wray Herbert.

Appearance and Design

At the time of writing on the left hand side of the title pane the initials APS and the words ‘Association for Psychological Science’ appear while to the right is the title – ‘We’re Only Human’. The APS initials appear at the bottom of the screen also. However I wasn’t able to find an about section. A quick google search reveals a bio on Wray Herbert who is described as having 25 years experience in writing about science and medicine and writes in a number of prestigious publications. On the right hand pane there is a link to podcasts which leads through to a website for the Association for Psychological Science. The right hand pane also contains links to past months in the archives as well as links to previous posts and an RSS feed. The background for the site is dark red, with the articles containing black text on a beige background and a brown paint-like theme running in horizontal and vertical strips across this background.

Content

Herbert writes about articles that appear in the journal Psychological Science and effectively weaves them into a narrative through devices such as the personal anecdote and the discussion of popular films. The articles typically are a few paragraphs long and summarise the material in an easily ‘digestible’ form. Herbert also covers evolutionary psychology in a number of articles also.

• The blog starts in May 2006 with an article on crossword puzzles and Herbert interprets an imaging study with altered activity in the visual and temporal cortices during task completion. There were a number of articles that I found interesting
• This article discusses research suggesting some characteristics of eye gaze in a sample of older adults and the suggestion that gaze can be a means for regulating emotions
• This article looks at a study examining the performance of autistic children and adults on cognitive tasks in comparison with a control group
• This article looks at a study examining the effects of loneliness in young and older adults
• An article on a study showing a link between the readability of instructions for exercise and the likelihood of carrying out exercise in a student population
• An article on the possible evolutionary benefits of positive emotions
• An article on research into different patterns of  internet use in adolescents with different health effects
• An article on a study looking at the relationship between walking backwards and vigilance!
• An article on a study looking at meaning making and Kafka

Conclusions

The blog is an accessible means for keeping a finger on the pulse of some of the psychology research that is coming out and which features in the journal ‘Psychological Science’. The research is varied and the articles effectively convey the meaning of the research.

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The book reviewed here is ‘Socialnomics’ by Erik Qualman and narrated by Nick Sullivan. I was interested in listening to this audiobook in order to gain insights into wider cultural changes driven by social media technology. Such cultural changes are closely intertwined with illness in numerous ways and whilst illness is not the subject of the book I expected that the material would be indirectly relevant. Sullivan gives a solid performance as the narrator, using subtle changes in intonation at time to highlight the more important material. Turning to Qualman’s work itself, I found that this covered a variety of social media technologies such as YouTube, Google and Facebook. He looks at how social media transformed politics with the example of Barack Obama’s political campaign in the run-up to his election as president. Qualman also addresses the business sector illustrating how social media will affect their relationship with customers. I was puzzled by Qualman’s use of the term ’schizophrenic behaviour’ when referring to behaviour that changed from one situation to another. I thought perhaps what Qualman was referring to here was persona, the promotion of a behaviour appropriate to the social context and indeed a little after the initial reference he indeed refers to persona. He even recognises the serious nature of schizophrenia and emphasises this when using the term although. Apart from this Qualman covers a broad range of material, suggesting future trends in places and speculating on potentially successful strategies for companies. There are a number of stories that feature throughout the work that serve as exemplars of the phenomenon that Qualman is describing. One of the themes that emerged within the book was that social media is accessed by people of all ages. Qualman also discussed how social media is influencing the relationship between employers and employees. On a broader note, I thought many of the points could be generalised to the relationship between organisations of varying sizes and individuals both inside and outside of these organisations. Thus a number of the arguments could be applicable to non-business organisations e.g. government and non-government organisations. These in turn would have some relevance to healthcare delivery on a number of levels. I found Qualman’s book to be informative and helpful in providing an overview of the influence that social media is having on wider society.

References

Erik Qualman. Socialnomics. Narrated by Nick Sullivan. Audible inc. 2009.

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The paper reviewed here is ‘The Use of Health Information Technology in Seven Nations’ by Jha and colleagues. The authors examine the uptake of electronic health records (EHR) in 7 industrialised nations – the Uk, Netherlands, Australia, New Zealand, Germany, Canada, United States and conclude in the abstract that they

‘found that many have achieved high levels of ambulatory EHR adoption but lagged with respect to inaptient EHR and HIE (Health Information Exchange)‘

The authors suggest in the introduction that there has not been uptake of EHR in all parts of the US (although the article was published in 2008) and they were interested to see how the uptake of EHR compared to other industrialised nations. This was done with a view to identifying methods of improving uptake of EHR in the US.

In the methodology, the authors describe some of the terms in more detail. Thus they describe the HIE as the transfer of clinical information from one organisation to another. Interestingly the definition of EHR that they use includes decision support tools. The authors are quite rigorous in their approach to identifying relevant information – they conduct a literature search using established medical databases such as Medline, others using search engines such as google and also make contact with recognised experts in each of the six non-US nations in the study. I couldn’t find any reference however to the keywords that were used in the medline search which would be useful for replication purposes. The authors note that there has been a recent paper providing the information they need on the US explaining why the US is excluded from the above searches.

In the results section the authors note that due to the definition of EHR that they use there were few studies that fulfilled the criteria for identifying the relevant information. The only studies that included this information examined ‘ambulatory care’ which I understand to refer to care which doesn’t require inpatient admission. The authors were able to identify relevant studies in four of the countries and needed to utilise expert opinions for the other countries. There was sufficient information on the US however. They give figures for the US and I think that 10% of single practioner practices use EHR while up to 50% use EHR in larger practices (although they had used the term HER which I suspect is a typing mistake). While the figures for Canada for EHR came out at about 20% the figures for the UK revealed uptake of about 89% in General Practices. In the Netherlands this was figure was 98% for GP’s. Figures of 79% for GP’s in Australia and 92% of primary care providers in New Zealand were documented.

In the US they identified figures in hospitals of about 5-15% although commenting that the reliability of the data was relatively low. For other countries there was data on features such as electronic prescribing but little commentary on EHR. Thus there appeared to be a consistent pattern from the available data of higher uptake of EHR in primary rather than secondary care.

In terms of health exchange information networks they identify Infoway in Canada which focuses on uptake of EHR and HIE strategies, non-profit regional health information organisations in the US and the Switchpoint in the Netherlands amongst others. The authors cite pay-for-performance as one of the factors influencing the uptake of EHR in their study. They also note that the US has a number of measures of performance but these have not in general been linked to incentives.

The authors present their data in a number of tables and their discussion extends to electronic prescribing along with a number of other recommendations. The paper is informative, the methodology clearly stated and the researchers have identified relevant contact figures for further information in a number of the nations under study. The multiple data sources is a particular strength of the study. I found in particular the comments about clearly identifying performance measures to be particularly interesting. The use of electronic health records in itself does not necessarily imply that there is a high quality of healthcare as there are many other factors which determine the quality of a service most obvious amongst which are the healthcare practitioners themselves. However it might be expected that electronic health record systems would improve efficiency of workflow, information retrieval and contribute effectively towards decision-making. This is a useful comparison of national services which could serve as a template for future comparisons.

References

Jha A K, Doolan D, Grandt D, Scott T and Bates D W. The use of health information technology in seven nations. International Journal of Medical Informatics. 77. 2008. 848-854.

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The article reviewed here is ‘Literature and Happiness’ by Norman Holland and published in the journal Psyart in 2007. Psyart publishes articles which examine psychological perspectives on the arts. In the abstract (headnote), Holland writes that

‘I maintain that we do literature because it is fun, because it makes us happy. And it makes us happy because the act of experiencing literature mimcs the brain processes of successful living‘

I was intrigued to read a little more to see what Holland meant by this. He begins by looking at the origins of the word happiness and an overlap with terms such as luck in indoeuropean languages. He then describes a modern meaning in which the pursuit of happiness is validated in a western society. Indeed this features in the positive psychology movement (see review here). He writes about reading for pleasure and as a literary critic and then discusses psychologist Mihalyi Csikszentmihalyi’s description of happiness in flow – equivalent to absorption in a task. He then equates the first type of reading – the reading for pleasure with the activation of a wanting and liking system – the neurological correlates of which are the mesocortical and mesolimbic systems. He refers to a Seeking model described elsewhere with regards to the wanting and liking systems. This is where he draws the analogy with ’successful living’ as he suggests that the cycle of wanting and liking are routine and exclusive drivers of our behaviours. With regards to literary criticism he relates this to activity within the peri-aqueductal grey matter (PAG). The connection he makes is with a theory of ‘personal style’ described elsewhere in which the PAG plays a prominent role.

In terms of other articles reviewed previously this has a different tone far removed from papers describing studies with quantitative and qualitative methodologies. The article is essentially an essay in which a structured hypothesis is described. There are various methodologies that could be used to explore this model in further detail ranging from focus groups through to surveys and imaging studies. Nevertheless this ‘top-level’ informal-at-times discussion is just as valid as rigorous qualitative or quantitative studies in that it disseminates a speculative model which can lead to further discussion. There are many reasons for reading and many functions that it may satisfy as well as numerous brain regions or systems that may be involved in the process quite apart from the PAG, mesolimbic and mesocortical systems although each should start with a suitable evidence to justify their inclusion in the model. Is my peri-aqueductal grey matter helping ‘me’ to write this review? I’m not entirely sure, but until I’d read this paper I wouldn’t have entered my stream of consciousness. There at least it has already had some success.

References

Holland N. Literature and Happiness. Psyart. Gainesville. 2007. I page. ISSN: 10885870.

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The paper reviewed here is ‘The Role of Genetics in Delirium in the Elderly Patient’ by van Munster, Rooij and Korevaar. In the abstract van Munster and colleagues write that

‘Two important gaps in daily practice with delirium are the pathophysiological obscurity and the low recognition rates. Genetics offers the possibility to contribute knowledge to both of these gaps with its unique and diverse techniques‘

The authors give an overview of delirium in the introduction before going on to consider the syndrome of delirium. They consider the difficulties of diagnosis given the relatively short window of time which may be available to make the diagnosis as well as a number of other practical issues. The authors consider briefly and in turn several hypotheses about the aetiology of delirium including the dysregulation of dopamine or acetylcholine, the stress response and the immune response particularly the response involving cytokines. The authors then go on to consider the genotype and phenotype of delirium.

The authors hypothesise that if genetic risk factors are present, the precipitants for an episode can be ‘milder’. They also suggest that the study of the genetics of delirium is comparatively more difficult than with other diseases as the average age of onset of delirium may be causally related to the relative dearth of twin studies in this area. They then look at the methodology of genetic studies including the gene-wide association studies and look at some of the advantages comparing them with invasive procedures.

They use the broad categories describe above to suggest some suitable candidate genes which are listed in table 1. These can be compared with the genetic studies that have already been carried out and which are described in a later section. A number of the studies examining APOE4 associations for instance have not produced such interesting findings. The authors conclude with some suggestions of how future studies can facilitate a better understanding of the role of genetic factors in delirium including cohort studies.

I was persuaded by a number of the arguments particularly the suggested model combining precipitants with the genetic risk factors. While there is no explicitly stated methodology for the construction of the paper the authors have used a systematic approach towards the article which identifies a list of candidate genes as well as justifying an investigation into the genetics of delirium as well as highlighting potential difficulties of such an approach. This is a young field and articles such as this provide a useful overview.

References

van Munster B C, de Rooij S E and Korevaar J C. The role of genetics in delerium in the elderly patient. Dement Geriatr Cogn Disord. 2009. 28. 187-195.

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An independent report by Professor Sube Banerjee, commissioned and funded by the Department of Health on the use of antipsychotics in dementia has been published (freely available here). Professor Banerjee has considered the evidence base including systematic reviews and meta-analyses regarding the use of antipsychotics in dementia and the report contains an estimate of the national morbidity and mortality associated with the use of antipsychotics in dementia. The report recognises the need for antipsychotics in certain situations and goes on to make a series of recommendations which focus in particular on clinical governance, recommendations which should lead to an improvement in the quality of care. The government have produced their response to this document (freely available here) and support these recommendations indicating that a national audit of antipsychotic use in dementia will be undertaken initially at six-months and then annually for at least three years and that the National Clinical Director for Dementia will take on a leadership role in this area. The Royal College of Psychiatrists has welcomed the report and responded here emphasising the need for input of specialist older adult mental health services. The response of the Alzheimer’s Society who have also welcomed the report is here. NHS choices have coverage of the report here.

The 26th Annual Pittsburgh Schizophrenia Conference took place on November 13th 2009. An 11.7T MRI scanner is being developed in France through a pan-European partnership and is due to begin operating in 2012. In a press release from the company that undertook the researhc, in conjunction with university researchers, the gene product for the gene Rps23r1 was associated with a reduction in two Alzheimer’s Disease related proteins amyloid beta and tau in a murine model. A recent study involved 205 Norwegian couples and used ‘client feedback’ therapy during problematic episodes in their relationship. At 6-months after the last session, the researchers reported a 50% reduction in divorce or separation rates compared to those who did not receive this intervention. The approach is described as patient focused research (the Research Advocacy Network has more information on this).

News Round-Ups

The ‘Heal My PTSD’ blog has a news round-up which includes the use of telemedicine for PTSD. Mind Hacks has another episode of Spike Activity where he reviews the news including a link to a study showing an association between creativity and horizontal eye movements, adding to previous research suggesting an association with recall of information.

Psychiatry 2.0

The FDA has convened the social media hearings to examine the issue of regulation of pharmaceutical companies use of social media and this has been widely discussed in the mainstream media, the blogosphere and the twittersphere. An article here has lots of discussion in the comments section.

This BBC article looks at Google Wave and includes a interview with the founders and some examples of use. Google wave is a collaborative tool that is described as facilitating the linking of ideas and data, allowing for instance data to be inserted relatively easily by multiple authors into a collaborative document. There is further coverage of Google Wave applications in this article which contains an embedded video and lists uses including research where Google Wave has provided benefits. The ICS healthcare blog has an article on how the doctor-patient relationship might be changing due to the influence of factors such as health 2.0. Ted Eytan in his blog has coverage of a study published in May that involved a focus group of patients who use the internet. The findings included an expressed interest by the people in the study to have access to their medical records. ‘360 digital influence’ discuss trends in the use of social media by doctors here including a look at research in this area. John Grohol has an article at PsychCentral on how ‘first impressions count’ online and argues that these impressions are formed through inspection of photographs and he also reports on a study looking at Facebook use which is due for publication next year. There is a presentation available here on how web 2.0 might affect education. The Gov 2.0 conference is due to take place online on December 10th 2009. Biomedcentral has an open-access article on a ‘database of everything’. A German petition is currently underway requesting that all publicly funded studies should be made available through open-access articles. The ZZoot blog has coverage of a recent workshop on the future of the semantic web for scientific communication. In this article there is a look at an organisation which matches researchers with research participants.

Evolutionary Psychiatry

Dr Shock has a link to a video showing that squirrels work together to recall where food is located in the environment. The combination of social cooperation and memory abilities displayed here may be important in understanding similar abilities in primates including humans. Recent evidence suggests that the Sahara may have experienced wet periods roughly 120,000 years ago and 50,000 years ago and that this may have facilitated the migration of early humans across the Sahara. There is an article at Live Science on the decreasing size of the human brain over the last 10,000 years which asks the intriguing question ‘is our evolution accelerating?’. The FOX-P2 gene product in chimpanzees was found to behave differently to the gene product in humans in a recent study which might contribute to an explanation for the absence of spoken language in chimpanzees.

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The blog reviewed here is ‘Psychotherapy Brown Bag. Discussing the Science of Clinical Psychology‘.

Appearance and Design

The background is white including in the title pane. The title pane features what looked to me like a series of progressively fading blue trees. However this might be a concrete interpretation. So they could also be letters (o, p and q) which is consistent with the image of a blog (words) or people with the tear drop shapes representing heads (so looking from above it would be a group of people huddled together) which would fit with psychology (maybe this is a variant of the Rorschach test!). Just below the title pane is an index – here the reader can navigate using the archives menu while there is also an ‘About Us’ and ‘Links’ section (amongst others) that can be accessed. The articles occupy the left two-thirds of the screen. On the right hand one-third of the screen there are a large number of features – a search bar, twitter, options, RSS feed icon, subscribe option, recent comments, recent posts and categories as well as adverts. At the end of the articles themselves there are a number of options including the ability to disseminate the articles using social media tools as well as a rating system.

Articles

The first article in the archives is from February 2009. A number of articles contain a number of references to the research literature, suporting the main arguments in the articles  themselves. Many of the articles give an overview of a topic (e.g. Distress Tolerance in Problematic Behaviours). In an article on binge eating, Anestis explains the diagnosis in more detail and also includes links to a number of books on the subject. In this article, he explores impulsivity in detail. The authors cover current research, discussing studies in detail. For instance in this article, there is a discussion of a study looking at an interesting (almost abstract) computerised therapy for social anxiety which showed promising results. Indeed there is a series of articles on online treatment approaches for different conditions (e.g. insomnia). Michael Anestis, doctoral candidate in clinical psychology, writes two interesting articles on dialectical behavioural therapy and explains how this can be used with a mindfulness-based approach (see here and here). The authors also look at the use of approaches to specific contexts  (e.g. see this article). A number of the articles address commonly posed questions such as this article on why group data is useful for informing individual therapeutic approaches. In an article about a related topic, Anestis addresses the role of clinical intuition versus actuarial approaches to decision making. A number of articles such as this one on Post Traumatic Stress Disorder look at changes that might take place in DSM-V.

Conclusions

The ‘Psychotherapy Brown Bag’ blog is in my opinion an excellent resource for those wanting to learn more about different forms of psychotherapy both from an experiential and more prominently an evidence-based perspective. The authors have written a number of very interesting and useful articles on pragmatic issues and have utilised a systematic approach in doing so. They also intersperse these articles with commentaries on contemporary issues for instance news stories reported in the media.

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The Royal College of Psychiatrists Podcast series has a new podcast featuring an interview with Dr Simon Moore, a clinical psychologist based in the Cardiff School of Dentistry who was involved in a longitudinal study published in the British Journal of Psychiatry in which there was found to be a significant association between ‘excessive’ childhood consumptions of confectionary and conviction for violent crime by age 34 (available here). Moore suggested a number of mechanisms including impulsivity and delayed gratification that could account for this association.

On a slightly related note I also watched one of the recent Horizon series which is available here (see restrictions however) titled ‘Why do we talk?’.  Although obviously not a podcast, I thought this was a very interesting episode which looked at the development of and origins of language. The episode features a researcher who has captured footage of his child learning to talk and is in the process of analysing a considerably large data-set. An example was given of the child gradually shaping the words ga ga into water. They also include footage of EEG activity in a baby while the mother speaks and there is also a brief interview with Noam Chomsky who proposed that language is innate. I was surprised to see footage of animals including dogs vocalising and to see that the position of the laryngeal apparatus was changed during the vocalisation process thus countering the prominent suggestion that humans are able to speak because their laryngeal apparatus is found inferior to the placement in other species. This apparently increases the range of movements that are available but increases the risk of choking (also the larynx is higher in human babies although it has been suggested that this doesn’t significantly reduce the range of available movements – also in the same article there is the suggestion that the larynx descended as far back as 600,000 years ago in Homo Heidelbergensis). The result of this evidence is that there is likely to be another explanation for humans having language and not chimpanzees for example. This means that the explanation is most likely to be found in the central nervous system. In this regards they also talk to some of the researchers and subjects who were involved in the research that led to the discovery of the FOXP2 gene which has been implicated in a number of conditions. Indeed only recently there was found to be a difference between the behaviours of the human and chimpanzee gene products at the cellular level. This has also been an area of interest in the study of Neanderthals where the version has been found to be the same as in humans and is intriguing in light of recent suggestions that Neanderthals and humans interbred although it is still unclear if there was any contribution to the modern human gene pool. There was then an interview with an autistic man with quite remarkable language abilities having learnt over 20 languages. During the interview he is observed learning a number of words from a new language (to him) and does this effortlessly and the researcher suggests that this in some way relates to an ability to master the rules of language although this is an entire topic in itself. There is also a fascinating look at a male finch that was reared separately from other members of its group and learnt to produce a rudimentary song. What was interesting here was that when the offspring was reared together but away from other members of the group that were able to produce full songs, they were able to improve their songs with time and were soon producing complex songs familiar to their species. This reminded me of one of Steve Pinker’s books on language in which he described how children were able to develop creole language without the intervention of adults. This seems to be consistent with Chomsky’s theory of an innate grammar. I thought this was an excellent episode which drew together many different lines of investigation to shed light on human language.

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The audiobook reviewed here is ‘Generation Text’ by Dr Michael Osit and narrated by Dan John Miller. The narration is clear with effective intonation helping to convey the material in an engaging style that keeps the attention of the audience. Osit writes about the impact of technology on children and offers advice to parents of children from the ‘text generation’. Osit doesn’t focus on research in this area but instead uses his experience as a child psychologist as well as his insights as a parent. As this is a relatively long work – the audio was over 10 hours long – the book explores a number of issues. Osit discusses some of his observations of the effects of trends in technology applications in society on child development. He supports these observations with case scenarios. On the basis of his experience as a child psychologist, he discusses some of the difficulties that children and adolescents face and offers parents guidance in this area. Thematic throughout the book is his suggestion that parents use a systematic process for parenting and this is supported by examples of behaviour that Osit recommends so that the reader can model this behaviour if they agree with it. A particular strength of Osit in this book is his ability to identify some of the wider technological trends in society that could impact on development, to identify possible problems and to suggest solutions. As the book covers many areas it will be interesting to see the results of research in this area as it becomes available.

References

Michael Osit. Generation Text. Narrated by Dan John Miller. Brilliance Audio. 2008.

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The paper reviewed here is  ’A Comparison of Psychiatric Consultation-Liaison Services Between Hospitals in the United States and Japan’ by Kishi and colleagues and freely available here. As the title suggest, the researchers make a comparison of consultation-liaison services in Japan and the United States and in the abstract there are a number of conclusions drawn. They begin with an introduction to their study. The researchers briefly describe some of their expectations of a comparison between the services in the two countries in this section.

The researchers describe their method in the next section. The researchers selected hospitals in Minnesota, USA and Kanagawa, Japan for the study. They write that cultural differences between the two countries might be reflected by the patterns of referrals to liaison services. They also state that the period of study was related to a change in the reimbursement fees for consultations although I wasn’t sure of the temporal relationship between the study period and this change. The catchment area of the Minnesota hospital was 3 million and in the Kanagawa hospital was 1 million. The researchers describe the data that was recorded during the study period. The researchers justify their use of an adjusted Length of Stay (LOS) figure which incorporates the timing of the consultation.

In the results section, there were significantly more men in the Minnesota sample (p=0.040), significantly more of the subjects were married in the Kanagawa sample – indeed almost twice as many proportionally (p<0.001) and significantly more employed in the latter sample (p=0.001). Surgical referrals seemed to be proportionally much higher in the Kanagawa sample than the Minnesota sample while the reverse was true for intensive care referrals although chi-squared and p-values weren’t displayed in the table for these figures. Interestingly almost twice as many referrals (proportionally) in the Minnesota sample had a past psychiatric history and this was highly significant (p<0.001). ‘Chemical dependency’ was the most common cause of referral in the Minnesota sample and ‘evaluation’ in the Kanagawa sample and both were significantly different from their counterpart values (i.e. in the other cities). Delirium was the most common diagnosis in the Kanagawa sample and depression in the Minnesota sample and again both proportions were significantly higher than those in the counterpart populations.

In the discussion, the authors suggest that cultural factors might not play a role in the differences in prevalence of depression between East Asian countries and western countries (however an interesting study is reviewed here). They then suggest that in Japanese culture there is a focus on the collective rather than the individual and that this may influence interactions with mental health services. They also comment on referrals from physicians to psychiatrists for ‘psychosocial issues’ which was a frequent finding in referrals. In their discussion the authors note a number of limitations to the study including the lack of controls which would be helpful in better understanding the cultural differences. Additionally they note that the selected hospitals may not be representative of other teaching hospitals in the respective countries.

As this was a comparison of retrospective data and they were interested in characteristics, the absence of primary outcome measures meant that in effect this was an exploratory analysis and adjustments may help to clarify which are the most interesting findings. It would be interesting to explore the findings with regards to referrers and diagnoses using a different paradigm e.g. case-controlled registry-based studies.

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The paper reviewed here is ‘Somatic Awareness in the Clinical Care of Patients with Body Distress Symptoms’ by Bakal and colleagues and freely available here. The authors describe Body Distress Symptoms thus

‘Symptoms of somatic or body distress (BD), more widely known as medically unexplained symptoms (MUS) or functional somatic syndromes, are characteri(s)ed by patterns of persistent physical complaints for which adequate examination does not reveal specific pathology’

Thus the authors equate Medically Unexplained Symptoms, functional somatic syndromes and symptoms of body distress in their definition. The authors go on to justify their favouring of the term BD and cite evidence suggesting that reattribution therapy which attempts to move the explanation for functional bodily symptoms to a psychological cause does not lead to an improvement in outcome measures. However the article is concerned with BD rather than RT meaning that the efficacy of RT would be explored in more detail in a systematic review which may result in more complex conclusions. The authors then go on to discuss the origins of Bodily Distress Disorder (BDD), discussing the three factor model and then focusing on how core symptoms might relate to the regulation of breathing.

I disagreed with the section on ‘depression and sadness in context’. While it is important to distinguish between ‘normal’ sadness and depression (for which there are many diagnostic criteria) the authors also make some suggestions about prolonged antidepressant use and then finish the section by stating that they do not think that antidepressant treatment is the answer. I would argue on the other hand that appropriate treatments are made only after a carefully considered assessment and that recommendations regarding the optimal treatment strategies should be guided by this individual assessment, the evidence base and the local treatment protocols.

The authors answer some of these points in their section on tacit knowing and somatic awareness. Even here I would argue that they are discussing an area which includes the clinician’s intuition and that where this is carefully honed it should be consistent with related areas such as the clinical evidence base. I would argue that the clinical evidence base is not an area distinct from clinical accumen but is an investigation of clinical data and an attempt to draw meaningful knowledge from this area. The definition of ‘tacit knowledge’ adds an air of mystery by referring to knowledge at the periphery of attention. Within this section, the authors refer to non-verbal material which the physician may use during the clinical process. Such ‘tacit knowledge’ can be systematically converted into explicit knowledge by a close study of such phenomenon and indeed various methods for measuring such factors have long since been developed and employed both in clinical practice and research.

I found the discussion of somatic awareness to be a more interesting contribution if we consider the mind to be both a function of brain as well as being better described by a symbolic system that differs from that used in discussion of the ‘brain paradigm’ (e.g. see here). I was interested however to find out a little more about how the authors intended to align ‘neurobiology’ and ‘consciousness’ as according to the paradigm discussed in the previous sentence this might not be a suitable starting or indeed end point. The authors invoke some of Damasio’s thoughts on the mind-body relationship. My interpretation of what the authors were trying to say was that there is mind-brain-body relationship and that as the body is involved in this relationship it can serve as the focal point for discussions and that this is just as valid as making the mind or the brain the focal points. The justification for this would be that any ‘focal’ point is in itself a simplification of the more complex relationship that occurs between the three and so it doesn’t matter which of the triad serves as this focal point it will still be a simplification and explanations will always return to the complex interactions between mind, body and brain. However by using the body as a focal point for this discussion, the model is apparently made more accessible.

In the final section the authors consider how ’somatic awareness’ might be incorporated into medical practice. Again I disagreed with many of the points in this section. For instance, the withdrawal of medication was difficult to justify as patients may be on a number of medications for different conditions. Although some may not be prescribed as psychotropics they may in some cases have such side-effects and it would be useful to see the management suggestions in such cases where withdrawal is not possible. As above, a blanket statement about medications does not address the complexities of individual needs and even on a theoretical basis there are many counters to this suggestion. Encouraging a focus on introspection and monitoring both symptoms and bodily sensations seems to be a useful approach that could be developed further in a subsequent article again with reference to the evidence base.

In summary, the authors broach psychosomatic issues by consideration of ‘body distress’ although I found a few statements that seemed axiomatic and could be argued to be too simple to address the complexities of individual needs without careful consideration of process, the evidence base and consequences. It is useful however to have discussions in this area.

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The reviewed article is ‘Depression: An important comorbidity with metabolic syndrome in a general population’ by Dunbar and colleagues from 2008 and freely available here. In the abstract the authors conclude that

‘Metabolic syndrome was associated with depression but not psychological distress or anxiety‘

So is it possible on the basis of this study to draw the above conclusions. The researchers completed three cross-sectional studies in rural Australia. The first thing to say is that as the study was conducted in rural Australia the findings might be specific for this population. It seems more likely that this should be generalisable. However if we consider urban versus rural settings for instance a number of other factors come into play ranging from the structure of health service provision through to social networks and lifestyle which might influence either metabolic syndrome or depression or both. Men and women ‘aged 25 to 84 years were selected from the electoral roll’ by a random sampling method. I couldn’t find a reference to the type of random sampling method that was used but it is reasonable to suppose that there was no obvious selection bias as a result other than the self-selection that results from participation. The authors do note however that the study did not include those that had left the region and this is relevant in the context of the above point about urban versus rural settings. The researchers identify a number of outcome measures including psychosocial factors and factors relevant to the diagnosis of metabolic syndrome such as fasting glucose and waist and hip circumference. The criteria for metabolic syndrome were clearly identified. The researchers also used the Hospital Anxiety and Depression Scale, a commonly used scale which aids the assessment of depression in the hospital population. However the authors also used the ‘Kessler 10 measure’ which I wasn’t familiar with and describe it as a five-point likert scale where cumulative scores result in categorisation into low and moderate-high levels of ‘psychological distress’ in the last 4-weeks. The internal consistency values for K10 and the HADS subcomponents were provided ranging from 0.79 to 0.87. The primary outcome measures (or at least I presume they were the primary outcome measures) were clearly stated and the author examined the relationship between anxiety, depression and the metabolic syndrome. The statistical analysis of other relationships between the many variables that were used in the study was also clearly stated. 409 subjects met the criteria for the metabolic syndrome and a comparison was then made between those with and without the metabolic syndrome. I didn’t particularly understand the following within the results section

‘Participants with the metabolic syndrome were more likely to have moderate to severe depression (10 vs 6.9%, p = 0.069)‘

In the remainder of the sentence the authors write that with regards to another measure there was no statistical significance. However the p value above would not be significant either (at the 5% level). However the researchers did find a significant difference between metabolic syndrome and the diagnosis of depression (i.e. without reference to specific subtypes such as moderate or severe) and this time the difference reached a significance of 0.013 and depression scores were 3.41 versus 2.95. Thus there is a mean difference of roughly 1.5 points on the HADS depression subscale (I presume that it was this subscale although not stated explicitly in the sentence) at the group level.

So the relationship appears significant but the direction of this relationship is unclear as it was a cross-sectional study. A longitudinal study might be able to shed light on the directionality of the relationship. The authors speculate that an inflammatory pathway might mediate the link between depression and the metabolic syndrome.

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News in Brief

The National Institute of Clinical Excellence has released guidance on mental wellbeing at work. The document has a wide audience including members of the public (where applicable in the UK) and complements previous NICE guidance in the workplace. The quick reference guide contains 5 recommendations relating to strategic/coordinated approaches to mental wellbeing, assessment of opportunities for wellbeing of employees, flexible working, the role of line managers and supporting micro, small and medium-sized businesses. This has been widely reported with a number of articles looking at how these recommendations might impact on health services themselves (see here, here and here). This comes at the same time as a report by the Chartered Institute of Personnel and Development (CIPD) which produced findings from a survey of 2000 employees which included results relating to mental health (covered here). The researchers in an american study covered here found that of 472 million prescriptions for psychotropic medications prescribed between August 2006 and July 2007, only 1/4 were prescribed by psychiatrists. Virtualised desktops save time in booting up the computer and in this article a proprietary system using virtualised desktops was suggested to save clinicians 30 minutes on average each day

Research in Dementia

There is coverage here of a 20-year longitudinal study published in Neurology which identified associations with the development of mild cognitive impairment and it will be interesting to see how these findings inform further research in this area. This article looks at another study published in Neurology this time on Frontotemporal Dementia (FTD) and finding that 42% of subjects had a family history on the basis of a related outcome measure  (see here for further information). There is coverage of the recent Society of Neuroscience conference in Chicago over at the Alzforum and this featured a number of presentations on Alzheimer’s Disease.

Research in Pervasive Development Disorders

A neuroimaging  study (n=88) compared people with Asperger Syndrome and Autism with controls and found a significant difference between the Asperger and Autism groups in terms of structural MRI findings with the latter group having increased grey matter volume in the frontal and temporal lobes (Toal et al, 2009). However it will be interesting to see this data be included in a meta-analysis with other similar studies as well as to see the findings of larger replication studies. This study is timely given the recent discussion about dropping the diagnosis of Asperger Syndrome (see below).

Research in Psychosis

There is a discussion here of some of the recent genetic evidence of similarities between Schizophrenia and Autism in terms of analysis of copy number variants. The possible role of a form of interneuron known as the gliaform cell in psychosis is discussed in this article.

Publications on Affective Disorders

The National Institute of Clinical Excellence has released guidance on the treatment of depression in people with chronic health problems – the quick reference guide is here. A small case series which looked at deep brain stimulation for severe depression provided some evidence of efficacy although given the sample size, it will be interesting to see the outcome of a relevant systematic review or meta-analysis which incorporates this data.

DSM-V

There was discussion recently of the diagnosis of Asperger syndrome being dropped from the next edition of the DSM and this will mean an expansion of the autism diagnostic category. This was originally discussed in a New York Times article (which requires (free) registration). The article features an interview with Dr Catherine Lord, who is one of 13 members of the working group on autism and neurodevelopmental disorders. The group are considering a number of amendments to the autism diagnosis including the addition of comorbidity that have been associated with the condition including disorders of attention and anxiety. However the suggestion regarding Asperger syndrome has not yet been ratified by the group. There have been a number of responses in the media. This article contains interviews with a doctor who runs a clinic, a parent of a child with Asperger’s syndrome and the president of a non-profit organisation for raising awareness of the condition. There is some information on the DSM-V process here.

Psychiatry 2.0

There is further discussion of the DSM-V Asperger syndrome diagnosis on the left-brain, right-brain blog and at the time of writing there are 87 comments, testimony to the interest this discussion is creating. Dr Grohol also covers this over at Psychcentral. At the ISCI healthcare blog there is an article looking at some of the ways in which twitter is being used in healthcare. MindHacks has another news roundup in ‘Spike Activity‘ and included is a link to an interview with Terry Pratchett about Alzheimer’s Disease. The ‘Heal My PTSD‘ blog contains a round-up of Post-Traumatic Stress Disorder (PTSD) news including the use of a virtual reality environment for re-experiencing trauma as part of a therapeutic intervention. This BBC article looks at some of the ways web 2.0 technology is being used by the research community. Patients in the USA are beginning to carry their healthcare information around with them in iPhone apps as reported in this article. The Science in the Open blog has an article looking at how an open collobarative framework might change science (Science 2.0) with the possibility of the science being separated into data acquisition, data analysis and dissemination of results. An article here looks at recent research which counters the argument that use of the internet has casued people to become more isolated. They cite research which suggests that people are not more isolated than in 1985 and elsewhere that people who use the web regularly are more likely to participate in social activities such as meeting up with friends . See here for more information.

Miscellaneous Research

A study of babbling in babies (covered here) found evidence that after only an hour’s exposure to a new language, the baby’s babbling with the speaker of that new language differed from that with speakers of the native language.

References

Toal F, Daly EM, Page L, Deeley Q, Hallahan B, Bloemen O, Cutter WJ, Brammer MJ, Curran S, Robertson D, Murphy C, Murphy KC, Murphy DG.Psychol Med. 2009 Nov 6:1-11. [Epub ahead of print]. Clinical and anatomical heterogeneity in autistic spectrum disorder: a structural MRI study.

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The podcast reviewed here is another in the University of California in Los Angelos grandround podcasts. This could more properly be called a videocast. This episode focuses on the genetics of late life depression and is presented by Associate Professor Warren Taylor. The audio and video quality are both of a high standard and I found it easy to focus on the content of the presentation. Taylor looks at a number of the risk factors for and associations with late life depression. He then focuses in particular on the genetic associations suggesting along the way that these might be indirect, mediated through vascular pathways for example. Taylor then discusses some of his own unpublished research going through some of the primary outcome data as well as the exploratory analysis. I thought this was a useful overview of an expanding area of research. I’ve been impressed by the UCLA grandround podcasts and like the Maudsley debates which are also available in podcast format this seems to offer a very useful model for psychiatry departments to communicate information about some of their activities. This opens up a number of other possibilities that range from seeing what people in the field are doing through to gaining overviews of a more specialised area of interest. It will be interesting to see if this podcasting approach expands into other departments. This episode is another interesting addition to the series.

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The blog reviewed here is ‘FABLE‘ an acronym for ‘Fictional Autobiography of Life Experience’. I first came across the blog via the author Cole Bitting’s Twitter profile after exchanging a few messages with him on Twitter. So here are the results of my look at the blog….

Appearance and Design

The title pane consists of the blog title with an effective shadow effect on a woody background. The main background is a slightly off-black colour (i’m not particularly good at naming some of these subtle shades of colouring!) with white text. Individual articles are demarcated by a white dotted line at the end of each post. The reader can navigate by selecting the page numbers at the very bottom of the page. On the left hand side there is a link to a descriptions of songs that Bitting refers to in the text. There is an About section in the title pane and on the left hand pane there are links to an RSS feed as well as links to Web 2.0 resources such as Twitter. There are also occasional images that complement the text.

Articles

The first article is dated 28th September 2009. In this first article, Bitting tells us about fables and our relationship with them. Within this first article Bitting also tells us of the high regard in which he holds Damasio’s work ‘The feeling of what happens. Body, emotion and the making of consciousness’. I, like many people have found Damasio’s writing accessible and extremely interesting and used this in the foundations for the building of a model of the role of the Insular Cortex in emotional regulation as Damasio’s work has influenced people such as Craig in his development of a model of the Insular cortex (see here). In the second article, which is philosophical in nature, Bitting produces one of the statements which will feature again in the blog – the distinction between what is useful and what is truthful. As I understand it, Bitting is arguing that when a narrative is formed does not necessarily represent an underlying truth but instead relates to utility. In this ‘Perspective: Objectify Yourself, Witness Life’ article, Bitting discusses some foundations for the neurobiology of first person perspective and what I found really interesting here was his use of triangle and inverted triangle symbols for concepts creating an effective symbolic shorthand. In ‘Open Up, Confront the Fury’, parts 1 and 2 (of a 3-part essay – with the final part not published at the time of writing) Bitting looks at how writing can be an effective means for confronting and managing disturbing emotions (in psychodynamic terms this is equivalent to sublimation). However this is quite thematic in Bitting’s writing.

Summary

If I were to summarise Bitting’s writing, I would characterise an underlying theme of exploring the neurobiology of narrative therapy using Damasio’s works as a foundation for this process. However, Bitting himself has an elegant style of writing with emotional depth and so the reader is able to enjoy his writing on another level while exploring what is a fascinating area of inquiry.

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The audiobook reviewed here is ‘The Beginner’s Guide to Dream Interpretation’ by Clarissa Pinkola Estes who also narrates the audiob0ok. Firstly turning to the narration, I thought this was exceptionally good. Compared to the narration in the previous audiobooks I have reviewed here, which have also been of an exceptional quality, Estes brings a unique approach.  She uses a style which gave the impression of listening in to her having an informal conversation interspersed with relevant anecdotes and always in a very light-hearted manner. She is able to do this while covering the introductory material to dream interpretation. There was some overlap with material covered by John Betts in his excellent podcast series on Jungian Analytic Psychology (e.g. see reviews here, here, here and here which link to relevant episodes). Thus we see familiar themes such as the benefits of keeping a sleep diary and Estes refers in the work to Jung’s approach to dream analysis. As this is a relatively short introductory guide to dream interpretation it serves the purpose of informing those new to the field as the title suggests and Estes attains this goal succinctly by explaining the central concepts while holding the listener’s attention. What I found particularly interesting in this book was the description of the common types of dreams that occur across many cultures including falling, flying and animals amongst others. Indeed listening to this list triggered one of my recent ‘forgotten’ dreams and perhaps reinforced that many of my dreams would fit into these common themes (although it could of course be coincidence!). However another fascinating resource reviewed earlier on the blog – the Dream Journal (see review here and site here) consists of dream narratives entered by members of the forum. A look at this at the time of writing revealed common themes or content in dreams including friends, relatives, searching, ‘peaceful’, fear, water and driving! While this is not a formal research area and members are self-selected (meaning it might not be representative of the general population) there are sufficiently large numbers of dreams to be able to ask some interesting questions. This site also shows that inquiry into the subject of dreams can follow both a qualitative and quantitative approach and while it is inherently difficult due to the nature of dreams it is not unreasonable to expect that such study will (and has) produced useful results. It is interesting to note that dream analysis has preceded the psychoanalytic movement and indeed the more formal analysis dates back many centuries. Nevertheless the Swiss psychiatrist Carl Jung contributed many valuable insights into this field and as Estes is a Jungian analyst she is able to communicate many of these insights to the reader. I found this to be a very useful resource for those new to the field of dream analysis.

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The article reviewed here is ‘The Alignment of Information Systems with Organisational Objectives and Strategies in Health Care’ by Bush and colleagues. In the conclusion in the abstract the researchers ‘confirm’ that alignment of IT is an important area in healthcare organisations and that

‘Finally, it contributes by suggesting future study of alignment’s predictors and effects in health care organi(s)ations‘

In the introduction, the researchers distinguish between strategic alignment of information systems and short term developments which are responses to new technology and use in other services amongst other reasons. They identify clear research questions such as the process by which healthcare services choose their information systems as well as barriers and incentives for managerial uptake of IT. They then cite evidence which supports their central argument for the importance of alignment of strategy and IT and examples of failure of IT systems when there is no clear alignment.

The researchers then describe the methodology for their study. They have identified ‘20 healthcare organi(s)ations in a mid-western US city’. There weren’t explicitly stated inclusion criteria for the selected organisations and the researchers note that they chose a heterogenous group of organisations to represent variation in healthcare services. A structured interview was used but I thought the methodology for analysis of subject’s responses was not clear. The researchers identified people within the services who procured the IT systems and approached them to participate in the study.

The organisations chosen included a mental health service, acute and chronic care (presumably general medical) settings and outpatient clinics. The data on employee numbers and information system details are included also. There are a large number of sections in the results section corresponding to the components of the interview. They identified a number of strategies within the organisations that were objectives for alignment with IT systems and these included patient safety, growth, technology focus and staff development. They then describe the results for methods that managers used to choose IT systems. These methods included formal evaluation, return on investment analysis and ‘board of directors approval’. They then described the interview results relating to factors which supported uptake of IT systems. The key actions for managers which contributed to uptake seemed to be site visits. With regards to organisational characteristics facilitating uptake subjects most commonly thought this to be the involvement of senior management. Managerial actions which perceived to hinder uptake included involving ’stakeholders too little’, ineffective communication and the decision making process itself. The hindering characteristics of the organisation included a ‘lack of management support’, ‘lack of resources’ and ‘resistance to change’ amongst others. The researchers then propose a system for alignment which involves identifying the organisational strategy, envisioning the information system through to implementation.

The study produced some interesting results although I would have been interested to learn more about the methodology for the analysis of results. The results here are higher level and subsequent research can move in various directions from the use of a different sample set with other specificied qualitative methodologies through to the use of quantitative methodologies including large surveys and cost-benefit analyses of information technology uptake when services have been stratified according to the results of the study.

References

Bush M, Lederer A L, Li X, Palmisano J and Rao S. The Alignment of information systems with organisational objectives and strategies in health care. International Journal of Medical Informatics. 78. 446-456. 2009.

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The paper reviewed here is ‘Follow-up psychotherapy outcome of patients with dependent, avoidant and obsessive-compulsive personality disorders: A meta-analytic review’ by Witold Simon. The title summarises the broad aim of the study and in the abstract, the authors conclude that

‘The study indicates that therapy gains are usually maintained at follow-up for Cluster C clients treated with cognitive-behavio(u)ral and psychodynamic approaches as well as social skills training‘

Just to recap, the DSM-IV cluster C personalities refer to the anxious avoidant personality disorder (AVPD), the dependent personality disorder (DPD) and the Obsessive-Compulsive Personality Disorder (OCPD).  In the objectives section, the authors clearly outline the questions they aim to answer including the efficacy of therapy on specific and general outcome measures, efficacy of follow-up, relative therapy responsiveness of individual personality disorder subtypes and relative efficacy of therapy types. The methodology is clearly outlined incuding databases used, search terms within the databases and inclusion criteria for papers. The researchers have used detailed criteria for describing the papers and students were trained to use these criteria with the papers. The criteria scored highly on inter-rater reliability. The authors identified 15 studies between 1982 and 2006. The authors commented on the heterogeneity of treatment approaches as well as in a number of other variables. For each of the four questions they posed, the authors described the number of randomised controlled trials and non-randomised studies. In the results section they state that all of the treatments except brief dynamic therapy were effective in showing ‘improvements’ by the end of therapy compared to controls and referred to Table IV. However on inspection of Table IV, I noted that effect sizes were given but I wasn’t clear about which outcome measures the effect sizes related to. In the section on follow-up therapy the results are discussed for 3 and 6-month follow-ups and given the range of therapies examined the significant findings cover many therapies in individual trials. I couldn’t identify a statistical pooling of study results in the table or the section on follow-up studies. Indeed on closer examination, I could find no reference to effect sizes in the tables or to outcome measures nor any other indication of the effects of treatment. In the text, again I could find no reference to these measures and instead there are general remarks about individual studies or small groups of studies. In the section on differential effects according to diagnosis, the authors report that these results are ‘inconsistent’ and describe these qualitatively without any obvious reference to a pooled-analysis which might at least offer a statistical answer. A little later in the conclusions, the authors refer again to the effect sizes and here they pool the data for effect sizes using Cohen’s Classification. The effect size they explain refers to the percentage of people getting better with therapy. However it is not clear what ‘getting better’ means as improvement might be considered differently in each study and would make comparisons difficult. I didn’t see any other quantitative results given in the discussion.

In summary, perhaps the most convincing evidence was provided for the follow-up data, and here the authors have included the pooled effect sizes although there still remains the question of what exactly is meant here by ‘an improvement’. There is also the question of how diagnoses have been established in each study. For instance there has been a suggestion that anxious avoidant personality disorder has an overlap with social phobia e.g.  (Tillfors and Ekselius, 2009). If this is the case it would be interesting to see how social phobia has been excluded in these studies although the authors have referred to the heterogeneity of methodologies in the studies. The lacks of explicitly stated pooled effect-sizes in other sections of the paper make this difficult to interpret and one obvious comment is that a meta-analysis should be repeated as more study results become available although this can be said for all meta-analyses.

References

Tillfors M and Ekselius L. Social phobia and avoidant personality disorder: are they separate diagnostic entities or do they reflect a spectrum of social anxiety? Isr J Psychiatry Related Sci. 46(1). 25-33.

Witold Simon. Follow-up psychotherapy outcome of patients with dependent, avoidant and obsessive-compulsive personality disorders: A meta-analytic review. International Journal of Psychiatry in Clinical Practice. 2009. 13(2). 153-165.

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The article reviewed here is ‘Valproate and Neuroprotection Effects for Bipolar Disorder’ by Murad Atmaca. This is a brief review looking at the potential neuroprotective effects of Valproate in Bipolar Disorder (BPaD). There is no stated methodology for this review. The author considers the evidence for BPaD as a neurodegenerative process by focusing briefly on one study showing a reduction in glial cells in area 9. There is then a look at Proton Magnetic Resonance Spectroscopy imaging studies which allow visualisation of cell components (e.g. choline-containing compounds which are found in neurons and glial cells). Atmaca then focuses on one of these compounds – N-acetylsaspartate (which is found in neurons alone) and builds the argument for suggesting that this may not primarily be a proxy marker for neuronal structural integrity one of the assumptions made in the literature as there is a reversibility in lowered NAA levels. However in order to progress, a decision has to be made about what NAA does represent and Atmaca seems to settle on the conclusion that lowered levels of NAA are equivalent to a loss of neurons or related losses (e.g. loss of axonal function). Using this assumption, Atmaca then looks at some of the MRS research in BPaD and notes that in one study the ratio NAA/CHO was lower in controls compared to those on a combination of Quetiapine and Valproate. There is then further indirect evidence of a protective effect of valproate against excitoxicity. A number of cellular mechanisms are then considered – effectively Atmaca attempts to outline some possible pathways through which any such effects might occur before finishing with a look at some evidence of reduced brain volume reduction with Valproate. Although cellular mechanisms would be expected to form the basis for drug effects, the more convincing evidence for drug effects come from sufficiently powered longitudinal randomised-controlled trials preferably over a reasonably long time period. However, this paper is concise and Atmaca puts some pieces of the jigsaw puzzle together although time and further evidence will tell if these are the right pieces.

References

Atmaca M. Valproate and neuroprotective effects for bipolar disorder. International Review of Psychiatry. August 2009. 21(4). 410-413.

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News in Brief

There is preliminary evidence that inflammation in the hippocampus may be associated with schizophrenia although it will be useful to see the results of further studies in this area. In a study (n=109) of people with depression and controls there was found to be an association between depression and overestimated retrospective recall of somatic symptoms and this is just one of many ways in which depression and physical illness may have complex interactions. There was a recent study which used a large number of outcome measures which investigated collectivist versus individualistic cultures and the authors suggest that the former are associated with a lower genetic predisposition to depression. However it is important to note that there are cultural differences in the use of diagnostic classifications (e.g. see this review).

In the BJPsych there is an interesting article by Professor Michael First who writes about the potential for harmonisation of DSM-V and ICD-11 which is a widely discussed topic (First, 2009). There are a number of points of interest in the article and he notes that there are investigators involved with revisions of both systems which should help to contribute to attempts to harmonise both systems. The discussions around these systems will no doubt increase. There is also a supplemental issue to the BJPsych which focuses on long acting injectable antipsychotic medication with review articles and original research*. Articles included a systematic review of RCT’s and observational studies of oral versus long acting injectable (LAI) depots, a review of psychopharmacology and side-effects of LAI’s, a systematic review of second-generation LAI’s and a review of  UK prescribing practice amongst many other articles. There is a recent study which provides evidence of a relatively small difference in the rate of decline of memory in those with Alzheimer’s Disease with or without diabetes. Those with diabetes had a slower rate of decline (although the effect size was relatively small) and it will be interesting to see further replication studies in this area.

Technology review have a collection of images about representing 100 years of visualising the brain. A comedian has been invited to contribute a humorous perspective to a production on mental health by a primary care trust. There is a clip of the performance in the article and the argument is that the comedy can help to overcome stigma through education. You can see the responses of members of the audience in the clip. There is a recent statement from a geneticist Professor Paabo that Neanderthals and humans interbred according to analysis of the Neanderthal genome (see also here). The specific evidence base for this conclusion is not clear** and it will be useful to see further evidence when it is published. However the remaining question is whether or not the Neanderthals contributed to the modern human gene pool which is a separate although related question which may be answered with the completion of the sequencing of the Neanderthal genome. If this were so, it would have many implications. Another paper on genetic material – heterochromatin may in the future help to answer the question of whether the offspring would be sterile.

Psychiatry 2.0

Dr Shock links to an educational video about the redesign of the PubMed interface which is useful for those undertaking literature reviews, database searches and related activities. Sandy Gautam has started a new blog – My 2 Brains and in this post he reflects on twitter including a look at how it relates to the expression of self. MindHacks has his weekly round up here. There is an article here about web-based healthcare. The Journal Cell has an article on twitter and at least one of the scientists quoted in the article found that it was useful in keeping up to date with developments in their field.

** I couldn’t identify a relevant press release at the website

References

*November 2009, Vol 195, Supplement 52

Michael First. Harmonisation of ICD-11 and DSM-V: Opportunities and challenges. The British Journal of Psychiatry. 2009. 195. 382-390.

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Psychiatry 2.0 refers to the Web 2.0 applications which are relevant to psychiatry. Related areas include Health 2.0 and Medicine 2.0.

Last Updated 31st October 2009

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In the 28th October edition of the Nature Neuropod, Kerri Smith interviews researchers who have published recent interesting research in the field of neuroscience. In one of the interviews Smith talks with researcher Ted Abel who has identified a cyclic AMP signalling pathway that is modified in the hippocampus during sleep deprivation such that the levels of phosphdiesterase-4, which degrades cAMP are increased. Further when this pathway was blocked, sleep deprivation-related memory impairment was reversed. There may be therapeutic implications pending further research. There is also an interview with Professor Pasko Rakic who has been looking at the evolution of the central nervous system in mammals. There is  a fascinating interview with Eve Marder about individual differences in the central nervous systems of crabs, moving away from the paradigm of averaging group properties. This question of the difference between individual and group properties is an important one which is relevant to many different areas of research in the life sciences including clinical sciences (see for instance the paper reviewed in this article). There is also a look at research on place cells – which code for spatial locations. The slow pace and clearly enunciation work well for the complex material that is carefully explained for the listeners.

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The book reviewed here is ‘The Greatest Show on Earth’ by Richard Dawkins. Both Dawkins and his wife actress Lalla Ward narrate the book in an engaging style and in the process convey the awe of nature that permeates the book. Indeed for those unfamiliar with Dawkin’s works – he is a champion of communicating the beautiful and at the same time inexorable logic of evolution while at the same time answering the common criticisms that have been levelled against evolution. In my opinion, Dawkins writing represents the embodiment of rationalism in search of an ephemeral eternal truth about nature which because of the subject of its enquiry takes on a transcendent quality. Dawkin’s latest work references many of his earlier works, reiterating important nuances in evolutionary theory such that it parallels a collection of axiomatic proofs building to a final conclusion. The conclusion in this case is the essence of several billion years of evolution on Earth. Dawkins examines the possible origins of life with a fascinating reference to Darwin’s profound passage on the chemicals in a pond which might contribute to the beginnings of life. He covers artificial, natural and sexual selection and illustrates each of these with elegant examples that reaffirm the concepts. Indeed what it is striking is Dawkin’s ability to effortlessly take such examples which are selected from across vast expanses of time as well as geographically and phylogenetically disparate regions and which reveal a supreme familiarity with the natural world. Indeed it seems that any debate about the underlying principles of evolution should begin with a demonstration on both sides of such familiarity particularly as the significance of the natural world is rarely contested. Dawkins also discusses the gene pool and this part in particular I had found interesting. I had overlooked that the individual and successful genes are part of a gene pool within the organism and this relationship between an individual gene and the remainder of the genome (or genomes if the wider group is considered) adds a necessary layer of complexity. For instance, the small changes in genes which may initially cause problems can be compensated by the actions of other gene products. This is interesting in the light of recent evidence that in people, each generation results in an average of 100 mutations in the genome*. In this regards it was also interesting to note that different parts of the genome have staggeringly different rates of mutational change with such changes being particularly rare in histone-related genes. On further reflection about some of the underlying evolutionary principles, I thought that these might easily be abstracted in mathematical form and this became more evident when Dawkins describes one of the computer programs he had written to simulate evolutionary changes (indeed genetic algorithms have been particularly successful in real world applications). This again testifies to the skills and effectiveness of Dawkins in translating such refined arguments into a format that is easily accessible. He has in the process developed a language which combines the underlying logic of evolution with those additional components of knowledge which reach out to a wider audience**. This is another indispensable work for those with an interest in the wonders of the natural world.

* It is tempting to suppose that multi-gene mutations may produce significant changes in a network effect although such an effect is improbable if such mutations are independent (given the size of the genome)

** It would be interesting to see if such rules could form the basis for an open-source educational and research software paradigm

References

Richard Dawkins. The Greatest Show on Earth. Narrated by Richard Dawkins and Lalla Ward. Random House Audio Books. 2009.

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The blog reviewed here is ‘Doctor Dymphna’s Diliberations‘.

Appearance and Design

The blog has a black background and a slightly off-black background in the central pane on which the white text of the articles is overlaid. The title pane consists of the blog name together with a colourful photo-like design. At the time of writing on the right hand pane there is an ‘About’ section for the blog, links to the associated twitters, blogroll, category cloud, recent posts and links to other websites. The blog can be navigated via an archived index also on the right hand pane. The blog is hosted at WordPress.

Articles

In the first post, there is an explanation of why the blog was started as well. Although there is a suggestion of abandoning anonymity, I couldn’t find a reference to the author’s name although this is apparently identifiable from the related twitter. As I couldn’t find a reference to the same name in the blog, I have refrained from using it in case they’re not equivalent. What I found interesting was that the author uses a combination of mindfulness-based therapy, cognitive-based therapy and pharmacotherapy. Some of the posts broached broader issues which could be argued by some to cross over into other distinct and separate domains. There are also interesting articles such as this on lifestyle approaches based on the research literature. The author also writes about her son’s condition and how this affects her. This article looks at some of the authors reasons for tweeting and indeed it is through the twitter account that I first came across this blog. There are also a number of book and film reviews.

Conclusions

This is a relatively young blog which usually has a few posts every month. The articles are sufficiently long to explore the topic of interest and to present these from the author’s perspective. I found some of the psychotherapeutic posts to be particularly interesting.

Addendum (10.11.09)

The About section has subsequently been updated – the author of the blog is indeed Dr Elizabeth Cordes

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The article reviewed here is a short report in the Lancet Neurology by Adrian Burton on the applications of YouTube in neurology with a particular focus on neurodegenerative conditions (Burton, 2008). Burton looks at a few channels on YouTube and provides opinions on the likely success of such channgels with the helpf interviews with relevant figures in the field. Although a number of channels are discussed, two in particular are focused on – the UK Alzheimer’s Society channel and the UCSF Memory and Aging channel. There is a discussion of whether these channels will remain in the ‘background’ in terms of viewings given the competition they face from other videos on the site which include those from television companies as well as viral marketing videos from large companies trying to reach a global audience.

At the time of writing, the Alzheimer’s Society channel has 53 clips uploaded. In this clip for instance, Neil Hunt, Chief Executive of the Alzheimer’s Society talks about Alzheimer’s Disease. At the time of writing the channel also has videos in Urdu, Punjabi, Hindi and Bengali. There are also interviews with people with Alzheimer’s Disease who describe their experiences and discuss some of the stigma that has been associated with the condition as well as educating viewers about misconceptions which contribute to this stigma.

The University of California San Francisco channel contains a number of videos about dementia including one on cognition in dementia, moral reasoning in Frontotemporal Dementia (FTD), FTD and emotions, and in this video Dr Bruce Miller explains how useful YouTube can be in education about dementia.

I had looked at videos on vascular dementia on YouTube in this post and concluded at that point that it required a lot of searching to find a few videos that were useful (which of course depends on the purpose of the video and the needs of the audience). However it is only a matter of time before this becomes a very useful medium. There are a number of reasons why I would expect this to become a more important medium for education purposes. Firstly it is not unreasonable to assume that the number of videos on YouTube will continue to increase. If a static proportion of these videos comprises useful educational material then such an increase would be expected in such educational material also. Secondly indexing methods may be expected to improve, be this within the YouTube site itself or through external sites which index some of the useful material in YouTube. The assumption here is that the videos will remain on YouTube indefinitely. Thirdly the methods for video production within the general population may be expected to improve with time as more sophisticated technology becomes available to the general population thus facilitating communication. Fourthly the proportion of the population (globally) with internet access will be expected to increase with time and assuming that a certain proportion of this population contributes videos to YouTube this would again be expected to increase the amount of educational material available (which ties in with the first point) but may also improve the drive for video production as there should be a larger potential audience for this material.

The article is a useful starting point for discussion around this topic and it will be interesting to see developments even within the next year in this field.

References

Burton A. YouTub-ing Your Way to Neurological Knowledge. Lancet Neurology. Vol 7. December 2008. pp1086-1087.

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The article reviewed here is ‘Implicit and Explicit Aspects of Sequence Learning in Presymptomatic Huntington’s Disease’ by Ghilardi and colleagues and freely available here. In the abstract, the authors conclude

‘These results suggest that both explicit and implicit aspects of sequence learning may be impaired before the onset of motor symptoms. However, when attentional demands decrease, explicit, but not implicit, learning may improve‘

Thus the authors compare and contrast implict and explicit learning in Huntington’s Disease (HD) for a very specific task. The study revolves around a sequencing task and some assumptions. The assumptions are that in this case, implicit and explicit learning can be demarcated according to different elements of the response to the task. Thus for instance they argue that as learning proceeds, the movements become more efficient, saving energy and that this occurs implicitly. They also argue that the number of anticipatory movements in the task is a proxy for explicit learning. However it could be argued that there can be an overlap. Thus the subject could tire of the movements involved in the task and consciously seek to perform these actions more efficiently. Further these actions could be accompanied by an internal dialogue which could almost certainly be considered an explicit form of learning or it could occur non-verbally where the subject nevertheless attends to this goal. Similarly for the initial period of learning the task involves consideration of the sequence of events but here too it could be asked ‘does the learning take place consciously’ (the same could, I think, be asked of this example where the question could be asked  ‘is this chimp consciously or explicitly aware of what he is doing?’). In effect then, it might be reasonable to ask if implicit or explict learning are continuous rather than discrete functions or even if this characterisation is task specific such that it might not be possible to generalise from single tasks.

The researchers have considered a large number of variables which are given in tables 2 and 3. Interestingly they mention that there is a ‘post-hoc analysis’ and a null hypothesis is not clearly stated although the authors do discuss their interpretation of the different components of the task response. The researchers have corrected for the multiple comparisons by using Bonferrini corrections. On the tasks, the subjects with presymptomatic HD (the number of CAG repeats averaged 41. The greater the number the greater is the risk of conversion) performed significantly worse on the implicit and explicit learning components of the tasks as interpreted by the researchers. My initial impression was that the explicit task involved sequencing and might under Baddeley’s model of working memory be attributed to the central executive. There would be expected to be executive dysfunction if the frontal-subcortical loops are affected by the disease process which is seen in HD. The only question here is whether or not there is interruption of the frontal-subcortical loops as this is prefmanifest HD. The researchers also found that if they reduced the complexity of the task there was no significant difference between the premanifest HD subjects and the controls on the ‘explicit learning’ but there was a significant difference on the ‘implicit learning’ task.

The researchers discuss their results and comment on the possible involvement of the dorsolateral prefrontal cortex and a number of other pathways. They also suggest that implicit memory involves primary motor cortex and supplementary motor areas but it is also interesting to note that the cerebellum is thought to play a significant role in this type of learning for motor tasks. I would be interested to see a larger replication study with clearly delineated primary outcome measures and a range of tasks examining both implicit and explicit memory.

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The paper reviewed here is ‘Beyond the Brain: widespread pathology in Huntington’s Disease’ by van der Burg and colleagues.The article is written by a group from the Swedish Lund Institute Neuronal survival unit and is classed as a ‘personal view’. However there is a small green box towards the end of the article which contains details of the search strategy and selection criteria which thus allows the reader to gain a better understanding of how the article was orginally constructed as well as providing a useful starting point for someone interested in updating the article. The article focuses on non-neuronal aspects of Huntington’s Disease (HD) in keeping with the expression of Huntingtin in such tissues. The article begins with a look at some of the posited functions of the Huntingtin protein which sets the scene for an exploration of non-neuronal manifestations of HD. There is a look at some of the processes that may contribute to weight loss including possible alterations to Insulin processing and adipocytes although much of the work here is in murine models. The potential impact of mutated Huntingtin on gene expression in myocytes, the expression of Huntingtin in cardiac myocytes, possible actions on osteoblasts or osteoclasts and altered immune response are all considered. The authors then return to the question of the cellular basis of these observations before looking at how such a discussion may inform the search for biomarkers and novel therapeutic paradigms. This is a concise review which references 110 papers and thus provides the reader interested in this area with a useful starting point for their investigations.

References

Van der Burg J M M, Bjorkqvist M and Brundin P. Beyond the brain: widespread pathology in Huntington’s Disease. Lancet Neurology. 2009. 8. 765-74.

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Research In Dementia

The researchers found that gamma-secretase, an enzyme implicated in Alzheimer’s Disease pathology binds to a class of  transmembrane proteins known as tetraspanins  (Wakabayashi et al, 2009) as well as to a number of other proteins. The tetraspanins have a number of different functions within the cell and it will be interesting to see how gamma secretase relates to these functions. There is further coverage here.

News In Brief

Experimental evidence has shown that expression of IL-6 in murine brain can lead to removal of amyloid plaque by microglial cells. There has been significant evidence to suggest a role for inflammation in the disease process and these new findings show that the relationship between inflammation and build up of Amyloid Plaques in the brain is complex. In one study there was found to be an association between plasma levels of ABeta42 and risk of conversion from Mild Cognitive Impairment to Alzheimer’s Disease and it will be useful to see further replication of these findings. Levels of a class of transcription factors NFAT’s (Nuclear Factors of Associated T-Cells) was significantly elevated in the hippocampi of subjects with Mild Cognitive Impairment or Alzheimer’s Disease compared to controls and at least one pathway has been suggested between activation by Amyloid plaques and expression of regulated genes.

A study in the BMJ showed an increase in the number of prescriptions of antidepressants from 1993 to 2004 and this was attributed to the use of long term prescriptions. There is further coverage here. In the Proceedings of the National Academy of Sciences there is a paper on the use of a new genome sequencing technology – whole exome sequencing (which focuses on genes coding for proteins rather than the entire genome sequence) in a case which resulted in a rapid diagnosis and it will be interesting to see further developments in this area.

There is also evidence that neighbouring groups of Chimpanzees approach the same problem in different ways which the researchers have interpreted as cultural differences. Such interpretations may have implications for developing models of human culture.

Blogosphere

Over at Science Life there is coverage of the Neuroscience conference in Chicago which amongst other items reports on a talk by Erik Kandel, the genetics of anxiety and neuroscience in social media. October 19-23rd was Open Access week and over at Beta Science, Morgan Langille writes about the use of an open-access website BioTorrents for sharing data and other resources. Over at Medical News Today there is a look at an association between gamma synuclein and depression. Software Advice has an article on iPhone applications for doctors and medical students.

References

Wakabayashi T, Craessaerts K, Bammens L, Bentahir M, Borgions F, Herdewijn P,Staes A, Timmerman E, Vandekerckhove J, Rubinstein E, Boucheix C, Gevaert K, De Strooper B.Nat Cell Biol. 2009 Oct 18. [Epub ahead of print]. Analysis of the gamma-secretase interactome and validation of its association with tetraspanin-enriched microdomains.

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The podcast reviewed here is the October 2009 edition of the American Journal of Psychiatry podcast which is freely available here. I’m not sure if it was the browser i’m using (e.g. the performance of browser specific plug-ins) but the narrator’s voice appeared to me to be fast paced and clipped. A study – the TADS study is discussed. This is a 36-week trial comparing placebo, fluoxetine, CBT or a combination in the treatment of depression in adolescents. The results are complex and discussed in the context of previous trials in this area. There is also a look at the interaction between cluster B traits and suicide. There was a discussion of a curious finding in emotional processing with antidepressants – the researchers in one study found that changes in emotional processing were manifest before changes in mood in response to antidepressant medication. There is also a discussion of binge drinking in middle-aged and older adults. There is a lot of material covered in this podcast, sometimes complex and I found myself listening to parts of it again to gain a better understanding of the material. I found the material to be very informative.

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The article reviewed here is ‘Cognitive Impairment in Multiple Sclerosis: Evidence-based Analysis and Recommendations’ by Jeffrey Rogers and Peter Panegyres. While the review is highly structured, there is no methodology outlined, which might be useful for instance for those wanting to update the review. In the introduction the authors outline some of the associations of cognitive dysfunction in Multiple Sclerosis (MS) including those in the area of employment and rehabilitation. The authors then look at the neuropsychological profile of MS covering processing speed, memory retrieval and attention amongst others. Neuroanatomical considerations are addressed briefly before the authors turn to factors which influence cognitive dysfunction. This was a useful section examining factors such as disease subtype and duration. They then look at screening tools for cognitive dysfunction in MS drawing attention to the performances of the Paced Auditory Serial Addition Task and the Clock Drawing Test. Although there are a number of reviews of cognitive dysfunction in MS and this one is now 2 years old, the subject is sufficiently broad for this to be useful and I found the section on screening to be particularly informative.

References

Jeffrey M Rogers and Peter K Panegyres. Cognitive Impairment in Multiple Sclerosis: Evidence-based analysis and recommendations. Journal of Clinical Neuroscience. 14. 2007. 919-927.

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The blog reviewed here is ‘Open MRS‘.  Open MRS is an acronym for the Open Medical Record System and is described on the Open MRS website (the main website is found here) as follows:-

‘OpenMRS is a community-developed, open-source, enterprise electronic medical record system platform. We’ve come together to specifically respond to those actively building and managing health systems in the developing world, where AIDS, tuberculosis, and malaria afflict the lives of millions. Our mission is to foster self-sustaining health information technology implementations in these environments through peer mentorship, proactive collaboration, and a code base that equals or surpasses proprietary equivalents‘

The invitation is made to the reader to contribute to this collaborative effort.

Appearance and Design

There is a white background which takes on a graded beige colour towards the title pane region of the page. The articles appear on the left 4/5’s of the page and articles are demarcated by thick blue lines. On the right hand side of the page, the reader can navigate through the site according to categories (‘what people talk about’), RSS feeds for the site, as well as a list of contributors. Previous articles can be accessed at the foot of the page by clicking on the arrow icon which takes the reader to the next page of articles. These have to be clicked through page by page.

Articles

There is no ambiguity here – the articles are highly technical often focusing on the actual code being written within the Open Medical Record System. The blog dates back to October 2005, but the articles start regularly from May 2007. On this page, the author describes the need to create a browser based form for data collection thus outlining a strategic object for the project in a semi-technical language. In an article on this page, Mathew Harrison reviews some useful books for designing open source projects. Vladimir writes his initial thoughts about coding a rule builder for the database. While superficially not sounding particularly interesting to the uninitiated, it is in fact a useful method for giving flexibility to the user in their interactions with the database. The rule builder would enable information to be retrieved from the database and displayed in a specific format. So for instance, they give the example of a list being generated for patients who need their bloods checked that day – logistically speaking this is potentially very useful for a health service. In another post, Matt describes the creation of a layer for allowing mobile phones to access data on the database. With time, more developers are recruited internationally, bringing their skills to bear on the project. Programmer Ime Asangansi joins the project and in an article from April 2nd 2008 describes the modification of an established part of the database interface – Xforms using archetypes. In a June 26th 2008 article the difficulties of correctly identifying patients in the database are discussed and this type of problem recurs in various database applications. At the time of writing version 1.5 of the Open MRS has been released and it is interesting to read about the actions behind the scenes during each part of the development cycle.

Conclusions

This is a highly technical blog about the development of an open source medical database. The blog is interspersed with a number of less technical articles which are able to engage a more general audience. The blog is particularly suited to those with an interest in open source healthcare paradigms as well as those with an interest in health databases. The developers are contributing to a noble cause which hopefully should lead to an improvement in healthcare for people in parts of the world still awaiting highly structured IT healthcare infrastructures with all of their accompanying benefits.

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The audiobook reviewed here is ‘The Education of Children’ by Alfred Adler. The book is narrated by Robin Lawson who reads expressively and  at a moderate pace. Adler is considered to be one of the founders of psychoanalysis and he has had a profound influence on the subsequent development of psychotherapy and counselling. In this book as the title suggests, he writes about the education of children. I found the work a little surprising. Prior to coming across this title I had not thought of Adler as someone with a particular interest in the education of children although knowing his importance in the development of psychotherapy. Educational psychology on the other hand is a vast subject which comprises multiple domains of knowledge that have been developing over a considerable period of time. Adler’s work consists as with the work of other psychotherapists including Jung, Freud and Winnicott of his ideas and understanding discussed in the context of his experience without obvious recourse to empirical evidence. The book consists of a considerable number of generalisations and in some cases these are followed by educational recommendations from Adler although these same recommendations are now more than 80 years old. I was interested in the book for the insights it gives into Adler’s interpretation of child development. He discusses the concept of the inferiority complex, a concept which has had considerable influence in popular culture. He also discusses the importance of birth order on subsequent psychological development and interestingly there is contemporary research in this area. I found that the book was well narrated, the ideas clearly elaborated on by Adler but that there were many generalisations, the material was over 80 years old and there was an absence of empirical data. The strength of the book is in conveying Adler’s theoretical understanding of psychology as well as giving some insights into Adler’s thinking.

References

Alfred Adler. The Education of Children. Blackstone Audiobooks. Narrated by Robin Lawson. 1991.

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The paper reviewed here is ‘Relationships between 24-hour blood pressures, subcortical ischemic lesions and cognitive impairment’ by Kim and colleageus and freely available here.

In the introduction, the authors give a very interesting overview of the relationship between blood pressure and subcortical lesions. In particular they focus on the nocturnal blood pressure as there is typically a diurnal cycle with a drop in blood pressure during the night – the so-called dipping phenomenon (and hyperdipping depending on the magnitude of the drop). They discuss some of the evidence of risk associations with non-dipping. They also discuss subcortical vascular mild cognitive impairment (SvMCI).

In the study, the researchers compared 24-hour BP values in controls, people with Subcortical Vascular Dementia (SVaD) and people with SvMCI. People with SVaD and SvMCI were recruited from a memory clinic in Seoul, Korea while the controls were recruited from a cardiology centre again in Seoul. I wasn’t clear on how SvMCI was diagnosed and thought it might have been a complex judgement. There are details given in the paper and the authors do acknowledge the difficulties in attributing cognitive impairment to a subcortical vascular cause but they state that other causes have been excluded. Nevertheless the MRI scans in themselves would not be suitable for detecting amyloid plaques that would be present in an AD (although they have looked specifically for other markers of AD pathology on the MRI). Blood pressures were obtained using ambulatory blood pressure monitoring and a 3 Tesla MRI scanner was used for the MRI scans and they use a specific protocol to assess the images for vascular lesions. Cardiovascular risk factors were identified in the participants. The Seoul neuropsychological screening battery was used and a breakdown of this screening instrument is given in the paper. They also state that the

There were a number of exclusion criteria although this didn’t affect the final numbers too much (89 included with SVaD or SvMCI initially and 79 after exclusion). On looking through the methodology and results, I noticed that there were a large number of comparisons being used and the researchers were also using the Tukey’s test – which is used in a post-hoc analysis. The researchers described their main findings as an increased systolic blood pressure variability in the SVaD group compared to the SvMCI group as well as an ‘disruption’ of the nocturnal BP rhythm in the SVaD and SvMCI groups. The researchers themselves note that this is not a prospective study and that the SvMCI diagnosis was made in the ‘absence’ of established criteria for SvMCI. While these were potentially interesting findings, I noted the post-hoc analysis and would be interested to see a larger replication study, prospective in design and using these results to inform the primary outcome measures in the next study.

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The Neuroscience Information Framework Version 2.0 is now online. The NIF is described as

‘A dynamic inventory of web-based neuroscience resources: data, materials, and tools accessible via any computer connected to the internet‘

The NIF is also described as a National Institute of Health Blueprint for Neuroscience Research initiative (see also this review of a paper on the Neuroscience Information Framework). The NIF Tools include a registry of electronic catalogues of neuroscience resources, a ‘deep web’ resource – the NIF Data Federation, the NIF Web Index – essentially a search tool for neuroscience information on the internet and the NIF vocabulary which includes Neurolex. Neurolex is a neuroscience lexicon which at the time of writing contains 7972 terms. Such a lexicon has implications not just for the ability to find relevant information on the internet but also has potential for facilitating neuroscience dialogue.

A small study of people with Alzheimer’s Disease (AD) compared with people with mild cognitive impairment and healthy controls (n=55) provided evidence that there was a correlation between the PET and CSF markers of ABeta but that they did not correlate significantly with cognitive impairment (Jagust et al, 2009). In a cross-sectional study of symptoms in people with bipolar disorder (n=88) published in the journal of the World Psychiatric Association, the researchers found a significant association between the mixed affective state and negative cognition and hyperactivity (article freely available here).  In a study of people in the Andean highlands in Ecuador (n=167), the researchers used the Spanish version of the Beck Depression Inventory II and identified that the scores on the somatic component of the scale were significantly higher than the cognitive component (article freely available here). The researchers interpreted this as  resulting from the influence of culture on the expression of the depressive illness. There is an interesting article on the National Dementia Research Brain Bank here. A meta-analysis of prospective and case-control studies examining the relationship between smoking and Alzheimer’s Disease which adjusted for a number of factors including tobacco company affiliation of the studies showed that smoking was a significant risk factor for Alzheimer’s Disease (Cataldo et al, 2009). A post-mortem study comparing the brains of people who had Alzheimer’s Disease and hyperphagia with those who did not found a significant reduction in 5HT4 receptors in the former group  (Tsang et al, 2009). In an intracranial electrophysiological study published in Science, the researchers provided evidence that language processing occurs in Broca’s area and is divided into processes for grammar, meaning and articulation with each process being separated by milliseconds.

There is a preliminary report on a new technology which measures electrical signals between the central nervous system and the vestibular apparatus in the ear. The Australian research team state that they are able to characterise responses in a number of central nervous system disorders and they include depression. There is a website which details the technology and which also contains a link to a promotional video. Using Medline, I was able to find 5 studies including 1 on schizophrenia and 1 on depression, although both had small sample sizes they provided data on the application of the technology. It will be interesting to see  further published data with larger sample sizes as this becomes available. Researchers have provided indirect evidence that Macaque monkeys experience the ‘Uncanny Valley‘ effect. This effect describes the tendency for people, or monkeys in this case, to become uncomfortable if computer simulations of members of their species are too realistic. The finding in monkeys suggests an evolutionary basis for this effect. It will be interesting to see if this has implications for social bonding.

Blogosphere

The Neurocritic has an interesting article on ‘Neurocinema Neurocinematics’ here. Professor Charlton has an interesting post on science here.

References

Cataldo JK, Prochaska JJ, Glantz SA.J Alzheimers Dis. 2009 Oct 8. [Epub ahead of print]. Cigarette Smoking is a Risk Factor for Alzheimer’s Disease: An Analysis Controlling for Tobacco Industry Affiliation.

Jagust WJ, Landau SM, Shaw LM, Trojanowski JQ, Koeppe RA, Reiman EM, Foster NL, Petersen RC, Weiner MW, Price JC, Mathis CA; Alzheimer’s Disease Neuroimaging Initiative. Neurology. 2009 Oct 13;73(15):1193-9. Relationships between biomarkers in aging and dementia.

Tsang SW, Keene J, Hope T, Spence I, Francis PT, Wong PT, Chen CP, Lai MK. J Neurol Sci. 2009 Oct 7. [Epub ahead of print]. A serotoninergic basis for hyperphagic eating changes in Alzheimer’s disease.

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In the 15th October 2009 edition of the Nature Podcast there is a look at a study of Colombian Guerillas who learnt to read in adulthood. This was a structural study (although I wasn’t sure if this was a structural MRI study) comparing the guerillas with people who learnt to read in childhood. The team wanted to learn if there were any differences between the two groups in terms of brain structure. Triangulating with the abstract in the Nature paper, the researchers found differences in the angular gyrus, interhemispheric connections and dorsal occipital gyri amongst others. They also suggest that the Angular Gyrus modulates information in the dorsal occipital gyrus although I wasn’t clear on how this was inferred from the structural  data (a post-mortem study might infer this from the directionality of individual synaptic connections). In the 8th October edition of the Nature Podcast, there is a look at a study of personal genotyping in two companies which found differences in the results between the two which the researchers attributed to the use of different gene markers. There is also a discussion of some of the recommendations for such testing. They also report on a genetics conference in Honolulu in which genome wide association studies and linkage analyses in 1000 autism families finding a significant association with a region on chromosome 5. In the 1st October 2009 podcast there is a brief report on a study in people with partial cortical blindness who were presented with faces and who developed examples of physiological mimicry (e.g. muscle twitching in the relevant areas). This has implications for the pathways involved in emotional processing and also the level at which it is undertaken (i.e. conscious versus unconscious).

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The blog reviewed here is the ‘Medical Ethics Blog‘. The blog is about medical ethics as the name suggests and is written by Stuart Laidlaw, a journalist at the Toronto Star (to which the blog is affiliated) and book author.

Appearance and Design

The title pane contains references to the Star and links to other sites on the Star’s website. The blog has a central white pane with cyan panes on the left and right hand side. The articles are written on the right-hand 2/3’s of the central pane and are displayed with black text on a white background. On the left hand side of the central pane, there are numerous links including articles archived by month, links to other relevant sites and article categories.

Articles

The blog starts with the first article listed under May 6th 2008. In this article, he looks at Medical Tourism, a theme which is developed through the blog. In this article, he looks at Wal-Mart’s move into healthcare. This article looks at medical blogs and this one at reporting on drug trials. The interaction between religious beliefs and refusal of treatment is discussed in this article. This article looks at a considered amendment to a UK government bill to enable tissue to be removed from people lacking capacity to be used in research and the story continues to covered in this article,  this article and this article. The ethics of genetic testing for children are covered in an article in which a company makes claims about prediction. This article looks at american Senator Charles Grassley’s investigation into Pharma ghostwriting and states that company executives thought up titles for articles and then employed ghostwriters to draft the articles. I found this article on a fake submission to an online journal quite interesting as the issue of trust between authors and editors appears. This very issue of trust is surely interesting from a sociological perspective as it shows the type of  ’relationship’ issues that influence science away from the theory and must be factored into a ‘comprehensive’ model of science. I was also quite interested to see a debate generated across the newspapers (?news sphere) in Canada about these issues in a similar way to the debates that are generated across the blogosphere. There is a discussion here of whether academic fraud should be criminalised. Laidlaw also looks at the Canadian Journal of Medicine’s decision to make reporting of conflicts of interest for authors more stringent.

Conclusions

I was impressed by Laidlaw’s willingness to tackle very controversial areas. Laidlaw presents difficult issues that are in need of wider debate and I sensed that the blog has gathered momentum in terms of the rate at which articles are produced as well as the nature of the issues that are discussed. There are also a number of articles discussing issues relevant to psychiatry.

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The audio book reviewed here is Dr John Sarno’s ‘The Divided Mind’ narrated by Paul Hecht and John Boles. I didn’t realise there were two narrators until checking the credentials after listening to the book! In any case, I found it clearly narrated and well paced. The material in the book is quite complex and would repay close study for the reader interested in psychosomatic medicine. Sarno originally trained in general medicine and at his website is described as a Professor of Rehabilitation Medicine. I found it difficult to draw conclusions about the material in the book as I think it requires considerable reading around the subject but found it very interesting. Sarno develops some of the underlying theory of Alfred Adler and Sigmund Freud. He maintains that there are a number of mind-body disorders and refers to Adler’s description of the brain giving rise to physical symptoms. Indeed he quotes from Adler who discusses possible mechanisms by which the brain can produce effects on the body. This appears to be the basis for psychoneuroimmunology and he refers to Professor Candice Pert’s work on the ‘Molecules of Emotion’ (see review here). He distinguishes between Freud and Adler in that he states that Freud did not consider the notion that bodily symptoms could arise from the brain for the purposes of ‘distracting’ the brain (or mind) from distressing emotions. Through his work Sarno suggests that these emotions include rage and gives clear examples where anger is controlled at the conscious level only to emerge in symptoms. I wasn’t clear on the abbreviation TMS in the book and only realised it was Tension Myositis Syndrome on looking elsewhere. Sarno’s arguments are logically developed and seem to me intuitively valid. However a quick search of Medline using the keyword ‘Tension Myositis Syndrome’ resulted in four references with one being a 2007 study by Schechter and colleagues. Such a search may not produce all of the relevant studies although it would be useful to see further formal evidence to support both the diagnosis and the treatment efficacy.

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The paper reviewed here is ‘Mobile and Fixed Computer Use by Doctors and Nurses on Hospital Wards: Multi-method Study on the Relationships Between Clinician Role, Clinical Task, and Device Choice’ by Andersen and colleagues and freely available here. In the abstract the authors draw a number of conclusions including the following

‘Nurses’ work, and clinical tasks performed by doctors during ward rounds, require highly mobile computer devices‘

as well as

‘In selecting hardware devices, consideration should be given to who will be using the devices, the nature of their work and the physical layout of the ward‘

The researchers aims were stated as answering the following

‘(1) which device is used by whom, where, for which clinical task, and in collaboration with whom? and (2) what impact does the design of the device have on its use on hospital wards?‘

The researchers used a complex design for the study which involved direct observation of staff during task completion as well as questionnaires and assessment of the hardware devices (assessed with the usability criteria listed here).  The study was set in 2 geriatric wards in Sydney. It could be argued that these results are generalisable but also that the study’s findings are restricted to this particular type of service (i.e Australian geriatric wards). In favour of the latter, in some services configurations ward rounds may be conducted in one place in which case stationary computers would have benefits over mobile devices with the former typically having more resources per unit cost. Devices included desktop PC’s and devices on wheels as well as tablet PC’s.

The study was conducted over an 18-day period and included doctors and nurses with an average of just under 3-years experience on the study ward. It would have been interesting to see the results if staff had been stratified according to the number of years experience on the ward and it would have been particularly interesting to see the results in those with the most experience (although experience may influence the roles). The observational data collection took place between 7am and 4pm. A number of details were recorded in the study and the clinical tasks documented are listed in Table 1. The authors also include a schematic diagram of the wards illustrating the placement of some of the computers.

Given the nature and amount of data that was collected, there are numerous results in both quantitative and qualitative formats. In terms of the observed tasks, I found the following particularly interesting

‘The most frequently observed tasks were administering drugs (31.4%), preparing drugs (27.9%), and reviewing a patient’s chart (15.4%)‘

Nurses were predominantly using computers-on-wheels for their tasks particularly in conjunction with medication administration. Just under 40% of the doctors were using tablet PC’s – mainly to ‘review charts and view results’. Furthermore the doctors weren’t using the tablet PC’s when not on the ward round. In the questionnaires, several of the staff said they had not received training in using devices such as the tablet PC’s. This raises the important issue of how much these results are dependent on the training staff receive and how much training would have influenced the results reported here.

The researchers have been creative in the design of this study, trying to encapsulate the use of mobile and desktop computers in a hospital ward using a combination of quantitative and qualitative methodology. The study highlights some of the important factors that determine the success of such technology. These factors include the functions of the service, the types of devices, the functions for which those devices are being used, the software that is being used for those devices (although the operating system was specified, the individual software programs were not discussed in detail) and the training for both the software and the devices.

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The paper reviewed here is ‘Striosomes and Mood Dysfunction in Huntington’s Disease’ by Tippett and colleagues and freely available here. The authors write in their abstract that

‘we report here a significant association between pronounced mood dysfunction in Huntington’s Disease patients and differential loss of the GABAa receptor marker in striosomes of the striatum‘

In the introduction, the authors describe the importance of the GABAergic projection neurons in the striatum in the pathogenesis of Huntington’s Disease (HD) as well as noting the initial involvement of those neurons that project to the external pallidum.

In order to arrive at the above conclusions, the researchers compared 35 people with Huntington’s Disease with 13 control cases. This was a post-mortem study, retrospective in nature. The preparation of brains is described in the methodology section and the researchers state that the pathological grading was conducted by a pathologist with expertise in HD. For subjects with HD, the number of CAG repeats (associated with disease severity) in the gene region was assessed. The staining method for the specimens is then described.

As this is a retrospective study and the researchers were interested in correlating clinical features with pathological findings they required an instrument that was capable of capturing clinical features retrospectively. For this purpose they designed questionnaire for assessing motor,  mood and cognitive components of the disease. The details surrounding the construction of this questionnaire are given in the supplementary material. The questionnaire is administered to family members who recall information retrospectively. They validated this questionnaire by testing it in a family with HD who had also undergone testing on other clinical measures including the HADS for depression and anxiety.

Pathological specimens were divided into predominantly striatal loss, predominantly matrix or loss or a mixture of both. The researchers reported that ‘mood dysfunction indices again were significantly higher in the striosome-damaged group at clinical onset’. The striosome damage in this case refers to the loss of GABAa receptor immunostaining in these regions.  Although the CAG repeat correlations reproduced some previously well-established findings, the researchers also found that the average number of CAG repeats was significantly lower in the striosome-damaged group and further that the striosome-damaged group had a later-onset of disease.

This is a difficult paper to read as it covers a number of specialised areas including in particular the preparation and assessment of the pathological specimens. Nevertheless multidisciplinary studies of this type are essential in gaining a better understanding of the illness and correlating pathology with certain clinical features. I didn’t understand the finer points of the preparation of the specimens. I would argue though that striatal loss should be a continuous rather than discrete process and for the purposes of data-analysis there were three groupings (e.g. predominantly striatal loss). However, when it came to the assessment of clinical features, I think it’s not unreasonable to say that there are obvious methodological difficulties with retrospective assessment of clinical features particularly as in Huntington’s Disease they manifest in several different areas including motor functions and cognition. There are well established measures for assessment of motor function in HD in living patients and a prospective design would be much better placed to test the hypothesis generated in the study. In such a design, clinical measures would be repeated at intervals and the most recent could be used in any post-mortem correlational analysis. In this study, one obvious objection would be a recall bias by informants in favour of their understanding of how the disease progresses. This might not tally up with the actual disease progression. However the researchers support their use of this method by the inclusion of a validation study in the supplemental material in a family with HD although even here large replication studies would improve confidence.

The study has generated a number of testable hypotheses. Furthermore these hypotheses place the structure of the striatum squarely in the centre of they hypothesis.

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The article reviewed here is ‘Beyond Mild Cognitive Impairment: Vascular Cognitive Impairment, No Dementia VCIND’ by Stephan and colleagues and freely available here. The abstract reads

‘The concept of vascular cognitive impairment (VCI) has been introduced to describe the spectrum of cognitive change related to vascular causes from early cognitive decline to dementia……………….However very little is known regarding the mildest stage of VCI, generally termed ‘vascular cognitive impairment, no dementia (VCIND)‘

and puts the aim of this paper into perspective.  The review contains no explicitly stated methodology but is divided into seven main sections. The role of vascular disease in ageing of the brain including atrophy is discussed briefly. The authors then look at classification schemes. The importance of Mild Cognitive Impairment (MCI) as a category is discussed as is the associations of vascular risk factors with MCI. The authors then distinguish between the broader term vascular cognitive impairment (VCI) and the more restricted use of the term MCI. The authors emphasise the current difficulties with VCIND as refinements in the diagnostic criteria are still needed and also look at the relationship of VCIND to dementia.  The ambiguity in this relationship makes it more difficult to make the case for a boundary between VCIND and MCI at the current time. The boundary issue however is the subject of the next section and the authors provide neuropsychological, neuropathological and neuroimaging evidence of differences between MCI with and without vascular pathology although the picture is less than straightforward. The authors then focus on the evidence for minimising vascular risk factors for progression to dementia. They suggest that there is relatively little evidence that this prevents MCI or improving MCI if it is already present although adding that modifying vascular risk factors is effective in reducing risk of hypertension and strokes. They conclude by identifying a need for further understanding in this area. The concept of VCIND is relatively young and it will be interesting to see how this develops.

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I’ve recently started using Twitter. For those not familiar with Twitter, it can be thought of as the SMS of the internet. On opening an account you can enter text into a dialogue box and send it out to the twitter  stream. In other words you can send out your words to the twitter audience, but there is a limit of 140 characters. The reason i’m mentioning this is because I’ve been finding that it has lots of useful applications in keeping up to date. Many organisations including the NHS and the Royal College of Psychiatrists as well as journals and people with an interest in psychology, psychotherapy, pharmacology and neuroscience send out relevant tweets. Although many people have been using twitter to discuss more general issues or ‘chat’ online, twitter also facilitates exchange of current, relevant and useful information on specialised interests. The nature of the medium means that it becomes very easy to discuss the items with each other as well in a free flowing dialogue only a little different to being together in the same room. Here i’ve included a few of these items which I discovered on Twitter and want to thank my fellow Twitterers for providing a lot of useful information.

The American Psychoanalytic Association has developed a diagnostic manual. To quote from their website

‘It systematically describes:

Healthy and disordered personality functioning

Individual profiles of mental functioning, including patterns of relating comprehending and expressing feelings, coping with stress and anxiety, observing one’s own emotions and behaviours, and forming moral judgments

Symptom patterns, including differences in each individual’s personal or subjective experience of his or her symptoms‘

This is a fascinating development and looking at the above, it seems as though the manual relates just as much to healthy functioning as it does to illness. It will be interesting to see how the use of this manual becomes integrated into clinical practice and the relationship of this manual to ICD-10/11 and DSM-IV/V.  An American study provided evidence of the cost-effectiveness of telephone-based Cognitive Behavioural Therapy for depression in primary care (covered here and here) although the application of these results will depend on local protocols and service structure. The study is in the Archives of General Psychiatry. Aaron Beck who developed CBT was awarded the Lasker prize for clinical research.

A prospective California study with 9000 subjects provided evidence of an association between higher levels of cholesterols in people aged in their 40’s and the subsequent prevalence of Alzheimer’s Disease in their 60’s to 80’s. The article is freely available here. Analysis of the data from the Nun study continues with over 500 brains obtained post-mortem. The Nun study followed up several hundred nuns, examining a large number of factors and identifying associations with Alzheimer’s Disease. In this article you can watch an interesting video containing interviews with some of the nuns as well as a post-mortem dissection of a brain with enlarged ventricles. The Nuns have been very generous in ensuring that their brains can be used for research after their death and this type of research is very important in coming to a better understanding of the disease process. A study has provided evidence of a possible association between a virus XRV and Chronic Fatigue Syndrome. In a study of people with Parkinson’s disease using a driving simulator and comparing this group to age-matched controls, the Parkinson’s subjects were significantly more likely to experience a crash under low visibility settings than the control group. There were a number of factors including visual processing speed which were significantly associated with driving performance in the simulator. A phase 1 clinical trial is currently underway to examine the potential neuroprotective role of the antibiotic Minocycline in acute ischaemic stroke.

A prospective study involving 10,094 subjects over 4 years looked at adherence to a Mediterranean diet and new-onset depression and found evidence of an inverse relationship between increasing adherence to the diet and incidence of new-onset depression. A conference on empathy took place at the end of September 2009 and the conference website can be found here. There is an estimate from one study that each person has roughly 100 new mutations in their genome based on an analysis of the difference in genes in two chinese men who shared an ancestor at the beginning of the nineteenth century. A 1 Billion dollar Japanese project to create a supercomputer which will amongst it’s many functions will aim to simulate life is currently underway and is covered here. An fMRI study in monkeys and humans provided evidence of activation of the inferior Parietal lobe in humans alone when watching tool-using activities. There were a number of other areas that were activated in both humans and monkeys when undertaking this task.

The Natural Health Service is an ambitious project being undertaken in the NHS to plant 1.3 million trees which should reduce the carbon footprint of the NHS.

Health 2.0

There is an article here looking at how medical doctors are making use of social media. This article looks at Scientists on Twitter.

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Today is World Mental Health Day.  The World Mental Health Day was started by the World Federation for Mental Health in 1992. The World Federation for Mental Health was set up in 1948 and their mission statement can be found here and includes the following:-

‘WFMH is an international membership organization founded in 1948 to advance, among all peoples and nations, the prevention of mental and emotional disorders, the proper treatment and care of those with such disorders, and the promotion of mental health‘

Their website contains more information on World Mental Health Day here. The theme for this year’s campaign is

‘Mental Health in Primary Care: Enhancing Treatment and Promoting Mental Health‘

A Google news search highlights examples of the recognition of World Mental Health Day including amongst others  Australia, Bahrain, Bulgaria, China, India, Northern Ireland, Pakistan, South Africa and Sri Lanka, The BBC have coverage here and are holding several ‘headroom’ events. In the blogosphere, World Mental Health Day is also covered in the London 2012 blog, Dr Deb’s blog, the Reach Out blog, Dr Samir Parikh’s blog amongst others. Just 17 years on and it can be seen from the above that the World Mental Health Day is already very successful.

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The podcast reviewed here is an Acta Scandinavica Psychiatrica interview with Professor Sir David Goldberg who recently received a lifetime award from the Royal College of Psychiatrists (see here and here) (also see here for a list of 10 books he recommends). This might be more properly considered as a video (which it is) and this is a fascinating interview with a psychiatrist who has made valuable contributions in many different areas. Aubrey Lewis is one of the prominent historical figures in British Psychiatry and there are many insights into his views and practices in this interview. We here his views on the General Health Questionnaire which he developed and which has gone on to become extremely successful being used across the world. We hear Sir Goldberg’s views on a number of clinical issues and there are many example of his wisdom:-

‘you listen not just to what the patient is saying, you listen to the music in their voice….it’s just as informative as listening to the heart sounds‘

He also discusses the book he has written with Ian Goodyear – ‘The Origin and Course of Common Mental Disorders’. While the interview is approximately 30 minutes long it contains many deep insights into psychiatry and provides an opportunity to learn more about Professor Sir David Goldberg and his work.

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The blog reviewed here is ‘Fierce Mobile Healthcare‘. I call it a blog, although it could also be considered as a series of news articles on mobile healthcare technology. This blog is linked in with a number of other IT healthcare blogs and this is a fast emerging area of importance.

Design

The blog contains a white background with articles written in black text on a white background. There is a white and blue title pane which links to other blogs in the series. There are links on the right hand pane to a free newsletter, white papers and events. The left hand pane contains references to press releases, popular topics and recent comments. At the time of writing there are also a number of adverts displayed. There is also a search bar and the reader can see the most e-mailed comments. In order to identify the archived news stories, the reader must click on the more button which brings up a longer list of news items as well as an index at the bottom of the page which orders the articles into pages.

Content

The articles date back to April 28th 2009. The immediately displayed post is a summary of the article. The reader needs to click on a link at the bottom of the page to get to the main article or associated press release.  Indeed this first article is about an award for a very useful piece of mobile healthcare software. I was quite surprised to read that in large scale disease surveillance studies that

‘health workers carried hundreds of thousands of sheets of paper to the field, a process that was inconvenient, expensive and environmentally unsound‘

The software in question, esurveyor, is an open source design (meaning the code is transparent, freely available and developed by a collaborative community) and has improved the efficiency of the data collection process as well as being the most widely used healthcare software for mobile devices. This technology when used in combination with the relevant hardware has enabled a number of organisations in sub-saharan countries in Africa to collect public health data which is then used to inform policy. Articles that I found interesting included the following

Use of a mobile communication system in an Accident Emergency system including devices which could be disinfected

New mobile healthcare technologies including software that analyses text messages to assess the owner’s mood

Using RFID to track hospital equipment covered in this article

An article on technology for older adults nicknamed nana technology (see also this article)

Appointment of an executive director at the UCLA Wireless Health Institute

A Florida trial of patient mobile touchscreen devices with multiple functions

The potential of mobile technology to change nursing practice

GPS Shoes to track people with Alzheimer’s Disease

Through several links – this article on 140 potential uses of Twitter in healthcare

Link to an interview with Jay Parkinson on the impact of internet technologies on health

Wireless Body Area Networks for detecting falls in older adults in the home

Article about a mobile screening tool for depression

Healthwear facilitating early hospital discharge

Article about a US insurance company backing telehealth care

Article on medical students use of mobile technology

Conclusions

This is a fairly specialised ‘blog’ with detailed news updates on emerging mobile healthcare technologies and trends.

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The audiobook reviewed here is ‘Linked. Unabridged’ by Albert-Laszlo Barabasi and narrated by Henry Leyva. The narration is clear and I thought engaging particulary as this is a book about mathematical concepts. To elaborate on this, the book is about the mathematics of networks although it is geared to the general audience and does not feature any explicit mathematical formulas which if included would be complicated due to the nature of the medium. Barabasi instead takes the reader straight to the implications of the maths in terms that are meaningful. He takes us through the lives of several mathematicians and physicists  leading up to the important discoveries in the mathematics of networks. In this regards he talks about the findings that were reported before but related to the commonly used term ’six degrees of separation’ which suggests that each of us is linked to everyone else by a maximum of six links. Two important concepts are discussed in the formation of networks – the fitness of nodes and the duration of time with the earlier nodes building more links and these are brought to life in the examples that he gives. I had read a previous book by Malcolm Gladwell – The Tipping Point – a number of years ago and was interested in the concept of connectors – people who have many connections with other people. Gladwell also wrote the book ‘Outliers’ (see review here) and I found some familiar themes taken up from this book including another look at connectors but this time from a mathematical perspective. The curious point that Barabasi made was that the same mathematical laws applied to very different systems from the way genes in Bipolar Disorder operate within networks or key genes in multiple organisms also operate in networks (e.g. some of the most ancient genes form the hubs of intracellular chemical networks in multicellular organisms) to the spread of infectious disease in the population, the growth of the internet and citations in the scientific literature. Barabasi has teamed up with scientists from many disciplines and produced many interesting and varied findings in the process. Barabasi also has the ability to convey this to the reader*.

*It would be interesting to see in what other ways these laws might applied to mental illness.

References

Albert Laszlo Barabasi. Linked. 2002. Narrated by Henry Leyva. Random House Audible.

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The article reviewed here is ‘The Genetic Epidemiology of Neurodegenerative Disease’ by Bartram and Tanzi and freely available here. This is a shortish review article without stated methodology which covers some of the main neurodegenerative disease – Alzheimer’s Disease, Parkinson’s Disease, Lewy Body Dementia, Frontotemporal Dementia, Amyotrophic Lateral Sclerosis, Huntington Disease and Prion Disease. In the introduction, the authors cover issues including the hypothesis that common gene variants CNV’s contribute significantly to common diseases. They also look at the difficulties associated with interpreting small genetics studies

‘Additional, and commonly cited, problems in finding complex disease genes beyond the most obvious are multiple testing, publication bias, and questionable replication‘

and further that

‘In the case of multiple conflicting reports, metaanalysis across all published studies and/or the evidence for a biochemical/functional consequence of the putative risk allele can help distinguish real disease genes from their harmless counterparts‘

Firstly the authors look at Alzheimer’s Disease (AD) and note the contrast between the genetics of early and late-onset Alzheimer’s Disease. The article covers the well documented associations with early onset AD and also the ApoE4 association with late-onset AD. As this is a 2005 article they will not have been aware of the more recent findings regarding the CLU, PICALM and CR1 genes although the other findings are just as valid today as when the article was first written and the authors provide a concise overview. In the second section on Parkinson’s Disease, the authors contrast the relative success in identifying genes in the early-onset form of Parkinson’s Disease (Parkin genes and Alpha-Synuclein genes) with that in late-onset Parkinson’s Disease.

In the next section they focus on LBD and look at alpha-synuclein, while in the section on Frontotemporal Dementia they focus prominently on the established link with Microtubule Associated Protein Tau. In the section on Amyotrophic Lateral Sclerosis they look at the associations with MAPT (as in FTD), Superoxide Dismutase 1 and ALS2. When considering Huntington’s Disease, they note the importance of the Huntingtin gene as well as a number of gene associations which are thought to influence the onset of the disease. In the section on Prion diseases they look at the PRN gene and the ramifications of various mutations of this gene. While this is four years old, it gives a useful overview of gene studies in the neurodegenerative diseases which can be supplemented by more recent reviews in the area(s) of interest.

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The article reviewed here is an open-access article ‘Differential Cognitive Impairment for Diverse Forms of Multiple Sclerosis’ by Gonzalez-Rosa et al and freely available here.  In the abstract, the authors write that

‘The present results suggest a cognitive impairment in the information processing in all of these patients…..This suggests a silent deterioration of cognitive skills for the BMS [Benign Multiple Sclerosis] that is not usually treated with pharmacological or neuropsychological therapy‘

The main question that can be asked here is how do the results, analysis and discussion in the article fit with the above conclusions?

Firstly the researchers have recruited two groups of Multiple Sclerosis subjects. One group has the relapsing-remitting form of Multiple Sclerosis characterised by periods of deterioration and then improvement while the other have received a diagnosis of ‘Benign Multiple Sclerosis (BMS)’ (see Appendix for link to another study on Benign Multiple Sclerosis). I wasn’t clear on how the diagnosis of Benign Multiple Sclerosis had been arrived at. I could not find an explicit reference to the sampling method for the three subject groups and I note that the sample sizes are relatively small with 45 subjects included in the study.

The Posner paradigm was used. This involves a visual display which shows an arrow. A target appears on the screen at the location of either the valid position (indicated by an arrow on the screen) or the invalid position and the subject has to respond by pressing the appropriate button. Both the accuracy and speed of responses are measured and both right and left hands are used which I assume is to avoid any bias from handedness. The underlying assumptions for this paradigm are that it taps into attentional mechanisms – disengagement from gaze target, movement to new target and engagement with new target. They also presented the subjects with standard stimuli and measured the evoked potentials in 4 leads.

Figure 1 shows a comparison of the measures for the invalid and valid trials. The confidence intervals for all of the pairings appear to overlap suggesting that amongst the many possibilities there could be no significant difference between the means. In other words the distinction between valid and invalid trials wasn’t particularly interesting.  Figure 2 shows the Evoked Response Potentials in the four leads in the different groups and the authors note the lack of a certain response – the N1 response in both MS groups. Figure 3 shows a 3d scatterplot of the three subject groups on axes denoting amplitude of frontal N1, response time and latency P300. The three groups are separated into clusters and although I found it difficult to judge the locations of the clusters from the diagram, it appears that the benign MS groups values lie further from the control group than the relapsing-remitting group. This apparent relationship from the visual inspection of the scatterplot also appears to hold for both % of correct responses with the RRMS and controls appearing closer to each other than the BMS group to either. The same holds for the reaction times and this suggests the importance of understanding the methodology of the selection of subjects for the study.

Nevertheless when the researchers performed an ANOVA on the comparisons they found that the control group responded significantly faster than either the RRMS or BS groups. They also found that the valid reaction times were significantly faster than the invalid reaction times using this analysis. Although there were interesting findings in terms of the evoked potentials, the authors draw conclusions about the cognition. In terms of the conclusions given in the abstract it can be stipulated that they researchers have demonstrated a significantly worse performance on a very specific task which involves focusing on a simple visual cue and responding to a visual target that appears on the screen. The magnitude of the increase in reaction times for the BMS group is somewhere in the region of an extra 50ms and so in this study at least it can be argued to be of significance. It would be interesting to see a larger replication study with use of additional psychometric tests.

Appendix

Article on Benign Multiple Sclerosis by Hawkins and McDonnell, 1999.

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The paper reviewed here is ‘Autophagy in Neurodegeneration and Development’ by Winslow and Rubinsztein and freely available here. As the title suggests, the authors discuss the role of autophagy in neurodevelopment and neurodegeneration. As in a number of other review articles that have been discussed here, there is no stated methodology although such articles represent an effective method of communicating important areas that have been selected based on the authors expertise. The paper is divided into 9 sections. In the first section the authors introduce the reader to the two main degradation pathways for proteins in the cell – the specific ubiquitin-proteosome pathway and the non-specific autophagy-lysosome pathway. In the second section they examine Yeast studies. I was intrigued to read that autophagy is induced during periods of starvation in Yeast. The authors summarise the main steps in autophagy that have been identified from Yeast studies. In the third section, the role of autophagy in development and health is examined and again the authors show the important role that autophagy plays in the stress response and deficiencies in components of the pathway can lead to neurodegeneration through the build up of proteins and the lack of nutrients derived from amino-acids. In the fourth section, the authors look at the interactions with other cellular processes and the impact this can have on autophagy proposing that

‘A number of diseases have been shown to manifest a deficiency in autophagy, identifying autophagy as an important secondary disease mechanism‘

In the fifth section, the motor function of dynein in autophagy is discussed as well as the association of under or over-representation of dynein with neurodegeneration which is possibly mediated through impaired autophagy. In the sixth section, the endosomal sorting complexes required for transport (ESCRT for short) are discussed including their association with Frontotemporal Dementia and their role in the processing of integral membrane proteins. In the seventh section, the role of the lysosome in degrading the cargo of the autophagosomes is examined as well as the pathological accumulation of autophagosomes. In the eighth section, there is a look at potential therapeutic interventions aimed at the autophagy pathway and in this regards they consider Rapamycin and intriguingly also Lithium as well as Carbamezapine and Valproate before concluding in the final section that

‘With its implicated roles ranging from viral infection and cancer to liver and cardiac disease.. autophagy’s importance in the maintenance of health is just beginning to be realised‘

The authors have written a review which is elegant in its simplicity and efficacy in communicating the significance of complex cellular processes with many pieces of the ‘jigsaw’ still missing. The authors have also shown the potential relevance of this system to a number of neurodegenerative processes.

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An in-vivo study has provided evidence that Dimebolin has a high affinity for the Serotonin 5HT6 receptor in vivo (Schaffhauser et al, 2009). Dimebolin under the name Dimebon was trialled in Alzheimer’s Disease and showed promising results. There may be a focus on this receptor for therapeutics if these results are replicated.  In this article, there is coverage of a prospective cohort study in Honolulu which includes post-mortems to clarify the processes leading to the dementia. The study has been going on for many decades and the researchers have now accumulated data from close to 800 autopsies and are able to compare this with neuropsychological and other data. NHS Choices discuss a study involving Olive Oil and finding that it binds to A Beta-derived diffusible ligands (ADDLs) and influences in turn their binding to synapses which may have implications for the disease process in Alzheimer’s Disease. In America, a group of neurologists have developed consensus guidelines for the use of cognitive enhancers in adults without dementia. Another study involved contacting retired American Football (NFL) players and conducting a survey over the phone. The researchers found a much higher prevalence of dementia in the NFL players than the national average.

There has been a relative large study comparing people with Tourette’s and OCD with healthy controls and finding no significant evidence of the former conditions with Streptococcal throat infection. There is contrary evidence which suggests that Strep throat infections can be associated with autoimmune processes which involve the central nervous system and these are termed PANDAS.

Scientific American have coverage of some studies supporting the hypothesis that long term relationships foster creativity. In the studies they contrasted analytical with creative thinking. The types of relationships considered were tested indirectly by the use of imagination or by presentation of words with subtle meanings related to the paradigm. However it could be argued that the relationship status of the subject would provide more convincing evidence. Steve Peters, psychiatrist and coach for the Olympic Cyclists is appearing on a television program to work with members of the public to improve their fitness. In this article that covers the story, Steve Peters discusses some of the underlying theory he uses (which appears to relate to evolutionary psychology). An anthropological study looked at old world monkeys and found that increasing neocortical size was associated with the ability to form large social networks.

References

Schaffhauser H et al. Dimebolin is a 5-HT6 antagonist with acute cognition enhanching activities. Biochemical Pharmacology. Vol 78. Issue 8. pp 1035-42. 2009.

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The podcast reviewed here is one of the UCLA Psychiatry Grand Rounds podcast series titled ‘Bringing Psychology’s ‘Positive Psychology’ into Psychiatry’ and freely available here. This is a video of a presentation by Professor Vaillante who has undertaken considerable research into the recovery process from several illnesses including schizophrenia. In this talk, Professor Vaillante examines ‘positive emotions’ and at the beginning of the talk he mentions provocatively the active ingredients of a treatment of ‘faith, hope and love’ in contrast with the psychodynamic exploration of feelings such as anger, guilt and shame.  The talk covers a broad range of topics which fit under the theme of ‘positive emotions’. I was interested to hear Vaillante talk about Autism as a disorder of attachment. He takes a look at the Limbic System and raises the possibility that this may have distinguished the dinosaurs from the mammals with the former group facing a mass extinction. Could emotions have played a role? (However there are a number of alternative hypotheses to explain this extinction which have taken centre stage). He also takes a look at the Insular Cortex (see here for the beginnings of a model on the Insular Cortex) including the Spindle cells and Mirror Neurons. Indeed he notes the much discussed hypothesised relationship to empathy. Vaillante brings together a number of findings including those from recent studies, encouraging the audience to examine possible connections and reappraise the role of ‘positive emotions’.

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The blog reviewed here is the ‘New Media Medicine‘ blog.

Appearance and Functionality

The blog has a professional look, with photographs used in the title pane and articles at the time of writing. The articles are written on a white background and the articles themselves appear over a grey background. There are tabs underneath the title pane – home, e-Learning, web design, forum, blogs and videos. At the time of writing, I found a number of videos under the video heading. Those listed included lectures on integrated biology. The articles in this blog are indexed according to time period and category and these links are found on the right hand pane.

Purpose

The about section is here and describes the founders of the site. Dr Paton has another blog on health informatics (reviewed here). There are also a number of colloborators. The blog is associated with an online medical community.

Articles

The blog begins with this introductory article which explains that it will update the reader on new media medicine. Articles I thought interesting

This article on RFID looks at how these devices are being used to track patients (see this review here for another paper on this subject)

This article links to medical Podcasts

This article links to a video of one of the originators of ARPANET, the precursor to the modern internet

This article links to free health software for mobile devices

This article looks at a text-messaging service for making appointments

This article links to a site about Doctors Gadgets

Summary

The posts are very brief but usually contain links to valuable resources on the internet. I found these links very useful and some were not only working 2 or 3 years after they were included there, but the sites themselves had developed. The reason I mention this is because links can become broken reasonably quickly depending on the sites that are pointed to which gives blogs a transient edge to them.  I’ll probably be making use of some of these resources myself. It’s a pity there are currently no posts after 2007. Maybe it will be updated in the future with more valuable links.

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The audiobook reviewed here is ‘Outliers’ written and read by Malcolm Gladwell. Gladwell is a journalist and established author who has had success with books such as ‘Tipping Point’ and ‘Blink’. Regarding the narration, Gladwell speaks slowly, clearly and persuasively through the audio. Turning to the content, Gladwell looks at the effects of ‘cultural legacy’ on success. In essence he is helping to answer a question about the influence of the environment in shaping our lives. The outliers in the title refers to people who lie outside the two standard deviations of the population and who have attained extraordinairy success. As in other popular science books that have emerged recently, Gladwell develops the theme of the 10,000 hours needed to attain expertise in a subject ( Indeed in medicine, changes to the working conditions of junior doctors has reduced the number of available hours for training and this has provoked considerable debate). His interpretation of the success of the Beatles will surprise some. He argues that not only is a considerable amount of hard work required to develop success, but also the right opportunities are needed to ensure that hard work is met with success.

Here a very subtle theme in his book emerges – that these circumstances take a considerable time to arise and it make take even centuries. He is not afraid to take anthropological and sociological research findings on a variety of cultural issues and condense them into simple and persuasive arguments. As an example, Gladwell looks at the results of children across the world on maths tests and notes that there are parts of Asia where the children emerge a clear standard deviation ahead of children in other parts of the world. I was reminded of the book Spark (reviewed here) which looked at how children in one school in America who utilised a sophisticated exercise program were able to buck the national trend (although there have been other interpretations of this also). He relates this to cultures in which persistent hard work are encouraged and that this has been encouraged over centuries. He brings counterexamples to support his argument. He also brings his own story into the work. I thought that writing in this way was quite courageous as it can be very difficult to write publicly about such personal material. He outlines how the conditions experienced by his Jamaican ancestry were needed to culminate in the experiences he needed to arrive at where he is. Gladwell takes the issue of environmental influence on behaviour and gives it a new lease of life, communicating the ideas convincingly and at the same time espousing the influence of cultural legacy and hard work as well as also raising the possibility that we can as a society move towards an environment which affords the needed (good enough) opportunities for all.

References

Malcolm Gladwell. Outliers. Read by Malcolm Gladwell. 2008. Hachette Audio

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The article reviewed here is a review article – ‘The Accuracy of Prevalence Rates of Multiple Sclerosis:A Critical Review’ by Poser and Brinar. There may be psychiatric comorbidity with Multiple Sclerosis including depression and cognitive dysfunction. Epidemiology plays an important role in the management of illnesses identifying trends, clarifying associations and establishing the illness burden at a population level which can be used in resource allocation. In this paper, the authors set out to critically review the literature on prevalence rates in Multiple Sclerosis (MS). One of the authors was involved in the establishment of one set of diagnostic criteria. In the introduction, the authors write that

‘Hundreds of epidemiologic studies measuring MS prevalence rates (PR) have been published all over the world‘

The authors state that is their intention to demonstrate uncertainties over the established prevalence rate of Multiple Sclerosis. There is no stated methodology for the review and it is possible that by setting out to demonstrate this point that there is a risk of selection bias in the cited studies. Indeed for this reason, a meta-analysis with clearly stated inclusion and exclusion criterion for papers could be justified when attempting to answer questions about the prevalence rates. A number of review articles do not necessarily follow a systematic approach and instead focus on established experts in the field identifying relevant papers and trends. In this paper, the authors argue that there are a number of factors which confound the establishment of prevalence rates for Multiple Sclerosis. The confounders are illnesses which share features with Multiple Sclerosis. Thus a significant proportion of the review is concerned with the distinction between Multiple Sclerosis and Disseminated Encephalomyelitis (DEM)  (including the recurrent form). This discussion is quite involved and includes evidence from neuroimaging as well as a comparison of the clinical course of both illnesses. The authors argue that in a number of studies, DEM has been included under the label of MS.  The authors also consider the overlap with Neuromyelitis Optica and MS as well as the occurrence of silent MS.

The paper shows some of the considerations that are taken when establishing prevalence rates. They would also be relevant to diagnostic construction. The questions here could be further tested using a meta-analysis.

References

Charles Poser and Vesna  Brinar. The Accuracy of Prevalence Rates of Multiple Sclerosis:A Critical Review’. Neuroepidemiology. 2007. 29. 150-155.

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The featured paper is ‘Cognition in Multiple Sclerosis: A Review of Neuropsychological and fMRI Research’ by Genova and colleagues. As the title suggests the authors examine the characteristics of cognition in Multiple Sclerosis. I could not identify a stated methodology. However the authors cite 140 papers throughout the paper which is reflected in both the breadth and depth of  relevant material covered. Broadly speaking the paper is divided into a section on neuropsychological profiles and another on the findings in functional MRI studies. In terms of neuropsychological profiling, the authors cover constructs ranging from working memory through to fatigue. They focus on the relationship of processing speed to a number of other constructs and suggest that clarifying this relationship further would be an important aim for future research as it would have implications for therapeutic strategies. Essentially if processing speed impacts on working memory and complex task completion then research in this area would be expected to inform therapeutic strategies. On the other hand, if there are confounders then they suggest that this would necessitate multiple treatment approaches. The authors explain a number of concepts as they cover material and I found this quite helpful. I find that this approach works really well in review articles and more so in those that cover many domains. With regards to fMRI studies, the authors emphasise the neuropsychology. Again their arguments are easier to follow as the article is to some extent self-contained allowing referencing to previously explained concepts. The authors draw attention to some of the conflicting findings in the field and the reader is able to use this information to facilitate selection and interpretation of future studies in this area.

The authors have written a clear exposition of the subject, carefully explaining important concepts and leaving the impression that the subject has been comprehensively covered in the neuropsychological domain. The relevance of processing speed to cognitive dysfunction looks to be one of the big questions in this field at the moment.

References

Genova H M, Sumowksi J F, Chiaravalloti N, Voelbel G T and DeLuca J. Cognition in multiple sclerosis: a review of neuropsychological and fMRI research.

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[archives]

The article reviewed here is itself a review article ‘Frontal-Subcortical Dementias’ by Raphael Bonelli and Jeffrey L Cummings. Cummings is a prominent figure in the field of Subcortical Dementia and has edited a book on the subject. This article is what I would term an expert review. Although there is no stated methodology there is a carefully considered overview of the field with the authors demonstrating a deep understanding of the field. They argue for the existence of a frontal-subcortical dementia. Thus they group an extensive list of conditions under this heading for the purpose of identifying common clinical features. While the section on anatomical circuits of frontal-subcortical dementia is useful, I found the discussion of neuropsychological features in the frontal-subcortical dementias to be particularly interesting. One of the tables in the paper covers ‘contrasting characteristics of cortical and frontal-subcortical dementia syndromes’ and distills a lot of material into an easily understandable format. The two types of dementia are contrasted in domains such as memory, visuospatial skills, calculation and mood. Even the simple presentation of the material in this way offers the reader a new perspective on a heterogenous conditions which they demonstrate have just as many shared properties as they do differences. The concept of a frontal-subcortical dementia may become more influential and it will be interesting to see how this develops.

References

Raphael Bonelli and Jeffrey L Cummings. Frontal-Subcortical Dementias. Review Article. The Neurologist. Vol 14. Number 2. 2008. 100-107.

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Research on Antidepressants

The British Journal of Psychiatry features two interesting studies on antidepressants. The first features a patient rating scale for antidepressant side-effects – the Antidepressant Side-Effect Checklist (AEC) which is included in the Appendix for the paper (Uher et al, 2009). The researchers compared this patient rating scale with a clinician rating-scale, the UKU in 811 subjects with depression who were participating in an open-label trial comparing Nortriptylline with Escitalopram. The Nortriptylline was included because of a strong affinity for noradrenergic receptors (it would have been interesting to see whether similar findings would have occurred with Reboxetine). They found that after correcting for the severity of depression, the AEC scores predicted discontinuation of escitalopram (although curiously not the Nortriptylline) and validated the use of the instrument for the purposes of establishing side-effects in antidepressants. In another study, this time qualitative, the researchers explored the emotional side-effects of the SSRI’s. The responses from the participants were grouped into 7 categories and there were many interesting comments from the participants (Price et al, 2009). Both a reduction in ‘positive’ and ‘negative’ emotions were reported and there was some supporting evidence from an analysis of comments on several depression related online forums. The authors suggest further quantitative studies to investigate the findings from this study.

Financial Skills and Risk of Dementia

Predicting which people with Mild Cognitive Impairment go on to develop dementia is an area of current research interest. There are many studies using different methodologies looking into this question. One predictor is that the size of the Hippocampus (size is inversely correlated with dementia risk) which has a robust evidence base. However, a recent study provides evidence that financial skills may be another marker of risk and this has been widely reported in the media (e.g. here, here and here). A research team, just published in ‘Neurology’ found that people with Amnestic Mild Cognitive Impairment who scored poorly on the Financial Capacity Instrument were more likely to develop dementia. The sample group were people with Amnestic MCI and are therefore already a select group who have been assessed as having formal difficulties with memory. They were being scored on a tool which measures financial skills. The size of the study is relatively small (n=163) and of these, 25 people with Amnestic MCI went on to develop dementia.

Blog Round-Up

Just to mention that the dead salmon study is generating a buzz in the blogosphere. The question is why the salmon’s brain activity showed up on the fMRI scan. Three issues affecting the interpretation of fMRI data are described in Developing Intelligence’s article – multiple comparisons, cluster comparisons and independence of multiple tests. For the interested reader, the pdf of the poster is located here. The authors presented the salmon with photographs followed by a ‘rest’ period and then analysed the change in BOLD signals in voxels. They performed one analysis without corrections. This ‘revealed’ a region of activity in the Salmon’s brain. They then carried out two types of comparison that are routinely used in the analysis of fMRI data using software packages such as SPM2. These corrections are necessary because if there is ‘random noise’ then some voxels should be firing above the threshold level just by chance. Thus you need to correct for both the combination of chance and the large number of voxels that are being examined. The two methods that are routinely used and included as a default in one statistical package are family wise error rate correction and false discovery rate correction.The debate that is currently taking place revolves around some posts which have likened these results to those of another study originally called ‘Voodoo Correlations in Social Neuroscience’ (reviewed here) and provoking much scandal before it surreptitiously changed its name to ‘Puzzling High Correlations in fMRI Studies of Emotion, Personality and Social Cognition’ (reviewed here). The point made in the Developing Intelligence article is that the ‘Voodoo Correlations in Social Neuroscience’ paper focused on independent tests whereas this paper focuses on multiple comparisons and thus a number of bloggers have misrepresented the paper. I would argue that both sides are probably right. Thus (and at the risk of sounding slightly pedantic), the Voodoo/Puzzling paper takes a broad swipe at fMRI study methodology from the statistical analysis right the way through to the way in which the analysis is presented within the papers. Thus

1. They do explicitly at one point, mention within-subject comparisons (i.e. changes occuring between tasks in the same subject)

2. In the second part of the discussion, the authors specifically ask the rhetorical question

‘Is the problem being discussed here anything different than the well known problem of multiple comparisons raising the probability of false alarms?’

In their response, the authors state that ‘The problem we describe arises when authors then report secondary statistics on the data in the voxels that were selected originally‘ before then adding ‘In the case discussed in this article, correlations are both the selection criterion and the secondary statistic‘.

3. However, most telling is Vul et al’s response to the responses to their original paper (available here) where they state explicitly that

‘6. We pointed out that although most studies used appropriate multiple comparison corrections (and thus identified voxels that do indeed have nonzero correlations), these methods are not always correctly applied, even in articles that have passed peer review’

One salmon tries to leap over a large waterfall while the other jumps into a hungry bear's mouth

However, taking the study a little further in a slightly tongue-in-cheek fashion, one interesting question to ask is

‘Why was any activity being picked up at all?’

The fMRI scan typically picks up oxygenated-Haemoglobin and it is the change in oxygentation of the Haemoglobin with delivery to the brain tissue that produces the signal. So if the Salmon was dead, we could safely assume that there was neither blood flow nor any delivery of oxygen to the brain tissue. So where is the change coming from? Well, I thought there was something fishy going on here and I was unsurprised to find a paper on the analysis of Salmon blood (freely available here). After looking very briefly at this paper, it appears the researchers in the fMRI study have omitted some crucial details for the interpretation of the data. Thus we do not know if their selected Atlantic Salmon was caught in fresh water or bracken water, as the corresponding temperatures would affect the oxygen dissociation curves of the salmon’s haemoglobin. We also need further information on the temperature of the room at the time of the scanning as well as the period of time for which the salmon had been deceased.

There is one possible explanation for the BOLD signals. They could represent a dissociation of the oxygen from the Haemoglobin with time. When the dissociation occurs, the magnetic properties of the Haemoglobin are altered and this will be picked up by the MRI scanner (oxygenated Haemoglobin is diamagnetic and deoxygenated Haemoglobin is paramagnetic). On moving from the presentation of the photographs through to the rest period there may be a continuing dissociation of oxygen from the Haemoglobin and it is this which is being picked up by the scanner. More interesting (and a very remote possibility) is that the authors of the poster have picked up deoxgenation in the Salmon’s Substantia Nigra, a region which is associated with Parkinson’s Disease in humans. The reason I mention this region is two-fold. Firstly, on the admittedly low resolution image of the Salmon’s brain on the poster, in the sagittal section, the activity is located close to the spinal cord and may therefore correspond to the midbrain (although I know next to nothing about Salmon neuroanatomy. I did however find a reference to the Substantia Nigra in Salmon). Secondly, in humans at least, the Substantia Nigra contains Haemoglobin which may offer it some protection during periods of anoxia and which also gives it the has a characteristic dark stained appearance (hence the name Substantia Nigra*). Salmon do a lot of moving about (as in the above picture) and the Substantia Nigra is involved in the regulation of movement. However against this hypothesis, the corrections in the statistical analysis eliminated the activation patterns, and there were at least two areas of activation in the uncorrected analysis.

Human Substantia Nigra - From Gray's Anatomy 20th Edition

So in summary, there’s a remote possibility that the imaging study was picking up the dissociation of oxygen from Haemoglobin in the Salmon’s Substantia Nigra post-mortem or as they infer, the activity was due to their incomplete analysis (particularly as the differences disappeared after the necessary corrections were made).

* The characteristic dark appearance of the substantia nigra is from the melanin in dopaminergic neurons.

Addendum

There may be another explanation for the findings. Thus if there is a mix of red blood cells (RBC) of varying levels of oxgenation, then the scanner may causes a realignment of the RBC’s according to their magnetic properties. If the magnetic field is applied as a pulse, then there will be further realignments when the magnetic field is changing. This may produce eddy currents, in which the Haemoglobin generates a reactionary magnetic field which will then ‘resist’ the next pulse of the scanner. If this were the case, it means that Haemoglobin molecules would undergo a more marked change in alignment during the initial part of the scan and this might explain the difference.

On a slightly different note, the brightest light in the known universe – the Diamond Light Synchrotron (see Podcast review here) is being used to examine iron deposits in Alzheimer’s Disease and together with the finding of Haemoglobin in the Substantia Nigra A9 cells, this is a very current area of research.

Addendum (4.10.9)

See the comment below from the author of the poster – Craig Bennett (also author of the blog at prefrontal.org) on the interpretation of the results.

References

Price J et al. Emotional side-effects of selective serotonin reuptake inhibitors: qualitative study. The British Journal of Psychiatry. 2009. Vol 195. No 3. 211-217.

Uher R et al. Adverse reactions to antidepressants. The British Journal of Psychiatry. 2009. Vol 195. No 3. 202-210.

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The podcast reviewed here is Nature Neuropod – August 2009 edition featuring Kerri Smith. The sounds quality is very good as would be expected from a Nature production. I couldn’t hear any background noise (e.g. clicks) and the dialogue is very clear and features interviews with neuroscientists. The podcast can are also displayed in segments, so that you can play individual parts of interest rather than listening to the entire podcast.

The August edition features an interview with a members of a team that is constructing a multimodal map of the brain. They have significant ambitions to replace Brodman’s map with something far more sophisticated and which will superimpose neurotransmitter data and fMRI to produce what they describe as a ‘Google Map’ and presumably means that information on different brain regions will be easier to locate. Mind Hacks also covers the podcast here. An intriguing post looks at ‘jumping genes’ or transposons/retrotransposons in the hippocampus. The transposons are genes that move about within the genome and are thought to be drivers of evolution. For instance in this Science Daily article there is a report on research into grapevine transposons and a comment on how they might have impact on genetic diversity.

In the Neuropodcast there is also a look  at a study of synaptic formation in the retina. In the study, the researchers challenge the notion that competition is required for shaping synapses between bipolar cells in the retina and offer a potentially new paradigm for synaptic formation.

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The blog reviewed here is ‘The New Social Workers Blog‘  which is a companion to a free American online quarterly magazine ‘The New Social Worker‘ a magazine written for social worker students and recent graduates. 

In terms of the presentation, the title pane is a white on blue background. The general background is a light green colour while the posts contain black text on a white background. At the bottom of the main pane, there is a Blog Archive which indexes articles according to the month they were posted. At the time of writing there are two right-hand panes. The first has a green background and contains links to sites related to the blog and magazine. The second, lower pane has a white background and links to the twitter account for the New Social Workers, as well as containing links to the blog authors, followers, a blog-roll and the RSS feed. The blog archive dates back to 2008.

The first post is written by Ms T.J who has written almost all the blog articles and here explains that she is doing a full-time Masters in social work. Ms T.J writes about her experiences both on the social work course and in her own life. We hear about the sad deaths of a number of her close friends, the completion of course work assignments, Ms T.J’s other role as a writer for a magazine amongst many other postings. 

Here are just a few of the posts (and links) I liked

A post about National Social Work Month. This got me thinking. Maybe there’s a place for a National Psychiatry Day!

A post about the use of technology in social work with some comments about how web technology is already making an impact.

How the Homeless stay connected online. A post about a homeless man who runs an online forum as well as maintaining a significant online presence while sleeping under a bridge!

A link to this article on some ways in which technology is impacting on social work.

The ‘New Social Workers Blog’ gives the reader an insight into the experiences of  an American social work student and it will be interesting to see how the blog progresses with the course that Ms T.J is undertaking. 

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The audiobook reviewed here is ‘One Nation Under Therapy (Unabridged)’ by Christina Hoff Sommers and Sally Satel and narrated by Dianna Dorman. Dorman narrates clearly and with expression. I found that the narration made the material easy to listen to and helped to keep my attention focused.

As I wasn’t familiar with the authors before listening to this book I performed a quick Google search. Christina Hoff Sommers has been a Professor of Philosophy and has a Wikipedia article (a.k.a internet biography) which covers some of her other works as well as her views on gender and equity feminism. These views have apparently provoked much discussion. Dr Sally Sattell is a psychiatrist who is also widely published and amongst her other works is a look at political correctness in medicine. Sattell also has a Wikipedia article.

I found the content very interesting. Some of the material might be considered controversial but it can be argued that such dialogue is necessary as it facilitates reflection on and appraisal of practice. The authors focus on a number of issues relating to therapeutic intervention. One of the themes they explore is that of vulnerability of children. Thus they argue that children in schools are being increasingly ‘cushioned’, for instance being given less homework or parents responding to PE lessons that are considered too difficult. The authors are referring to the American schooling system in their work although it can be argued that it can be difficult to generalise as there will be heterogeneity not only between schools but also between pupils within the same school.

They also discuss how bereavement theories developed by Colin Murray Parkes, John Bowlby and Elizabeth Kubler-Ross (‘On Death and Dying‘) have been misinterpreted and also refer to Freud’s Mourning and Melancholia. Thus they argue that following bereavement, the bereaved will not necessarily follow a strict phases but that there will be considerable variation between individuals and that abnormal’ bereavement necessitating treatment occurs in a relatively small percentage of the bereaved (see also this review on Art Therapy and Bereavement). They also comment on what they describe as a movement towards providing counselling in those that have been recently bereaved despite the above although again this may be too fluid and heterogenous to characterise.

During the discussion of Post-Traumatic Stress Disorder there are many references to British Psychiatry including Professor Simon Wessely and an interesting quote from Aubrey Lewis who noted that the number of new cases of neurosis did not seem to increase during the Blitz in Britain. They consider the origins of PTSD in detail and look at some of the issues in the empirical research. They consider situations in which treatment for traumatic experiences is not warranted.

The term they use through the book is that of therapism, which is a movement they trace to therapists such as Carl Rodgers. They consider historical aspects of the origins of the person-centred movement that filled the gap created by the decline in the popularity of psychoanalytic psychotherapy. They argue that some of the values found within this movement have permeated society through various educational programs and that this perspective can create difficulties in establishing moral responsibility.

The authors raise many issues in an uncompromising and engaging style and this is a work which may continue to provoke much needed discussion.

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The article reviewed here is ‘Exploring the Persistence of Paper with the Electronic Health Record’ by Saleem and colleagues. The advent of the computer brought with it the promise of a revolution in the way that we work and visions of endless tasks that could be automated and data that could be stored out of sight and called up at any time from multiple locations. Much of that vision has been realised but paper based systems still persist even when electronic alternatives are available. This applies to health services as well as other sectors. The researchers in this study wanted to find out why health care workers continued to use paper based systems when electronic alternatives were available. They used a qualitative approach and in the paper’s abstract they conclude that 

‘In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EHR design, introduced potential gaps in documentation, and generated possible paths to medical error‘

The authors have therefore found both advantages and disadvantages to the use of paper from their study although their conclusions include the qualifiers ‘potential’ and ‘possible’. Furthermore, these results represent the healthcare worker’s opinions and experience of working within the system and therefore tell us about the system itself indirectly. Ideally this information could have been used to generate simple hypotheses which could have been tested using data from the system itself. Even so, it’s interesting to hear from the people using the system as their views may be translatable to similar services elsewhere.

What was the methodology?

The researchers conducted 20 semi-structured interviews with ‘key informants’ consisting of multidisciplinary professionals including doctors, nurses, pharmacists, IT and administrative staff. They provided an interview script in the Appendix. The term CPRS given in the example questions refers to the computerised records system. The questions were grouped into those for clinical staff and those for IT personnel. An example of a question for the clinical staff is 

‘What is your ideal workflow during your clinical work and how does it relate to CPRS?‘

An example of a question for the IT and administrative staff is 

‘Are there workflow improvements that you envision that could eliminate or reduce production and storage of some paper forms? Please explain‘

The questions were exploratory. This meant that the researcher could respond with further unscripted questioning depending on the subjects answers. 

What were the results?

The results were grouped into themes. They were difficult to summarise given the heterogenous responses elicited but some of my highlights are given below

1. Efficiency. Doctors would prefer to handwrite complex orders as this was thought more difficult using the system.

2. ‘Knowledge/skill/ease of use’. In some cases clinicians were simply uncomfortable using the system and in other cases were unaware that tasks could be completed within the system.

3. Memory. This was interesting. Some clinicians used paper to help them remember things.

4. Sensorimotor preferences. Subjects would sometimes like to hold the paper as it was ‘tangible’ and a physician expressed the view that it would impair communication with the patient if used during the interview (although from the comment, I think this rests on the assumption that the clinician would have to face away from the patient while using the computer).

5. Awareness. In some cases, staff would ask the patient to hand their blood pressure measurements in paper form to the physician

6. Task specificity. Sometimes the system would present the physician with information relevant instead to their colleagues. One physician therefore ensured that only alerts relevant to him/her were printed out and stored.

7. Task complexity. At times the system could not manage certain complex tasks at all and a paper workaround was necessary.

8. Data organisation. Clinicians sometimes needed to view the data in different formats that were unsupported and moved instead to paper.

9. ‘Longitudinal data processes’. The researchers cite the example of viewing longitudinal INR values which was not possible on the computer system.

10. Trust. Paper was viewed by one clinician (secondary source) as providing ‘proof’ that they had documented an item.

11. Security. Due to use of a university e-mail account, paper print-outs were used in one case to avoid use of the e-mail.

Conclusions

The authors discuss the results above and draw a number of conclusions including the following:-

‘Paper-based processes are not always inefficient or inferior to corresponding computer processes. However, paper processes may circumvent the intended use of the computer system, increase the opportunity for losing clinical information, and create new potnetial paths to medical error‘

However, there are a number of limitations to this study. Firstly, the researchers did not conduct further tests to verify the results objectively. For instance, they could have observed subjects engaged in tasks and quantified their work patterns as further supporting evidence. Thus these results serve to inform further studies. Secondly, there is a small sample set consisting of professionals from a number of different disciplines. Doctors form a small sample of this group. Thus to gain more useful information specific to a profession such as doctors, further studies would be required. Thirdly, the study relates to a very specific computer system at a specific point in time and therefore a number of the results may become redundant as the system is further refined through time. 

In conclusion, the study provides preliminary evidence that paper has many useful properties which have not been translated into one example of a computerised patient record system. Perhaps this is unsurprising, given the amount of time which paper has been used in civilisation.

References

Saleem J J et al. Exploring the Persistence of Paper with the Electronic Health Record. International Journal of Medical Informatics. 78. 618-628. 2009

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The paper reviewed here is ‘Development of Criteria for a Diagnosis: Lessons from the Night Eating Syndrome’ by Stunkard and colleagues. The authors of this paper argue for the inclusion of a syndrome ‘Night Eating Syndrome’ (NES) in DMS-V. DSM-V, although not yet published,  has already produced a lot of interest. Many groups recognise this as an important time to influence the classification of mental illnesses. In their abstract, the authors conclude by writing that

‘..research on NES supports the validity of the diagnosis and its inclusion in DSM-V‘

So the question to ask on reviewing this paper is ‘Do the authors justify their conclusions?’.

The authors begin by quoting Blashfield et al’s 5 criteria for inclusion in DSM-IV. As I wasn’t familiar with Blashfield’s work I performed a quick internet search and found that he is a Professor of Psychology who has a particular interest in diagnostic classification. He was part of the working group for Personality Disorders in DSM-IV. He’s written a number of papers on diagnostic classification and has developed evident expertise in this area. Blashfield’s criteria are 1. ‘There should be at least 50 journal articles on the proposed diagnostic category in the last 10 years….’ 2. Diagnostic criteria should ‘include self-report measures, structured interviews and rating scales’ 3. ‘There should be at least 2 empirical studies by independent research groups demonstrating high interclinician correlations’ 4. ‘The proposed category represents a syndrome of frequently cooccurring symptoms, described in at least 2 independent studies’ 5. ‘There should be at least 2 independent empirical studies showing that the proposed category ” can be differentiated from other categories with which it is likely to be confused’.

Before looking at how the authors have addressed each of these 5 criteria, how useful are these criteria? Turning to the first point – ‘there should be at least 50 journal articles’ -  this seems like an arbitrary number. Why not 100 or 25? Does it matter which journals the articles appear in? What kind of articles should they be? Do editorials count? or reviews? or letters? The qualifier that they should be ‘in the last 10 years‘ also raises other issues. This qualifier means there should be, on average, 5 papers a year for those 10 years. Practically speaking there are going to be certain people or groups that are interested in specific syndromes. If this is so, then it would mean that they would need to have a high and consistent output for at least 10 years in the area of the syndrome. If they wanted the syndrome of interest to make it into DSM they would need to adopt a long-term perspective with sustained investment of (probably) significant resources.  This means that there would be a 10-year delay before new diagnoses make it into DSM and if you add the time between publication of DSM editions this could be up to 15 years. This means that people may not have commonly agreed diagnostic criteria for well over a decade and may use alternative diagnostic criteria. Within the dementias for instance, Lewy Body Dementia is one diagnosis that has more recently emerged and would benefit from the support of diagnostic classificatory systems such as ICD and DSM.

Turning to point 2, this seems entirely reasonable. The aim here presumably is to triangulate the evidence base for the diagnosis and it could be argued that this should be taken even further. Point 3 raises similar issues to point 1. Why the choice of 2 empirical studies? Surely there is a more subtle use of the empirical data which could be used in place of this. Although they refer to interclinician correlations perhaps a reference to construct and face validity might be more useful or instead of 2 empirical studies – a threshold value for inter-rater reliability. Point 4 also makes reference to 2 studies while also referring to ‘frequently cooccurring symptoms’ which is a defining feature of a syndrome – a symptom cluster. Finally Point 5 refers to the differentiation from other categories. It can be argued that this is a very useful feature as ideally it would mean that syndromes included in DSM should have little diagnostic overlap. However, many illnesses do have an overlap and the distinguishing features may take a while to emerge offering another perspective on cross-sectional empirical studies which demonstrate good diagnostic separation.

Even though these shortcomings can be raised, there has to be a starting point. The authors proceed to work through each of the criteria showing how the data has been accumulated to satisfy most of the points. The diagnostic criteria are described thus

‘1. evening hyperphagia (the consumption of at least 25% of daily food intake after the evening meal)

2. three or more nocturnal awakenings with ingestions per week, or

3. both behaviors (1 and 2)’

On the third point however they recognise a need for multicentre trials with independent investigators demonstrating good inter-rater reliability. They then add some supporting features for the diagnosis. They argue that it may act as a ‘pathway to obesity’ and that there is ‘psychiatric comorbidity’. In this regards I was intrigued to see an associated with ‘depressed mood’ but the authors note that

‘many night eaters become more depressed in the evening‘

I presumed that they italicised the word ‘more’ in order to distinguish it from the low mood that is characteristically described in the morning in depression. If this is the case, then it should be noted that the diurnal mood variation described in depression is characteristically described in the mornings but can occur in the evenings also – the important feature is that there is a consistent change in mood. So the next question to ask is ‘Can night eating form part of the clinical picture of depression?’. If it can then that has implications both for depression and for the night eating syndrome. There are further arguments in support of the diagnosis including features of the circadian rhythm.

I would be more convinced if there were substantial arguments to distinguish this syndrome from ‘healthy behaviour’. ‘Healthy’ might not be the right word here but what I mean by this is why does someone getting up at least 3 times a week and eating constitute an illness behaviour? I think it is reasonable at this stage of an illness construction to provide arguments to distinguish this ’syndrome’ from healthy thoughts, feelings and behaviours. People might for instance wake through the night for other reasons and the eating becomes associated with this period of wakefulness.

The ‘midnight snack’ in the UK became a cultural icon occurring in clever marketing campaigns for certain drinks, foods.

The R Whites campaign even won an international award for their campaign in the early 70’s. The authors also show that the SSRI’s can be useful in managing this syndrome and this emphasises the importance of distinguishing this from healthy behaviours.

While the authors provide lots of supporting evidence, it is precisely at this stage that the diagnosis needs to be examined critically and wider dialogue engaged in.

References

Stunkard A J et al. Development of Criteria for a Diagnosis: Lessons from the Night Eating Syndrome. Comprehensive Psychiatry. 50. 2009. 391-399.

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The article reviewed here is ‘Distinct MRI atrophy patterns in autopsy-proven Alzheimer’s Disease and Frontotemporal Lobar Degeneration’ and is freely available here. In the abstract, the conclusion reads

‘Compared with FTLD, AD patients had decreased gray matter in posterior parietal and occipital cortex, whereas FTLD patients had selective atrophy in anterior cingulate, frontal insula, subcallosal gyrus, and striatum (p<.001, uncorrected). These findings suggest that AD and FTLD are anatomically distinct, with degeneration of a posterior parietal network in AD and degeneration of a paralimbic fronto-insular-striatal network in FTLD‘

There were a lot of findings in this study which obviously generated a lot of data. However the conclusions above focus on answering a specific question from the data set – is there an anatomical difference between the brain atrophy that is seen in Alzheimer’s Disease (AD) and that seen in Frontotemporal Lobar Degeneration (or FTLD for short)? The researchers are quite clear in their conclusions. In AD there is degeneration in a posterior parietal network and in FTLD there is degeneration in a fronto-insular-striatal network. The temporal lobes are presumably being omitted from the conclusions because the temporal lobes are affected in both conditions.

In terms of selection of subjects, the researchers have excluded Corticobasal Degeneration (CBD) and Progressive Supranuclear Palsy (PSP) due to the pattern of anatomical involvement (see (Sha et al, 2006) for a discussion both for and against the amalgamation of FTLD, PSP and Corticobasal degeneration). This exclusion would be expected to reduce the parietal involvement in the FTLD group however as the researchers note that CBD has  an asymmetrical parietal lobe involvement. The researchers then sample a subgroup of subjects that had undergone postmortem at the University of California San Francisco Memory and Aging Centre with confirmed diagnosis of AD or FTLD. I wasn’t entirely clear on how the sampling was done (e.g. was it consecutive post-mortems?) and so there may be another source of selection bias. A number of subjects were excluded for a variety of reasons including movement artefact during the antemortem MRI studies. Antemortem dementia severity was assessed using the Clinical Dementia Rating Scale. Diagnosis was obtained antemortem using the NINCDS-ADRDA criteria for AD which I understand are quite robust and the Neary consensus criteria for ‘FTD clinical syndromes’ (other criteria for FTD have been developed subsequently).

A 1.5 Tesla MRI scanner was used and the earliest scans for subjects were included in the analysis. The authors used a previously described protocol for the Voxel Based Morphometry. Multiple comparisons were made of the voxels – AD with FTLD, AD with controls, FTLD with controls and so on. The researchers corrected for multiple comparisons by using family-wise error correction and the analysis was undertaken using SPM2. A protocol was also used for the post-mortems and the researchers specify NIA-Reagan criteria for AD and McKhann work group diagnostic algorithm for FTLD. SPSS was used for the statistical analysis and ANOVA, t-tests or Chi-squared tests were used depending on the data type.

The results of the VBM are displayed very succinctly. Comparison of AD and FTLD were shown very clearly. Both AD and FTLD had regions where the grey matter volume was on average greater than in the other group.  However I was surprised to see what was written about the correction for multiple comparisons. After the correction for multiple comparisons the only significant finding was that the grey matter volume in the striatum was larger in AD than in FTLD.

So does this negate the conclusions drawn in the abstract quoted above? It seemed so to me. I double checked the results and then looked at the discussion. In the discussion, the researchers actually comment on the correction for multiple comparisons. They write that the uncorrected anatomical differences between AD and FTLD fitted with their a priori hypotheses. These same conclusions though surely go against the assumptions in the methodology. If the correction for multiple comparisons is unimportant, why include them?

I wasn’t convinced and came away thinking that the main finding was that striatal degeneration may distinguish AD and FTLD. There are clauses though, even with this conclusion. Ultimately there was a small sample size. The confidence interval would have been wide for the volume differences which may have explained the lack of significance after multiple comparisons. The researchers give nice explanations for their hypothesised differences between AD and FTLD and it may well turn out that they are right but I don’t think this is the study to show that. Maybe this data can be aggregated with other data in a later meta-analysis (a case for an open-source imaging database for dementia studies (as in the Alzheimer’s Disease Neuroimaging Initiative).

References

Sha S, Hou C, Viskontas IV, Miller BL. Nat Clin Pract Neurol. 2006 Dec;2(12):658-65. Are frontotemporal lobar degeneration, progressive supranuclear palsy and corticobasal degeneration distinct diseases?

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News In Brief

In analysis of data from the Maastricht Aging Study, 35 healthy older adults without cognitive decline were compared with 30 older adults who displayed cognitive decline (using thresholds on several outcome measures) and in the latter group there was found to be a significant reduction in grey matter volume in the hippocampus, hippocampal gyrus, frontal and cingulate cortices. A meta-analysis of prospective studies of people with cancer and comorbid depression found that depression was associated with a significant increase in mortality and the paper is freely available here at the time of writing as well as being reported on here. A PET study of 53 people with ADHD compared to 44 healthy controls provided evidence for reduced dopamine receptors in the Nucleus Accumbens.

An emergency mobile text message system for people unable to use their voices in calls is being trialled by a number of UK telecommunication companies. A study looking at twitter provided evidence that 20% of twitters  involve exchanging information about ‘products’. Epi Collect Software on mobile devices has been piloted which enables ‘citizen scientists’ to gather data for science projects incorporating their location within the data. There is evidence from a small Japanese study (n=48) that male teenage young offenders are more likely to misinterpret disgust as anger than male teenage non-offenders. A team looking into the extinction of Neanderthals have found the remains of late ice age animals in a cave in Torquay and the remains include what could be a 25,000 year old Hyena.

Blog News

Dr Shock reports on a new resource for accessing research papers in this article. Frontier psychiatrist reveals his identity after writing an article in the Guardian. Dinah writes about the release of Jung’s new (old) book – the Red Book. Dr Jeff and Dr Tanya report on a new study showing a beneficial effect of exercise on depression in pregnancy and provide their typically high standard of useful resources at the end of the article. The Mouse Trap has returned after a brief hiatus (and is now up on Twitter). Following the debate around an earlier neuroimaging paper, Mind Hacks reports on a new paper (or rather poster) originally reported on by the Neuroskeptic titled

“Neural correlates of interspecies perspective taking in the post-mortem Atlantic Salmon: An argument for multiple comparisons correction”

The interested reader is directed to the links above but in this ’study’ the researchers subjected a dead salmon to an fMRI scan. They were ’surprised’ to find areas of activation (supported with a colourful image) in the salmon’s brain when it was presented with photographs of human faces. While there is more than one interpretation of this data (e.g. the salmon is not dead), the most ‘appropriate’ one relates to a debate about statistical methods in the data analysis – the need to correct for multiple comparisons. Mind Hacks also has a useful round up here.

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The Cochrane Collaborative have been producing podcasts to disseminate some of the results from their reviews. They already have 3 podcasts for 2009 at the time of writing. The podcasts are conveniently divided into short segments which cover an individual review and can be listened to separately which is very convenient. There was much material relevant to psychiatry.  Thus there is a review of therapies for Body Dysmorphic Disorder in this segment of the January 2009 Issue 1 podcast.  The review that is discussed finds evidence of a beneficial effect of SSRI’s, clomipramine and CBT. In this segment of the January 2009 Issue 1 Podcast, there is a discussion of approaches to reducing weight gain after smoking cessation including the benefits of exercise, a CBT approach to acceptance of weight gain and the use of Buproprion. In this segment of the January 2009 Issue 1 Podcast there is a look at a study which assessed the likelihood of publication of a paper according to the results. Trials involving several diseases were identified from the clinical trials registry and the authors found from their sample that trials with positive results had 4 times the odds of being published than the negative trials. In this segment of the April 2009 Issue 2 Podcast there is a look at interventions to reduce falls in the elderly and amongst other findings there were benefits for exercise with multiple components, tai chi and in specific circumstances cataract surgery and pacemaker insertion. In this segment of the April 2009 Issue 2 P0dcast there is a look at a study investigating the efficacy of the small and large patches for Rivastigmine and providing evidence of equivalent efficacy but with reduced adverse events with the smaller patch. These podcasts provide a useful resource, updating the listener on high-quality evidence based answers to different clinical questions.

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The blog reviewed here is ‘Jung Currents‘. At the time of writing, the blog is coloufully presented with an artistic title pane with a subtitle of ‘What’s up with Carl Jung’. The blog is written by Sparky, a psychologist who experienced a heart attack in 2005, which was a life changing experience. At the time of writing he has 27 other blogs which cover various topics and show the breadth of knowledge and interests of the author as well a focus on providing others with useful information (e.g. health). On the right hand panel there are two icons. The first is a link to people’s dreams and their interpretations on a separate page. The second links is very interesting and directs the reader to a separate site containing 40 images. The 40 images were created by Sparky following a heart attack and are linked to powerful quotations from different sources. The blog starts with this post, quoting from an article, in which psychoanalyst Dr Schenk reinterprets the act of dressing up for Halloween in Jungian terms with reference to archetypes. I found this article quite useful as it provided clear examples of how Jung’s concept of the archetype can be seen in popular settings. This helps the reader to understand the concept much more clearly and to appraise this critically. For example the simple act of a musician dressing up as a character from ‘undercover agent’ is interpreted in terms of the hero archetype and this is particularly appropriate when the musician describes how the effects that this action has on his thoughts and feelings. The implication seems to be that if the imagination incorporates elements of the archetypes that it resonates with the person’s psyche. The sceptic might argue that the act of choosing the hero costume has nothing to do with the archetype but that the costume has been chosen for idiosyncratic reasons or that one of the costumes was bound to be interpreted in terms of archetypes (i.e. selection bias) or that the concept of the archetype overlaps with although being distinct from popular cultural icons (which might arise for different reasons). Perhaps a biologically validated explanation for the archetype would be particularly convincing (whether that results from nature or nurture). In this post,  Sparky introduces the reader to Peter Birkhauser, an artist who spent many decades interpreting his dreams, undergoing analysis and creating paintings based from his dream material. In this post, there is an interpretation of a 4600 year-old dream of Gilgamesh, a figure from the Babylonian literature. There is apparently some controversy over whether Gilgamesh was an actual historical figure and this in addition to the drawbacks of interpretations based on historical records should be borne in mind (see here for information on the above (at the time of writing)). There is also a link to this site which contains references to Jung’s quotations. Here is an example.

‘All the most powerful ideas in history go back to archetypes. This is particularly true of religious ideas, but the central concepts of science, philosophy, and ethics are no exception to this rule. In their present form they are variants of archetypal ideas, created by consciously applying and adapting these ideas to reality. For it is the function of consciousness not only to recognise and assimilate the external world through the gateway of the senses, but to translate into visible reality the world within us‘

In this article, I was amused to find out that Jung has several profiles on MySpace. Apparently Freud has more profiles at the time of writing!

Although having relatively few articles at the time of writing, I found this blog (together with the linked references) to be very ‘deep’ and having many aspects – the personal narrative of a life-changing experience, the expression of Jung’s concepts and people’s experiences in art and the expression of Jung in the collective ‘internet’ conscious (or unconscious?)*.

Footnotes

* Indeed through this medium is it possible that Jung could himself become an archetype?).

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The featured audiobook is ‘50 Philosophy Ideas You Really Need to Know’ by Ben Dupre and narrated by Laurence Kennedy. Philosophy is a close neighbour of science and the intersection between the two is exemplified by philosphers such as Kuhn and Popper who can be said to have very strongly influenced the conceptualisation of science. The contents of this book are much broader than science covering areas such as morality, language and the origins of life. Firstly I thought that Laurence Kennedy does an excellent job of narrating with rich intonations, clearly articulated alternating with amusing impressions of various fictional characters. The combination of this narration with the brief outline of the 50 important philosophy ideas and the summary sentence  make this very easy to listen to. I learnt many things from listening to this such as the difference between a skeptic and a critic, utilitarianism, that the Plato’s Cave allegory has multiple layers in the interpretation and that Wittgenstein demonstrated the shared nature of language and reasoned against the validity of a private language. I find that books such as these, act as a map of sorts, helping to identify important markers for navigating in the philosophical ’sea’. Many of the ideas discussed in this work have potential applications in discussions of healthcare services and in consideration of health (e.g. the virtues) and illness. I found this to be an enjoyable audiobook, which made complex ideas easy to understand. 

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The paper reviewed here is ‘Public Views of Mobile Medical Devices and Services: A US National Survey of Consumer Sentiments Towards RFID Healthcare Technology’ by James Katz and Ronald Rice. As the title suggests, this paper is about mobile healthcare technology. The authors refer to RFID which stands for Radio-frequency Identification which is a means for geographically locating a chip using a radio-frequency emission from that same chip. At the time of writing, this technology appears to have been used in a number of transport systems across the world, for instance at toll booths or in some railway services or in other cases to ‘label’ assets to keep control of stock.  However another application is in healthcare and there has been some suggestion that the devices could be used to avert medication errors by containing valuable medical information that can be read by relevant devices. The most extreme example of suggested healthcare technologies are those in which the devices are implanted although I wasn’t entirely clear on why this would be necessary as a bracelet would contain necessary localising information. The most obvious healthcare applications are those in which the position of the device is used to estimate movement and indirectly therefore energy expenditure. The authors set out to see what the public’s (US) views were on the health applications of this emerging technology. The authors note in their introduction

‘As to RFID technology, a 2006 press release said that the technology is being used in areas such as laboratory analysis, mammograms, blood transfusions, medication delivery, prostate treatment, and LASIK eye surgery‘

In the introduction, the authors note a 2003 study in which the participants were largely unaware of the technology and of those that were aware of this technology, a small percentage viewed the technology ‘unfavourably’ due to health and privacy concerns they held. In the present study, the researchers sampled 1404 americans over the age of 17 using ‘random-digit dialing’. Thus already there will be some selection bias towards those that are in their house or have access to the landline at the time the researchers call and who are also willing to complete the survey. They checked the sample characteristics however and they were comparable to general population data from the US Census Bureau. They used 4 sets of questions

1. Questions relating to ‘general new video and text services for mobile phones’

2. Questions relating to ‘interest in potential healthcare services’

3. Questions relating to ‘trust, social support, and several Internet and privacy topics’

4. Questions relating to standard demographics

They asked about RFID’s on either mobile phones or else attached to the arm using ‘long lasting tape’. For the first set of questions, 71.2% favoured having a ‘hotline to the doctor’ and nearly a quarter were interested in having regular health updates. In the second set of questions, the researchers found that there was an emerging hierarchy of responses with emergency information and financial (although the insurance aspects of US healthcare policy at the time of writing should be borne in mind) favoured over health information updates. Interestingly if the more ‘invasive’ long lasting tape option was used respondents were more likely to rate the health information updates unfavourably. Regarding the third set of questions, the respondents average response indicated that they felt that too much information was given to companies and that understandably, people should have the right to control their personal information. In terms of the demographics, 54.3% were female and 77% white/caucasian with 29.6% being college graduates, 63.1% being married and 18.5% reporting income of at least $100,000 per annum.

What I found particularly interesting in this study was that there was a favouring of the use of mobile technology for emergency healthcare advice over the use for monitoring. I wasn’t entirely clear on many of the healthcare applications of RFID at this point and this might become clearer as time goes on. There didn’t appear to be strong feelings against or for the technologies on the whole from this paper although in very specific areas there were as the responses regarding emergency healthcare suggest. The results might well be different and indeed heterogenous were 10 or more viable and functioning healthcare applications presented for consideration by participants and I wonder if the framing of a more general question about the use of a technology (as in this study) is as useful as for very specific applications. The additional question which is quite useful is how much such surveys are predictive of the incorporation of such technologies into wider culture.

References

James Katz and Ronald Rice. Public Views of Mobile Medical Devices and Services: A US National Survey of Consumer Sentiments Towards RFID Healthcare TechnologyInternational Journal of Medical Informatics. 78. 2009. 104-114.

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The paper reviewed here is ‘Junior Physician’s Use of Web 2.0 for Information Seeking and Medical Education: A Qualitative Study’ by Benjamin Hughes and colleagues. The authors use a qualitative approach in order to characterise the use of Web 2.0 technology by 35 junior physicians and the conclusion of the abstract reads that

‘Results indicate that 53% of internet visits employed user-generated or Web 2.0 content with Google and Wikipedia used by 80% and 70% of physician, respectively‘

and this

‘Despite awareness of information credibility risks with Web 2.0 content, it has a role in information seeking for both clinical decisions and medical education‘

In interpreting these results, it is necessary to see firstly how the physician’s were sampled and their characteristics. The researchers chose graduates of a London Medical school and employed stratified sampling to ensure doctors were chose from a variety of specialities. Those that were chosen were either Foundation Year 2 or ST1. The authors suggest that this group would have a ‘Generation Y attitude towards the internet’. The term apparently refers to people born after 1975 and who are more comfortable with the internet than their parents (I’m not sure how valid this term is as there will no doubt be many factors that determine how a person interacts with the internet which could feasibly reverse the aforementioned relationship).

The researchers use three approaches to investigate the attitudes of the participants to Web 2.0 technology – questionnaires, a semi-structured interview and the use of a diary. Thus over a period of at least 5 days, the participants would keep a diary of their use of the internet including ‘the perception of whether they had used open or user-generated content versus sites where immeidate user contributions were not allowed’. I would argue that such questions have the potential to influence the behaviour of the participants. If a participant was keeping a diary for five days, they would surely be aware of the user generated content issues as they were using the internet. It is possible (although it would need empirical support) that if the participant was focusing on this issue during diary completion, this might influence in some way their tendency to seek user generated content. Perhaps a retrospective diary might avoid this possibility although this would create other drawbacks. The interviews were completed after the diary and here I would argue that the order should have been reversed. Thus a questionnaire prior to the diary filling would have avoided the risk of further bias secondary to the issues raised in the diary. I wasn’t able to find a definition of Web 2.0 nor a reference to Health 2.0 or Medicine 2.0 although both the latter terms have been assessed using a grounded theory approach.

A particular strength of the study was the use of 2 coders for the data that was acquired with a strong correlation in the marking as well as multiple data sources for triangulation (although noting the limitation above). 89% of the physicians used 1 or more ‘Web 2.0 tool in their medical practice’. In terms of other themes that were explored, this methodological approach provided quite rich data. An emergent theme was that Web 2.0 resources were utilised for background reading with one phyisican reporting being able to rapidly cross-reference one source with another. With closed questions (e.g. specific treatment questions), ‘best-evidence tools’ were used. There were further interesting comments about how Web 2.0 tool use was impacting on clinical practice. One physician defended the use of Web 2.0 technology by physicians, arguing that confirming information using such technology, while giving the appearance of a lack of knowledge should be more encouraging as it signals a checking strategy. Another theme that emerged was that physicians wanted more access to Web 2.0 tools at their workplace commenting that such sites were usually blocked at the workplace.

In conclusion, this is a study with a small sample size which is suitable for the qualitative aspects of the study. However for the quantitative aspects reported in the abstract, there would be benefits to larger replication studies. The results of this study lead to further interesting questions. We are seeing a marked cultural shift. A parallel question historically might be – what difference did Television and Radio make to the way doctors practiced or learnt (if any)? Should the use of sites with lower standards of evidence that the ‘best evidence’ tools be a cause for concern? I would argue that it depends on the use of the information. Physician’s interpret information – it is part of a doctor’s role. The internet and Web 2.0 technology has thrown up a massive amount of information sources and various tools for accessing this information. The assessment of the quality of information is a necessary skill in various kinds of decision making. Thus the question should be asked ’should we completely ignore low quality information sources’. The results from this study suggest that some doctors at least, triangulate their use of perceived low quality data sources – a sensible strategy for making use of this easily accessible information. It will be interesting to see in the not too distant future how a generation of ‘cloud computing‘ physicians practice (although it remains to be seen if that technology emerges successfully).

References

Hughes B, Joshi I, Lemonde H and Wareham J. Junior Physician’s Use of Web 2.0 for Information Seeking and Medical Education: A Qualitative Study’. International Journal of Medical Informatics. 78. 2009. 645-655.

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The article reviewed here is ‘Accelerated Clinical Decline in Well-Educated Patients with Frontotemporal Lobar Degenerations’ by Robert Perneczky and colleagues. The authors investigate the effect of education on clinical progression in Frontotemporal Lobar Degeneration (FTLD). The latter part of the abstract for the paper reads:

‘There was a significant positive association between education and CDR-SOB monthly rate of change, indicating a faster decline in the well-educated. Education was the only significant predictor of clinical deterioration‘

On reading the paper, I was thus interested to know what conclusions I could draw with regards to education and clinical progression in Frontotemporal Lobar Degeneration – what was the nature of the relationship described in the last sentence? and how convincing was the association between education and rate of clinical progression. In the introduction, the authors note some of the data on the relationship between higher levels of education and a ‘protective’ effect against dementia which translates into a higher threshold of progression of the underlying pathology before symptomatic manifestation followed by a period of more rapid symptomatic progression. The implication is that  cognitive reserve (equivalent to more years of education) increases the threshold for symptom detection (although this may not be the only effect). The question here is obviously more restricted, applying to FTLD.

Turning to the methodology, I wasn’t clear on the sampling procedure. The authors note which department the subjects were recruited from, identify them as being ‘consecutive’ subjects meeting the inclusion  criteria although I couldn’t identify these same criteria (or exclusion criteria). Two psychiatrists undertook the clinical examination using the Manchester-Lund criteria supported with the results of relevant clinical investigations which included a neuropsychological battery containing executive/frontal tests. Severity was assessed using the Clinical Dementia Rating Sum of Boxes (German edition). A number of the patients were taking antidepressants and anticholinesterase inhibitors/memantine (which might be expected to influence progression) and so there are already a few important ways in which the sample group is heterogenous (subjects were also stratified according to subtypes of FTLD – FTD behavioural variant, non-fluent progressive aphasia and semantic dementia). The authors also note that the ‘follow-up visit was based on a telephone interview in all patients’. They calculated disease progression as the endpoint CDR severity minus the baseline CDR severity divided by the time interval.

I interpreted the primary hypothesis as being the relationship between years of education and rate of disease progression. The authors note that they use backward and forward regression models and also an ‘exploratory analysis’ of the data which they argue precludes the use of a correction for multiple comparisons.

There were 35 subjects included in the study (22 with FTD, 5 with SD and 8 with NFPA). With regards to the primary outcome measure, years of education versus rate of progression, this data was illustrated in Figure 1 (a scatterplot) in the paper which shows a positive correlation between monthly rate of progression and years of education. Inspecting the scatterplot, it appears that with increasing years of education there is a wider spread of data around the regression line. The p value for the correlation is 0.02. However in terms of clinical significance a change of 0.2 points in the CDR correlated with an additional 9 years of education. A 1 point difference on the CDR for instance is the difference between ‘very mild’ and ‘mild’ severity. So 1/5 of this difference equates roughly to an extra 9 years of education. Nine additional years of education seems like quite a lot of additional education! As the remainder of the analysis was exploratory, I preferred to reserve judgement.

In conclusion, there was a significant correlation between the primary stated outcome of interest – years of education and the progression in clinical severity as measured using the Clinical Dementia Rating Sum of Boxes (German version). However, I thought that the effect size was relatively small. This study provides results which can be used to draw preliminary conclusions about the relationship between clinical progression and years of education in FTLD but as further studies of this nature appear, the possibility of aggregating data in a meta-analysis will become viable.

References

Perneczky R et al. Accelerated Clinical Decline in Well-Educated Patients with Frontotemporal Lobar Degenerations. Short Communication. Eur Arch Psychiatry Clin Neurosci. 2009. 259. 362-367.

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News in Brief

There was found to be a significant association between a variant in the gene LINGO1 and Parkinson’s Disease and Benign Essential Tremor suggesting that this gene may be involved in both conditions. The gene variant is identified with approximately 5% of people with either condition. A gene sequencing process mrFAST (micro-read Fast Alignment Search Tool) has demonstrated utility in detecting duplicated genome sequences and the researchers have noted an increased number of copy number variants in genes which are located in a segment of the genome which underwent significant duplication in the ape/human ancestor. The process has implications for detection of diseases in which copy number variants need to be estimated and has also been used in the 1000 Genome Project.

An interesting study provided evidence that early stages of the visual perception process were influenced by cue associated emotions and memories. Subjects were presented with faces showing different expressions and the subject’s rating of the emotions in the expressions was correlated with the activation of  their own facial muscles when the same faces were re-presented after having been modified to exhibit a neutral expression. Some evidence that reminiscence therapy can improve memory in the elderly is provided from a review of reminiscence therapy studies that was published in Scientific American Mind which also looks at other outcome measures. It will be interesting to see the results of a meta-analysis once further studies are available.

A comparison of longitudinal and retrospective studies provides evidence that people underestimate their experience of mental illnesss retrospectively. An American study of physician-patient interactions in primary care practices in Baltimore found a significant difference in communication-related outcome measures between white and black patients in areas including psychosocial interactions in consultations relating to blood pressure control. The researchers suggest that interventions focusing on doctor-patient communication may influence ‘racial disparities in the care of patients with high blood pressure’ although such research may have benefits in other areas of health care. The BMA has released a new document on ‘the effect of alcohol marketing on young people‘ and there has been wide reporting on this in the media.

In a fascinating anthropological study of the fairy tales Little Red Riding Hood shows that this fairy tale probably has a very ancient origin. There were subtle differences across the world – for instance in China the wolf is replaced with a tiger. The most closely related versions to the modern European were those from Nigeria and Iran. There are many forms of analysis of fairy tales including psychoanalysis (see here, here and here for instance. A study published in Science (n-192) and using a public goods game paradigm (used in the study of group behaviour) provided evidence that using a reward strategy for ‘good behaviour’ produced better outcome (e.g. contributions to the group) than with the use of punishment for ‘bad behaviour’. Evidence has been found that a species of New World Monkey – the Cotton Topped Tamarin are able to distinguish between ‘affiliate’ and ‘fear’ music produced by other monkeys. Such studies are useful for debates in Evolutionary Psychology.

An application - healthii - has been developed with the intention of improving the well-being of people engaged in social networking online. A recent trial on Twitter at the end of August and the findings should be reported in the near future. A Twestival Local (a local festival on twitter) is taking place (see the site here) to raise money for charity. There are two types of festival – one is global and the other involves individual cities which are identified on the map here. This shows one of the many extraordinairy ways in which Twitter is impacting on society globally.

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The podcasts reviewed here are the 27th and 28th in John Betts excellent series on Jungian Analytical Psychology which provides the listener with an accessible introduction to Jungian Analytical Psychology.

In the 27th episode, Betts tells the listener that there have already been 135,000 downloads of podcasts in the series demonstrating the well deserved success of Betts generous introduction to this subject. He then continues the discussion of individuation from the previous episode. He is careful to distinguish between individualism and individuation which are described as equivalent to the contrast between self-realisation and alienisation. Indeed this simple contrast is a valuable insight which facilitates an understanding of individuation. Along the way the term Jungianism is used, which apparently refers to a statement made by Jung that does not stand up to close scrutiny. In the 28th episode, Betts continues the discussion of individuation. This is an extremely interesting episode in which Betts brings his own experiences of another culture into the material. He considers the relationship between the individual and society during the process of individuation. What I found particularly interesting here was Bett’s suggestion that there is a marked contrast between Western culture and other cultures (he references a tribal culture) in the rites of passage into adulthood. Thus he describes the role of preparation for adulthood which may involve ritualistic dances and body piercing and suggests that this special period of preparation hasn’t been formalised in Western Culture meaning that teenagers effectively develop this themselves in behaviours that are can be considered rebellious. This is certainly a fascinating interpretation. He then looks at some of Klein’s writing on the subject of development – with the return through life to earlier phases of development e.g. the paranoid-schizoid position. He also looks at the stages of individuation as outlined by Jungian Analyst Murray Stein. Stein has written many influential books on the subject of individuation.

At the time of writing, these were the last in Betts excellent series on Jungian Analytic Psychology although it would be great to see more in the series as Betts produces engaging material and uses the medium very effectively. Betts also has a blog in which he answers questions about Jung here.

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The blog reviewed here is ‘The Differential Biology Reader‘ by Mark James Adams. At the time of writing, I thought that visually the blog was very well presented. The background is white throughout which gave a feeling of space and simplicity. A number of blogs have different colour backgrounds for the title pane, articles and side panes. These ‘frames’ within the page still exist but the design demonstrates that they do not necessarily need a clear visual boundary (e.g. colour change) for the separate spaces to be registered by the reader. Another feature of the blog is the use of interesting photographs of monkeys (the subjects of Adams research) with a standardised size which complement the overall design. The blog is effectively indexed with links at the bottom of the page – there were 8 ‘pages’ at the time of writing.

Adams describes himself thus

‘I am a student of quantitative genetics and a temperamental psychologist. Investigate personality in wild animals. A question I am trying to answer is Why do our personalities differ‘

Elsewhere, Adams informs the reader that he is studying Japanese Rhesus Macaques  (see here for my recent trip to Maharashtra District, India to observe the Rhesus Macaque here, here, here, here and here). Personality is in my opinion, a very difficult construct to define as it encompasses  (but is not limited to) identity, behaviour, cognition, emotions, social roles, relationships, values as well as debates on the roles of genetics and the environment. I would argue therefore that the study of primates can give us valuable insights into ourselves, on the basis of our close evolutionary relatedness together with an ability to study behaviours in the absence of either a spoken language or the symbolic tools of human civilisation. The chimpanzee and Bonobo would be expected to offer us the greatest insight into ourselves on the basis of evolutionary proximity.

The blog appears to start with this article (which is the earliest I was able to identify) which is dated July 5th 2008. Marks refers in a later post to open access and links to this article at PLOS one in which the researchers examine the relationship between brain activity and anxious temperament in primates. In another article, Marks looks at Imanishi Kanji who apparently developed the field of primatology. Marks notes that some of the articles he examines are not open access which I think is the case with the cited article in this post in which he reports findings that show that ‘Mellow Monkeys have Fewer Friends’. Why do macaques throw stones? – Maybe it’s just spontaneous as suggested in this post. 

In this article, Marks discusses the five factor model and the reader can try this out on themselves by following the link to the online questionnaire. The first question in studying personality in primates to gain a better understanding of human personality  is whether the concept of a primate personality is valid? This was actually the subject of a symposium described in this article. Along the way Marks makes some interesting comments on science research as in this post in which the statistical analysis of some studies is called into question. What I also found of potential interest is Mark’s reference to tools for creating life charts (as I wondered about the possible applications). He also considers traits in other species as well as cultural differences in personality. Here he reports on a Genome Wide Association Study looking at markers for 5 personality dimensions while also noting that only approximately 1% of variance is accounted for. Here he looks at how paleobiologists and archaeologist graphs of cultural evolution could be misinterpreted. A tool for assessing the personality of a blog was another useful resource. 

In the Differential Biology Reader Blog, Marks focuses on personality in humans and personality in primates (and other species). The blog is well presented, the material interesting and I found lots of useful resources for the study and understanding of personality.

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The audiobook reviewed here is ‘Spark’ by John Ratey and narrated by Walter Dixon. The narrator speaks clearly and in such a relaxed manner and with such apparent familiarity with the subject material that I had thought throughout most of the audiobook that it was the author narrating. I found this to be an uplifting book which promotes the benefits of exercise with reference to the evidence base. Ratey provides a convincing argument for bringing exercise into the treatment of different mental illnesses. The conditions he covers include depression, anxiety, dementia, ADHD, alcohol and substance misuse. Throughout the book he not only references the research literature but also illustrates his core arguments with case studies. While there is sufficient detail for this to be useful for health practitioners, I thought this book would particularly appeal to the public as Ratey is able to convey the essence of the science in a simple, accessible manner. He invokes references to neurotransmitters including serotonin, dopamine and opioids  as well as the importance of the Nucleus Accumbens and the Hypothalamic-Pituitary-Adrenal Axis. I was interested to learn that blood flow to the prefrontal cortex is apparently reduced during exercise (from an evolutionary perspective the opposite may have been expected – if hunting has played an important role in our recent evolution then we might expect movement to be associated with the use of executive/prefrontal cortical functions as prey is hunted). What I also found interesting was Ratey’s speculation that the benefits of exercise and of vegetables in the diet may be the induction of a stress response leading to cellular resilience. Ratey also talks about exercise as a brain building activity and he refers to the use of an innovative exercise program used in a school in Naperville, Illinois and associated with improved fitness levels and speculatively also with significantly improved academic results when compared to schools nationally in the USA. Ratey has taken on an ambitious task by covering a wide range of mental illnesses and specific situations where exercise may lead to improved outcomes. Conveying this is no easy task and to do so in a very interesting and persuasive manner is all the more impressive. No doubt, further studies will be undertaken to examine the relationship between exercise, the brain and mental illness. However Ratey’s book leads to inexorably to the consideration of how exercise programs could be used in mental health services.

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I have had the great privilege of writing a foreward for a new book by Jason Tune titled ‘Stigma. Worse than Psychosis’  which is available in both paperback (here) and e-book formats (here) from publisher Chimpunka. Jason has written courageously about his experiences of the stigma associated with a mental illness so that he can give hope to others who are in a similar position. Jason has gone from strength to strength and as he writes in the book is now working as a STAR (Support Time and Recovery) worker. The book is cowritten by Martin Warburton who has included a chapter about his own experience of stigma which complements Jason’s story. Finally, for people who aren’t familiar with the publisher Chipmunka, they focus (although not exclusively) on publishing books by people who have experienced mental illnesses and to quote from their site ’so that we can give more people a voice and change the way the world thinks about mental health’. There will be more here on Jason’s book in the future!

The article reviewed here is ‘Can Wireless Text Messaging Improve Adherence to Preventive Activities? Results of a Randomised Controlled Trial’ by Mihail Cocosila and colleagues. As the title suggests, the aim of the study was to determine if text messaging could influence health behaviour. In brief, the researchers conducted a randomised controlled trial in which half of the participants received text message reminders to take vitamin C and the other half did not. The primary outcome was the number of ‘pills’ taken. From the abstract, it can be seen that there wasn’t a significant difference between the two groups in the number of ‘pills’ taken. There was however a significant correlation between the number of return texts by participants and the number of ‘pills’ they had missed. So the main questions here are whether text messaging isn’t very helpful in improving health behaviour and whether information on the returned text messages is both valid and if so – is it useful?

Before turning to these questions, I was interested on reading through the introduction to see that there is an International Expert Forum on Patient Adherence and also to hear the researcher’s views on the potential health utility of text messaging:

‘Wireless text messaging applications have qualities that make this mobile service suitable for some interventions to address patient adherence through portable devices like cell phones: ubiquity, low intrusiveness, low cost and relative simplicity‘

Returning to the questions above, the first is – can we draw the firm conclusion that there is no direct relationship between health behaviour and use of text messaging as in this study? Well there are a few reasons why these results might not exclucde a beneficial use of text messaging for health behaviour. Firstly this is a small study and there is always the possibility that a larger replication study will produce different findings. Secondly it is difficult to know how taking Vitamin C can generalise to other health behaviours. Taking Vitamin C as a general and hypothetical preventative measure differs from other preventative measures such as exercise and also from taking prescribed medication for illnesses. Thirdly this is not representative of the general population (in the UK) as the participants were on average 23 years old. Also particpants were paid to take part and this financial incentive may have influenced their behaviourand differs from the need to take prescribed medication for an established illness. Fourthly in terms of the results – the researchers actually find and report a significant difference in adherence (change from baseline consumption of Vitamin C to endpoint) between the intervention and control groups using an ANOVA. Indeed the p value is very highly significant (p=0.001). The researchers note this might not be a meaningful difference as it amounts to an extra tablet each week. However they had not identified what would be a meaningful difference. So statistically significance is reached but it’s meaning is difficult to interpret. In terms of the number of tablets missed in the final week there was no statistically significant difference. So in conclusion, while an extra tablet a week may not be considered meaningful by the researchers there is some scope for arguing either way particularly as this a small study (n=99) which may be insufficiently powered to detect a ‘meaningful’ difference (there is an additional difficulty in that prior data would have been needed to determine a satisfactory sample size but this is an innovative study).

The second question is can we draw useful conclusions about the returned information. Here the intervention group returned information to the researchers – responses to the researchers text messages. However it was a bit of an unfair comparison as the control group didn’t have any text messages to respond to! In my opinion this part of the study lacks an appropriate control.

There were many more issues in the study which were considered – there were detailed statistical analyses, inclusion and exclusion criteria, a Java script for random allocation (which however was treated as a black box as far as I could tell), an increase in adherence rate in the control group (which perhaps represents a placebo effect – making no judgements about whether this is statistical or psychological) and controlling for overestimation.

In conclusion, this study looked at an important emerging healthcare phenomenon which incorporates mobile phone technology and while having a small sample size, can be used to inform power calculations and in meta-analyses.

References

Mihail Cocosila, Norm Archer, Brian Haynes and Yufei Yuan. Can Wireless Text Messaging Improve Adherence to Preventive Activities? Results of a Randomised Controlled Trial. International Journal of Medical Informatics. 78. 230-238. 2009.

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Is Twitternet Addiction a viable diagnosis? Or SMS addiction? Or mobile phone addiction? Or landline addiction? Or conversation addiction?

Twittering is appearing in lots of places. Is Twittering responding to culture or is it driving culture?

Maybe because twittering is getting popular or people are used to SMS texting….or maybe there’s an innate drive to communicate briefly

Why would people choose to restrict the length of their text when there are alternatives (such as blogs) or e-mails or leaving comments?

Twitters could be longer – just as long as blogs – but they aren’t. It’s a choice and one that’s becoming more popular…a twitter culture.

There is just enough length to say a sentence or two or to reference an interesting link on the internet – a dynamic weblink of sorts

The twitterer is limited to 140 characters. So communicating becomes a bit like texting and contrasts with the lengthier style of blogs.

What’s the difference between Blogging and Twittering? Here are a few posts on the blog in twitter style – an exploration of the medium!

The paper reviewed here is ‘The Delusional Misidentification Syndromes: Strange, Fascinating and Instructive’ by Christodolou and colleagues. This is a brief overview of the Delusional Misidentification Syndromes (DMS), a collection of syndromes in which the person holds delusional beliefs about the identify of another person, people or object(s). George Christodoulou has significant experience in this area having authored an article on this as far back as 1978 in which he first described and named the syndrome of subjective doubles. The collective familiarity of the authors with the DMS’s is demonstrated by their extensive references to the occurrence of the DMS in mythology and literature. The four DMS’s are described as Capgras Syndrome (in which familiar people are believed to have been replaced by doubles), Fregoli Syndrome (in which a stranger is recognised instead as a familiar person), Intermetamorphosis Syndrome (in which the familiar person and the other person have the same psychological and physical identity and can swap places) and the Syndrome of Subjective Doubles (in which the person believes that other people physically transform into themselves). The authors then cover a number of explanatory models for the DMS’s including agnosia of identification secondary to mismatching of sensory input and memories, defence mechanisms (e.g. projection and splitting), ‘regression to archaic modes of thought’, dysfunction in the right cerebral hemisphere (as well as a similarity to the reduplicative phenomenon), Bruce and Young’s adaptation to a face-processing model, Young’s interactionist model and Coltheart’s two-stage model. The article is succinct and the authors expertly navigate through this esoteric field which spans nearly 100 years. Perhaps a neat unifying theory may not be forthcoming given the considerable variation in phenemonology, comorbidity and sequalae and the field may settle with a number of successful explanatory models with identifiers for their use. Christodoulou and colleagues have written a concise and useful overview of the field which includes some of the most recent models for those interested in the Delusional Misidentification Syndromes.

References

G.N.Christodoulou et al. The Delusional Misidentification Syndromes: Strange, Fascinating and Instructive. Current Psychiatry Reports. 2009. 11. 185-189.

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The article reviewed here is ‘Delirium: Sifting Through the Confusion’ by Raheel Khan and colleagues. In the introduction, the authors place delirium in context by presenting demographic and other data. The authors intention for the article is to discuss the causes and treatment of delirium.

They start with a case study and subsequently discuss this citing relevant references, and covering risk factors including polypharmacy, mechanical ventilation, opioids, benzodiazepines as well as a number of other precipitants from the case study. The first case is broken down into two further parts – but together forming a narrative structure. After each segment of the case is presented there is a discussion which cites widely from the literature. The authors state that there is no FDA approved treatment for delirium and then go on to consider the advantages and disadvantages of antipsychotic medications. 

Table 2 in the paper is a very useful table which outlines some suggested advantages and disadvantages of medications that have been used in delirium. 

In the second case, the presentation includes traumatic brain injury and the authors consider this in the subsequent discussion. They then look at the pharmacological treatment of delirium and in figure 2 there is a complex treatment pathway which looks at the management of hypoactive or hyperactive delirium (although I wasn’t able to identify mixed delirium). Along the way, the authors speculate about the different processes that may lead to delirium and form the beginnings of a pharmalogical rationale for approaching delirium while also recognising in ther final discussion the limitations in the field and the need for further research. 

While relatively brief and necessarily case-based, I found the authors persuasive in their argument for a structured pharmacological approach to the treatment of delirium. 

References

Raheel A.Khan, Debra Khan and James A. Bourgeouis. Delirium: Sifting Through the Confusion. Current Psychiatry Reports. 2009. 11. 226-234.

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Three genes associated with Alzheimer’s Disease have been identified in 2 new studies published online today in Nature Genetics. Amouyel and colleagues conducted a two-part study (Amouyel et al, 2009). In the first part of the study they undertook a Genome-Wide Association Study involving 537,029 single nucleotide polymorphism’s (SNP’s) in a French sample of 2032 people with Alzheimer’s Disease and 5328 controls.As there were multiple comparisons, they needed to control for this (with a Bonferroni correction) and a marker in the CLU gene on chromosome 8 (8p21-p12) showed a statistically significant correlation just above the threshold.

They then attempted a replication in the second stage which involved 3978 probable cases of Alzheimer’s Disease and 3297 controls. This second stage involved subjects from Spain, Belgium and France. They confirmed a statistically significant association of CLU with the probable Alzheimer’s Disease subjects and additionally found a significant correlation with CR1 on chromosome 1 (1q32). The researchers then estimated the contribution of each gene to the risk of Alzheimer’s Disease and estimated that the attributable risk for APOE (a well established risk factor for Alzheimer’s Disease) was 25.5%, for CLU it was 8.9% and for CR1 it was 3.8%. Nevertheless the CR1 did not show up in the first stage of the study.

In the second study, Professor Julie Williams and colleagues (including Professor Michael Owen) undertook another two part study. This involved ‘up to 19,000 subjects’ in the initial stages of the study, these subjects being recruited from Europe and the United States. Again, this was a Genome Wide Association Study. After quality control measures, they looked at 529,205 autosomal single nucleotide polymorphisms in 3,941 people with Alzheimer’s Disease and 7,848 controls. They identified one marker in CLU (the same gene identified in the study above) and a second in the PICALM gene on chromosome 11. Importantly both of these findings were replicated in the second stage of the study which involved 2,023 people with Alzheimer’s Disease and 2,340 age-matched controls.They then looked further to see if they could identify which areas within the gene were significantly correlated and produces some candidate regions. The team point out that there are other significant genes which wouldn’t have been identified in this analysis.

Thus the three identified genes were CLU, PICALM and CR1.

The CLU gene (Clusterin) which was identified in both studies encodes an apolipoprotein which together with APOE is found in the central nervous system as well as other tissues. There are many suggested pathways for the involvement of CLU in the pathology of Alzheimer’s Disease. Thus CLU is found in the amyloid plaques found in Alzheimer’s Disease and there is evidence also suggesting that it may be involved in the removal of Beta Amyloid from the brain (by forming soluble complexes which can cross the blood brain barrier) and may play a role in inflammation in the brain.

The PICALM gene which was significantly associated with Alzheimer’s Disease in the second study encodes a protein that is involved in endocytosis. Mutations in PICALM (phosphatidylinositol-binding clathrin assembly protein) may therefore interfere with the transport of materials into the neurons and the team suggest that synaptic vesicle cycling may affected (for another study looking at vesicle cycling see the study below which involved a newly discovered protein – the Flower protein which may be involved in Calcium regulation within the neuron emphasising the importance of endocytosis in neuronal functioning).

The CR1 gene which was significantly associated with Alzheimer’s Disease in the second stage of the first study, encodes a receptor for C3b protein. The C3b protein forms part of the complement cascade and again there is some evidence suggesting that it may be involved in the removal of Beta Amyloid. The CR1 receptor may be involved in the process of phagocytosis  – when material is ingested by the immune cells.

Now that these gene associations have been identified it will be interesting to see further replication studies as well as studies examining the possible roles of these genes in further detail.

Two large studies ( n=2978 and n=1760) published at PLOS Medicine, looked at how patients make choices regarding medications and amongst the findings, people were best able to understand medication outcome information if this was presented in simple frequencies (e.g. per 100 of the population). Further information on the trials can be found here and here together with a discussion of shared decision making here. The N60 region of the RanBP9 protein has been associated with an increased production of Beta-Amyloid production using post-mortem and cell culture data and these findings may lead to the development of novel therapeutic interventions for Alzheimer’s Disease. This protein binds to another protein which is involved in the movement of RNA through the pores in the nuclear membrane. RanBP9 interacts with several other proteins also. A new finding reported in the journal Cell is that cells are able to move using a newly identified mechanism which involves a folding of the membranes to form filopidia and this involves the use of a protein sRGAP2 which is associated with neurodevelopmental disorders. This may have important implications for the understanding of neurodevelopment. A new gene association with deafness has been identified. Loxhd1 mutations impair functioning of hair cells and subsequently with hearing. Mutations of this gene were found in some families with deafness  (in a genetic database with genetic samples from hundreds of families with deafness). A protein – called the Flower protein – has been recently identified and found to play a role in the processes of endo and exocytosis whereby neurotransmitters are packaged into vesicles, released from the neuron and the membrane resorbed. Aggregates of the protein form channels which allow the entry of calcium into the cell and the research team suggest that this protein could be responsible for the close and necessary coupling of endocytosis and exocytosis.

References

Amouyel P et al. Genome-wide association study identifies variants at CLU and CR1 associated with Alzheimer’s Disease.  Nature Genetics. Advanced Online Publication (Published Online 6 September 2009).

Williams J et al. Genome-wide association study identifies variants at CLU and PICALM associated with Alzheimer’s Disease. Nature Genetics. Advanced Online Publication (Published online 6 September 2009).

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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

In August 2009, a Twitter was launched allowing updates and a look at relevant areas in the ‘twittersphere’. I also experimented with the news in video format (see the videos below). Medical/biological psychiatry articles reviewed included one on risk factors for falls in dementia. Psychotherapy/psychology papers reviewed included Winnicott’s influential paper on transitional objects. In terms of social psychiatry articles the ‘New Horizons’ document was looked at and this is currently in consultation and will form a blueprint for the next 10 years of the NHS Mental Health Strategy, building on the National Service Framework. These are exciting times and feedback is currently being sought from interested parties (see here and here). Books reviewed included ‘Evolutionary Psychiatry. The Origins of Psychopathology’ which I found particularly interesting as this field holds many implications for reinterpreting illness and health (evolutionary psychology) and perhaps facilitating the integration of psychological, sociological and biological domains as well as delineating boundaries. Further episodes of John Betts series on Jungian Analytic Psychology were reviewed including a look at Jung’s concept of the active imagination. Blogs reviewed included Linguistic Anthropology which covers a variety of area relating to language. In the news amongst many studies, there was a study that provided evidence of a significant association between the consumption of a Mediterranean Diet and prevalence of dementia, a study on EEG patterns in Alzheimer’s Disease and Frontotemporal Dementia with intriguing findings, another study demonstrating the efficacy of using iron particles to label cells for MRI detection, a survey on polypharmacy, Donepezil in vascular dementia, a finding that the MECP-2 gene (associated with Rett Syndrome) may have a wider role in the development of brain structure, the use of ultrasound in ablation of tissue in functional neurosurgery and the demonstration of perceptual rivalry in the sense of smell.

Biological Psychiatry Article Reviews

Medication Adherence and Admissions in Bipolar Disorder

Incidence and Prediction of Falls in Dementia. A Prospective Study in Older People

Neuroprotection for Huntington’s Disease. Ready, Set, Slow

Social Concepts are Represented in the Superior Anterior Temporal Cortex

Psychological Psychiatry/Psychology/Psychotherapy Article Reviews

A Balanced Psychology and a Full Life

Can the Brain Understand The Brain

Winnicott on Transitional Objects and Transitional Phenomena

Neuropsychological Deficits Associated with Alzheimer’s Disease in the Very Old. Discrepancies in Raw v Standardised Scores

Social Psychiatry Articles Reviews

The Social Connectedness of Older Adults: A National Profile

The Neuroscience Information Framework

Research in the Field of Psychiatry

New Horizons: Towards a Shared Vision for Mental Health

Social Buffering. Relief from Stress and Anxiety

Book Reviews

Qualitative Psychology. A Practical Guide to Research Methods

On Death and Dying

The Talking Ape. How Language Evolved

Textbook of Evolutionary Psychiatry. The Origins of Psychopathology

Podcast Reviews

Betts on Jungian Analytic Psychology #19

Betts on Jungian Analytic Psychology #21

Betts on Jungian Analytic Psychology #22

Betts on Jungian Analytic Psychology #23

Betts on Jungian Analytic Psychology #24 and #25

Blog Reviews

Singularity Hub

Wolfram Alpha Blog

Psyche Babel

Linguistic Anthropology

Miscellaneous Articles

The Amazing World of Psychiatry: A Psychiatry Twitter

News

Research in Mood Disorders

A post-mortem study (n=27) compared 17 people who had developed late-life depression with 10 controls and the researchers found a significant reduction in the volume of the pyramidal cells (to a greater extent in layer 5) throughout the cortex in the depression group. Interestingly the layer 5 cells are more susceptible to ischaemic damage which has also been noted to be more prevalent in people with late-life depression suggesting a possible hypothesis which could be explored in future studies (Khundakar et al, 2009).

Research in Dementia

The authors of an imaging study (n=comparing people with Alzheimer’s Disease or Mild Cognitive Impairment with healthy control used a ligand for the Alpha4Beta2 nicotinic acetylcholine receptor and found no significant difference between the groups after controlling for multiple confounders before concluding that this supported the hypothesis that aceytlcholine reductions are observed late in Alzheimer’s Disease (Mitsis et al, 2009). A double-blind placebo-controlled trial of Donepezil in Vascular dementia (n=707 completers) showed evidence of a small but significant improvement on ADAS-cog scores (0.6-1.15 points) at 54 weeks (Wilkinson et al, 2009). In a survey of hospice Medical Directors in the USA anticholinesterase inhibitors and NMDA receptor antagonists were prescribed in a small subset of people with advanced Alzheimer’s Disease and reasons given included stabilising cognition and addressing problematic behaviours suggesting a benefit for formal studies to address these issues (Shega et al, 2009). A small study (n=29) in female Chinese caregivers of people with dementia in Hong Kong found a significant improvement in self-efficacy of managing problematic behaviours in the people they were caring for (Au et al, 2009). In a retrospective analysis of data from an RCT of Rivastigmine in Mild Cognitive Impairment (n=1018) there was found to be a significant reduction in the rate of cognitive decline of male BuChE-K carriers (a variant of the Butylcholinesterase Enzyme Gene) and also in female BuChE wt/wt carriers (Ferris et al, 2009). The authors of a recent randomised double-blind study of Donepezil in young adults with Down Syndrome treated over a 12-week period concluded that the results supported the safety of Donepezil in people with Down syndrome although the efficacy results were more difficult to interpret (Kishani et al, 2009). In a post-mortem study there was found to be a case of Alzheimer’s Disease without uptake of radiolabelled Pittsburgh compound B (PIB) and the authors suggest that this compound might bind differentially to various forms of multimeric ABeta. The implication if this holds is that a PIB negative finding might not always exclude the diagnose of Alzheimer’s Disease. However as this is a single case, it will be interesting to see if these results are replicated (Rosen et al, 2009).

Research in Psychosis

In a study in which two psychiatrists assessed 100 inpatients, the diagnosis of schizophrenia was found to occur more frequently when using ICD-10 criteria compared DSM-IV and the researchers suggest that this might be due to the absence of an exclusion of an affective syndrome in ICD-10 (although there are references to affective symptomatology in ICD-10)(Cheniaux et al, 2009). In a longitudinal structural MRI study, people with schizophrenia were divided into good and poor outcome groups and in the latter group there was found to be a significant assocation with reduction in the volume of the putamen (Mitelman et al, 2009). In an 18-week double-blind flexible dosing study (n=147) of Clozapine and Ziprasidone in people with treatment-resistant schizophrenia the researchers concluded that both medications showed similar efficacy with reduction in PANSS scores being the primary outcome measure (Sacchetti et al, 2009).

Miscellaneous Research

In a study of residents in long-term care who were referred for psychiatric assessment (n=868) there was found to be elevated Thyroid Stimulating Hormone (TSH) in 10.8% of people and a significant association of elevated TSH with female gender (Sabeen et al, 2009). The authors of a systematic review looked at services providing acute time-limited residential alternatives to inpatient psychiatric ward treatment for people needing acute admission. The authors described their search strategy and were able to identify 27 studies for inclusion in their review. They assessed the quality of these studies and found that a number of the studies didn’t conceal allocation of subjects or adjust for confounders although they did provide evidence of outcomes comparable to acute inpatient treatment in a number of studies. The authors concluded that more research was needed in this area although there was ‘preliminary evidence’ to support the community-based alternatives examined* (Lloyd-Evans et al, 2009).

News in Brief

In a rather ingenious study (which is open access and freely available here) cognitive impairment and depressive were assessed in 16,800 participants in a cohort study and the results were correlated with data on ‘two-week average sunlight exposure’. The researchers did find a significant association between cognitive impairment and the sunlight exposure so it will be very interesting to see if this is replicated and if so how such a relationship might be working. In another study published in the Proceedings of the National Academy of Sciences, alpha-synuclein has been found to be transmitted from one cell to another within cell cultures and there was further supporting evidence for such an association and this has implications for therepeutic approaches in Parkinson’s Disease and related conditions. In a structural MRI study looking at 679 people (>=65 years) there was found to be an increased association between memory impairment and white matter hyperintensities and also an association between strokes and  non-memory cognitive impairment which remained after correction for factors such as APOE4 status and age. The authors of a PNAS study demonstrated increased toxicity associated with increased size of ABeta dimers that constitute the ABeta plaques. In a prospective longitudinal study of 1880 New York community dwellers there were found to be significant associations between consumption of a Mediterranean diet, exercise and a reduction in the prevalence of dementia. The authors of one paper examine the hypothesis that the Raphe nuclei might be an important component of the pathology of Alzheimer’s Disease (Simic et al, 2009). Further evidence for a link between Frontotemporal Dementia and Amyotrophic Lateral Sclerosis (ALS) has been found in a post-mortem study where the FUS (fused in sarcoma) protein (associated with ALS) was found in the neuronal inclusions in 15 people with frontotemporal dementia (Neumann et al, 2009). An analysis of the data from the Alzheimer’s Disease Neuroimaging Initiative provides further support for the hypothesis that conversion from Mild Cognitive Impairment to Alzheimer’s Disease is strongly influenced by Medial Temporal Lobe volume and particularly the volume of the hippocampus (Risacher et al, 2009). A small study involving 34 people without evidence of cognitive impairment, at post-mortem found a significant correlation between performance on a smell test (the Brief Smell Identification Test) and Alzheimer’s Disease pathology (Wilson et al, 2009). The smell test however can be influenced by smoking.

Using an analysis of EEG data from patients with Frontotemporal Lobar Degeneration and Alzheimer’s Disease, a team has found further evidence that in Alzheimer’s Disease there is increasing disconnection between areas in the brain. However they found that communication between areas became more structured in people with FTLD. The findings are relevant in terms of a disconnection hypothesis which maintains that in Alzheimer’s Disease there is a loss of function resulting from impaired communication between brain regions. A research team in Germany have provided evidence of ferritin in neurons in Parkinson’s disease. Iron metabolism has been implicated in the disease process and previous research has identified the ferritin in the glial support cells (see also this article in which the Diamond Light Source Synchrotron is being used to examine iron distribution in Parkinson’s Disease). An Israeli study has provided preliminary evidence for the viability of mesenchymal stem cells (which means there is no need for embryonic cells) in a model of Huntington’s Disease. By ‘labelling’ the cells with iron particles they were able to follow their progress using Magnetic Resonance Imaging and observed them migrating to their destination. It will be interesting to see further use of this neuroimaging technique as well as the work with stem cells. In a study looking at the MECP2 gene (methyl CpG binding protein 2). A mutation in this gene results in Rett Syndrome, a developmental disorder associated with seizures and cognitive impairment. The research team looked at the gene and the surrounding DNA in a total of 940 people who were healthy or who had developed dementia or psychosis. They found that one specific allele of MECP2 was associated with a number of changes in the structure in the brain including a reduction in the surface area. They also found that variations in the surrounding region were associated with structural changes in the brain and this gene region may turn out to have an important developmental role. Another study provided evidence that formal education reduced the risk of Alzheimer’s Disease even if there was a reduction in brain volume. New drugs – ATPZ’s have been identified which prevent the formation of  Alzheimer’s Disease tau protein clumping in vitro.

A German team have provided evidence that two Parkinson’s Disease associated genes – Parkin and PINK1 interact to maintain mitochondrial function and the researchers suggest that this may have implications for possible disease-modifying therapies. In a study of people who had developed concussion (20 subjects and 20 controls), neuropsychological testing identified executive impairment but CT and MRI scans did not pick up evidence of injury. However the researchers also used Diffuse Tensor Imaging and were able to identify areas of injury with particular involvement of the prefrontal cortex which was consistent with the neurospychology results. The researchers also found a significant association between the DTI identified injury and the executive performance  and the research team suggest that this provides evidence for a role for DTI in concussion. One research team have used ambient background noise during training exercise to help people with Parkinson’s Disease learn how to speak louder as the condition can affect their expressive speech. The team is now looking to make small modifications to their approach. There has been confirmation of the efficacy of delivery of a gene for Nerve Growth Factor in a murine model of Parkinson’s Disease in one study. The gene was delivered using a modified Adenovirus and the expression of the gene was modified with Doxycycline. A large study provided some preliminary evidence of a relationship between increasing diastolic blood pressure and cognitive impairment in people over the age of 45. The study involved 30,228 subjects from the longitudinal REGARDS study (Reasons for Geographic and Racial Differences in Stroke) but the association here was drawn from cross-sectional data obtained from the cohort and so it would be interesting to see replication using longitudinal data and other cognitive measures that are used for assessment of mild cognitive impairment. One study looking at older adults (over the age of 70)  (n=94) investigated the relationship between Body Mass Index and cortical volume as measured using tensor based morphometry. The researchers found a significant association between increasing Body Mass Index and a reduction in cortical volume and it would be interesting to see large replication studies.

In a recent poll by the Royal Pharmaceutical Society of  457 people over the age of 65, just under half of respondents reported that they were taking 5 or more medications and 60% thought that they were experiencing adverse side-effects. An american study of 630 drivers aged 55 to 93 found that 28% of the drivers were not aware of the effect of medications on driving. An intriguing in vitro study provided evidence that the antipsychotic pimozide kills several types of cancer cells. There has been a suggestion of closer monitoring of antipsychotic initiation in older adults with diabetes following the results of a longitudinal study of 13,817 older adults (>65 years) who had commenced antipsychotics and finding that compared to a group who had stopped antipsychotic medication 180 days previously there was an elevated prevalence of hyperglycaemia. In a recent poll of 2000 people over the age of 16, there were found to be gaps in knowledge in the respondents in areas of potential importance – for instance 26% of respondents did not think there were approaches to reducing their risk of developing dementia.

A diffuse tensor imaging study (n=20) provided evidence of structural abnormalities in the arcuate fasciculus in people who are tone deaf (half of the subjects were tone deaf). The researchers found that they could not identify the arcuate fasciculus in the right hemisphere. The arcuate fasciculus is a connection between the frontal and temporal lobes. A recent study has demonstrated that ultrasound guided with the aid of Magnetic Resonance Imaging was successfully in ablating tissue in the thalamus in people with neuropathic pain and it will be interesting to follow subsequent research in this area. A mutation in a gene – hDEC2 that occurs in an extended family that require only 6 hours of sleep has been associated with sleep duration using additional indirect evidence. An American cross-sectional study involving 559 women found an association between hopelessness and thickness of the carotid arteries which remained after controlling for depression and other cardiovascular risk factors. The arterial wall thickness is a risk factor for cardiovascular and cerebrovascular disease but it will be interesting to see replication using a prospective study design.

A cross-sectional study (the HUNT study) with 50,843 participants showed a significant association between an increased prevalence of occasional headaches and higher levels of caffeine intake. They also found that lower levels of caffeine consumption were associated with an increased prevalence of chronic headaches. With increasing numbers of under-18 drinkers in the UK developing liver disease and being admitted to hospital, the charity Alcohol Concern has called for an increase in the pricing of drinks. An American study has provided evidence that Alcohol adverts on cable television have a significant correlation with the likelihood of teenager viewing of the cable TV. They found that wine adverts were inversely correlated with an increasing percentage of teenage viewers in the audience but that there was a significant linear correlation with spirits, low-alcohol ‘alco-pop’ drinks and beers. This is interesting in relation to older studies which show that teenagers with ‘media resistance skills‘ in another american study were less likely to drink alcohol. Earlier this year an Australian study provided  evidence that adolescents there were seeing more alcohol-related adverts and the authors recommended a move towards regulation of adverts. In a small study (n=62) smokers were found to have a significantly reduced blood supply to the tongue and smaller flatter fungiform papillae (taste buds). This is also consistent with other research that shows an impaired sense of smell in smokers (see appendix in this article).

In a presentation at the Annual Convention of the American Psychological Association, a recommendation has been made for managing childhood obesity by encouraging positive body image and exercise in children. The NHS has been criticised in a developing argument about the future of American Healthcare and Gordon Brown has joined in the defence of the NHS using twitter! There has also been some recent research on Twitter that shows that just over 40% of the postings contain information about the minute-to-minute actions of the twitterers although just under 40% of postings were conversational. A Stanford study published in the Proceedings of the National Academy of Sciences looked at 100 students, examining how they responded to the data they were presented with. The students were divided into those that those frequently ‘media multitask’ (which means that they take in information from multiple media sources which is contrasted with focusing on a single task at any given time) with those who did not. The group found that the multitaskers performed worse than the comparison group on a number of measures including distractability. The study has been widely reported (e.g. here, here, here and here). In the Blogosphere, the study has been covered over at MindHacks and Not Exactly Rocket Science and the key point is that this study is demonstrating association rather than causality. So for instance, the heavy multitaskers may use this approach because they have a different cognitive profile.

The authors of a Finnish study state that they have found evidence that astrocytes mediate the blood vessel changes that are seen in fMRI studies and it will be interesting to see further information on this study as it becomes available. In a small (n=48) observational study of patients with breast and prostate cancer there was found to be a significant correlation between radiotherapy-associated fatigue and markers of cytokine activity and it will be interesting to see further studies in this area. A study in flies demonstrating two pathways – one for long term memory and the other for short-term memory may be of relevance to humans as there is a human homologue of a gene involved in these memories – Rutabaga.

A study with a small sample size provides initial results that suggest that westerners and East Asian people interpret facial expressions differently with the former group focusing on the whole face and the latter group focusing on eyes. However as noted, the sample size here is small and a larger replication study is needed to draw firmer conclusions in this regards. In another study, there was found to be an association between reading emotional words  and activation of muscles that are used during expression of those emotions. Further, providing people were able to use the associated muscles they experienced the relevant emotions when reading the emotional words and this influenced their judgements. In a study that compared people who spoke two languages with those speaking just one, researchers found that when reading cognate words, that is words that are similar in both languages, the bilingual subjects took less time to read these words suggesting that learning a second language influenced the way the primary language is processed. In an EEG study, the response to value-laden words was found to occur within milliseconds of presentation if this clashed with the person’s values and such information is of relevance to other areas including neuroimaging. A candidate gene KIAA0319 (on Chromosome 6) was investigated in 322 children with Specific Language Impairment and variations were found to be associated with language ability. In another study, researchers found that a phenomenon known as ‘perceptual rivalry’ occurs with the sense of smell. They presented subjects with two competing smells, one for each nostril and the subjects nted an alternation between the experienced smells. Such competition is noted in other sensory systems such as the visual system. The results of one study indicated equivalent efficacy for both red and blue light in maintaining nighttime alertness. In another study when looking at a clock subjects gave different times when either the clock was brought into their field of vision (in which case the time they gave fell behind the actual time) or if their eyes moved to the clock (in which case the time they gave was ahead of the actual time) and the results were interpreted as meaning that the cortical visual perceptual system anticipates the movement of the eyes.

There has been a presentation on work on lucid dreaming and the relation to dissociation at a recent European Science Foundation workship and there is also a discussion of a threat simulation theory which states that part of the role of dreaming is to recreate the threats that a person has experienced presumably so that they can learn to deal with these threats more effectively (almost like a virtual reality training simulation!). In a relatively small study (n=51) people with and without depression were placed on a weight reduction program and an average 8% weight loss in the depression group was significantly association with an improvement in depression scores although it will be interesting to see the results in the final published form.

Evidence from a Spanish 48,000 year old Neanderthal specimen shows the presence of a gene coding for bitter taste meaning the detection of bitter tastes occurred before the divergence of Neanderthals and humans. A 4000 year old tomb has been found in Forteviot, Scotland causing a significant reevaluation of not only local history but also significant events in Neolithic culture. Researchers found in one study that Capuchin monkeys spent more time near researchers if they mimicked the monkeys which was interpreted as meaning that mimicry is important for social bonding in these monkeys. If such findings are replicated and this mechanism has been conserved through primate evolution it may have implications for social interactions in humans.

References

Au A, Li S, Lee K, Leung P, Pan PC, Thompson L, Gallagher-Thompson D. The Coping with Caregiving Group Program for Chinese caregivers of patients with Alzheimer’s disease in Hong Kong. Patient Educ Couns. 2009 Jul 18. [Epub ahead of print]

Cheniaux E, Landeira-Fernandez J, Versiani M. The Diagnoses of Schizophrenia, Schizoaffective Disorder, Bipolar Disorder and Unipolar Depression: Interrater Reliability and Congruence between DSM-IV and ICD-10. Psychopathology. 2009 Jul 16;42(5):293-298. [Epub ahead of print].

Ferris S, Nordberg A, Soininen H, Darreh-Shori T, Lane R.Progression from mild cognitive impairment to Alzheimer’s disease: effects of
sex, butyrylcholinesterase genotype, and rivastigmine treatment.Pharmacogenet Genomics. 2009 Jul 16. [Epub ahead of print]

Kishnani PS, Sommer BR, Handen BL, Seltzer B, Capone GT, Spiridigliozzi GA,Heller JH, Richardson S, McRae T. The efficacy, safety, and tolerability of donepezil for the treatment of young adults with Down syndrome.Am J Med Genet A. 2009 Jul 15;149A(8):1641-1654. [Epub ahead of print]

Mitelman SA, Canfield EL, Chu KW, Brickman AM, Shihabuddin L, Hazlett EA,Buchsbaum MS.Schizophr Res. 2009 Jul 16. [Epub ahead of print]. Poor outcome in chronic schizophrenia is associated with progressive loss of volume of the putamen.

Shega JW, Ellner L, Lau DT, Maxwell TL.Cholinesterase Inhibitor and N-Methyl-D-Aspartic Acid Receptor Antagonist Use in Older Adults with End-Stage Dementia: A Survey of Hospice Medical Directors. J Palliat Med. 2009 Jul 21. [Epub ahead of print]

Sabeen S, Chou C, Holroyd S.Abnormal thyroid stimulating hormone (TSH) in psychiatric long-term care patients.Arch Gerontol Geriatr. 2009 Jul 16. [Epub ahead of print].

Sacchetti E, Galluzzo A, Valsecchi P, Romeo F, Gorini B, Warrington L; MOZART Study Group.Schizophr Res. 2009 Aug;113(1):112-21.Ziprasidone vs clozapine in schizophrenia patients refractory to multiple antipsychotic treatments: the MOZART study.

Wilkinson D, Róman G, Salloway S, Hecker J, Boundy K, Kumar D, Posner H, Schindler R.The long-term efficacy and tolerability of donepezil in patients with vascular dementia. Int J Geriatr Psychiatry. 2009 Jul 21. [Epub ahead of print]

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The podcast reviewed here is the 26th in Bett’s series on Jungian Analytic Psychology and is freely available here. This is the first in a series in which Betts focuses on individuation. Betts presents this episode with his usual clarity both in terms of narration and the content of the episode. He looks at collective values and their relation to those of the individual. Betts interpets some of Jung’s writings on the subject. Jung wrote that the individual must first understand the collective before they can successfully individuate. He also writes that the process of individuation requires considerable reflection and is consequently very difficult. I like the following sentence by Betts which captures some of what Jung has written.

‘we have to be in the world but not necessarily of it’

The collective values form part of the persona. Betts elaborates on this further by giving the example of the work persona and the related financial associations of keeping up mortgage repayments all of which form part of the persona which represents the meeting of the individual and the collective. He also discusses the difficulties associated with a rapid change in persona.

After listening to this, I began to interpret this process of individuation as simply the process of someone becoming an individual. I had previously wondered about the individuation process continuing through a person’s life and that person moving towards fulfilling their potential through the individuation process. This made a lot more sense to me after thinking of the process of becoming an individual. It is not too difficult to imagine that Jung spent his life developing and focusing on his individuality. Perhaps Jung held the value of individuality very strongly and brought the mind of a psychiatrist (and philosopher) to bear on how individuality interacts with the need to integrate and become a member of wider society.

Betts has produced a very nice episode which accessibly conveys Jung’s ideas on this subject.

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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

The blog reviewed here is ‘Modern Psychoanalysis‘. The blog reads ‘Join us to learn more or post your own thoughts’ in a similarly way to another blog reviewed here (Linguistic Anthropology). In terms of structure, the blog has a green title pane, a green background with articles containing black text on a white background. In the right hand panel, there are options to translate the blog into several languages, links to psychoanalysis sites of relevance, last 10 posts, archives and blog links. Additionally there is an ‘About Me’ section, a search engine box, Bloglines subscriber, stat counter and a cluster map. In the ‘About Me’ section, there is a link to the profile of the author who goes by the name Jim and states a location in New Jersey, United States. In the initial post by James G Fennessy (presumably Jim), there is an introduction to Modern Psychoanalysis with a mention of the ‘founder, Dr Human Spotniz’ and an emphasis on interventions which include

‘a wide range of interventions including ego reinforcement, emotional communication and resistance resolution‘

The next article looks at practical aspects of psychoanalysis including the length and costs of therapy, the use of the illness model and the levels at which a psychotherapist will work with the analysand. Here Fennessy considers the education in psychoanalysis and there are a few interesting quotes from Freud who made it clear that it was not just doctors who could receive training in psychoanalysis. In this article he considers a hierarchical approach to treatment resistance in modern psychoanalysis.

In ‘The  Narcissistic Defense‘, Fennessy looks at some of Spotniz’s writings and I noted some similarity to the writings of Winnicott that have been reviewed here although in a later post it is mentioned that Spotniz (1985) stated

‘Freud and his contemporaries did not recognise the presence of narcissistic transference as such and they did not know how to utilise it for therapeutic purposes’‘

Given the similarity of some of the above points to Winnicott it is interesting to see that Fennessy goes on to consider a late paper of Winnicott on ‘The False Self‘ from 1960. Fennessy then elaborates on Spotniz’s views on the narcissistic transference. Again Spotnitz’s views on id impulses are discussed as are those of Freud and Margolis on the ‘primary process’. Spotniz’s views on silence are considered here and the suggestion is made that this can be used as a holding environment (as described by Winnicott)  or psychotherapeutic space.

Fennessy’s Blog on ‘Modern Psychoanalysis’ provides a useful interpretation of the subject and a look at many complex topics in an accessible way. There have been no new articles that I could find after July 2008 and so this is an inactive blog which however goes onto attract new readers in much the same way as a book in a library although the dynamic elements still remain (e.g. comments section).

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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

The book reviewed here is ‘Jung. On the Nature of the Psyche’. The book consists of two essays ‘On Psychic Energy’ and ‘On The Nature of Psyche’ which as their titles suggest both focus on elucidating the concept of the psyche.

On Psychic Energy

Jung makes some interesting remarks about psycho-physiology:-

‘A psychology that treats the psyche as an epiphenomenon would better call itself brain-psychology, and remain satisfied with the meagre results that such a psycho-physiology can yield‘.

before going on to explain the estimation of psychic energy thus

‘Values are quantitative estimates of energy‘

He argues that subjective values can be estimated by comparison with each other. Indeed there are validated scales for this purpose. Jung also suggests that the unconsious values cannot be accessed or where it is accessed then it is transformed. I would argue that the unconscious is a rather broad term which covers some things which are accessible and others which are not. For instance, for a good deal of the time, we might not be so concerned about a certain food that we are averse to. However if we are served this food at a restaurant without realising, our unconscious thoughts and feelings associated with it will soon be reactivated and will govern our behaviour to a certain extent. Even before we are presented with the food, if we were to be asked our thoughts about this type of food, it would be sufficient to activate the associated feelings and thoughts. I realise that Jung meant something quiet specific when he referred to the unconscious but I find it difficult to justify the exclusion of an association such as that above  (aversive food) being excluded from the concept of the unconscious given that it is usually outside of conscious awareness but quickly comes to bear on the situation when appropriate and sometimes in the form of reflexes before conscious inhibition can be exerted. There are an abundance of such counterexamples that can be given.

Jung goes on to discuss the objective estimate of the ‘quantity’ of these values adding that he has demonstrated this in ‘psychology of dementia praecox’. The use of such terms suggested to me that Jung was perhaps in some way considering the above as axiomatic truths. He then explains the ‘psychological valency’ of such values in terms of their relation to complexes. He also states that the value can be inferred from the intensity of affect and that further this can be deduced from the  time spent on discussing or thinking about something as being correlated (my term) with the ‘energic value’.

What I found particularly interesting was that despite the earlier mention of psycho-physiology, Jung actually suggests that the values can be verified indirectly by means of psychophysiological measures including the ‘pulse curve’, ‘the respiration curve’ and ‘psycho-galvanic phenomenon’. He also mentions the sophisticated ability of people and animals to perceive ‘emotional  fluctuations’ in members of their own species. He comments on the interaction between mind and brain by saying that he has intentionally left this out of the discussion and that the nature of this is outside the realms of ‘our experience’.

Jung discusses a theory of constancy while distinguishing the conservation of psychic energy from Freud’s description of the libido.  Curiously he acknowledges that the psyche is not a completely closed system while also maintaining that a useful analogy can be drawn with the thermodynamic principle of conservation of energy – in this case being the conservation of psychic energy. Jung refers to entropy and here I would have to argue that Jung is wrong. I believe that the mind is a function of the brain and further that the brain in energy terms is not a closed system but openly communicates with other parts of the body and through these interactions with the environment. Therefore there is no justification for there being a constancy of psychic energy. The second point however is that the cellular apparatus of the brain while being subject to the laws of entropy actually functions to concentrate energy in a productive way. Thus if the mind is a function of brain, it is ultimately governed by a system which works to oppose entropy.

‘but the more the psychological system is closed off, the more clearly is the phenomenon of entropy manifested‘

Jung then discusses his fundamentals of libidinal theory as ‘progression and regression’, ‘extraversion and introversion’ and the ‘canalization of libido’.  During his discussion of these ‘fundamentals’ I was discouraged by his use of the term ‘primitive man’ when referring to tribal peoples and particularly his assertion that such people ‘had no knowledge of what we call will’. He expressed later a somewhat Eurocentric world view and I discounted the relevant arguments. He then goes onto discuss spiritual issues as well as expanding on Freud’s concept of the libido and looks at the occurrence of the symbolism of energy in different cultures.

On the Nature of the Psyche

In this essay, Jung again discusses the psyche and a philosophical approach together with consideration of philosophers and their works permeates this discussion.

‘for today we are of the opinion that, over and above all subjective certainty, objective experience is needed to substantiate an opinion that lays claim to be scientific….the empirical freedom of the will grows in proportion to the extension of consciousness‘

He refers to the origins of experimental psychology with Christian von Wolf in the 17th century before writing about the Wundt school in this essay (and also the essay above) and contests the assertion that everything psychic is conscious. He also notes Wundt’s dismissal of  there being a ’system of ideas’ behind symbolism. Jung then goes onto write about the significance of the unconscious in psychology and here he refers to William James and the ‘Varieties of Religious Experience’ in the footnotes. Along the way he comes up with lines such as this:-

‘The psyche is the greatest of all cosmic wonders and the sine qua non of the world as an object‘

Jung discusses the dissociability of the psyche and the role of the will. In his discussion of ‘Unconsciousness and Consciousness’ he invokes Occam’s razor which can be argued to be a dubious concept as it would exclude complex explanations of complex phenomenon and thus seems a pragmatic approach out of keeping with the structured approach that Jung has demonstrated. He then turns to alchemy and suggests that the imagery used here represents introspection into the workings of the unconscious. He then discusses archetypes and mentions a ’spiritual’ aspect thus

‘Often it drives with unexampled passion and remorseless logic towards its goal and draws the subject under its speell from which despite the most desperate resistance he is uanble and finally no longer even willing, to break free, because the experience brings with it a depth and fullness of meaning that was unthinkable before…..the archetype is pure unvitiated nature, and it is nature that causes man to utter words and perform actions whose meaning is unconcious to him, so unconscious that he no longer gives it a thought‘

He adds that these utterances are later ascribed significance to a ‘golden age’.

‘But we can in all modesty point out that mathematical thinking is also a psychic function, thanks to which matter can be organized in such a way as to burst asunder the mighty forces that bind the atoms together‘

This complements his statement in the previous essay that

‘even science caanot escape psychological conditions of knowledge and psychology must be peculiarly alive to these conditions‘

He goes onto discuss the collective unconscious and again in a similar vein to the above gives what I consider to be a profound insight – that the deeper understanding we seek for ourselves must ultimately form part of our own inner (psychic) experience.

‘for no explanation of the psychic can be anything other than the living process of the psyche itself‘

He finishes by emphasising that he is drawing analogies and nothing more than that. Jung’s knowledge and intelligence are evident from much of his discussion. I was surprised that he had suggested the use of psychophysiological measures for quantification of values implying that he did not consider a psychological explanation as all encompassing. The analogies with the principles of thermodynamics weren’t convincing although he does state at one point they are nothing more than analogies. His discussion of philosophy particularly European philosophy and of complexes are involved and would repay further study as well as extending in the latter case into other works.

References

Carl Gustav Jung. On the Nature of the Psyche. Routledge. Extracted from the Collected Works of Jung. Republished 2006.

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The article reviewed here is ‘Dementia and Its Implications for Public Health’ by Chapman and colleagues and freely available here.  The article is focused on the US population, but the issues here are relevant to other countries given the global demographics of aging populations. I couldn’t find an explicit aim for the review although the title suggests one itself. Looking at the methodology section, the authors specify the terms that they use in their search and also describe papers being retained as those that ‘provided definitional or diagnostic criteria for the disorders’ and they ’specified an interval of observation’. This covers a broad remit and the authors also denote a number of search terms for the most common forms of dementia. However they state that papers were ‘primarily identified’ in this way although additional methods for identifying paper are not stated (the most common method is to hand search the reference sections of each identified paper or search relevant journals). The years delimiting the search are not stated nor are the results of the search in terms of number of identified papers and the subsequent filtering process. 

On reading through the remainder of the paper, there were introductions to several relevant areas – depressive symptoms, delirium and mild cognitive impairment. Each of these is covered in a brief section explaining how they are related to cognitive impairment. The main forms of dementia are then covered - Alzheimer’s Disease, Lewy Body Dementia, Frontotemporal Dementia and Vascular Dementia.  Demographic data is given but also consideration is given to neuropathological processes and genetics. The authors then look at interventions including anticholinesterase inhibitors, memantine, NSAID’s, vitamin supplements, mental and physical activity. The authors then finish with stigma, caregivers and a final discussion.

There were some points about the paper that I thought about further. Some of the sections contained a mix of different types of information – for instance on looking at the brief sections on dementia, pathological processes were combined with manifestations of early Alzheimer’s Disease. The sections are too brief to be able to fully develop the subjects and so they could more properly be considered overviews. Thinking of the paper in this way made more sense for me as I could then see that the paper provides a broad overview of areas that could be relevant to public health effects of dementia. However if the aim was to contextualise the issues of relevance to the public health effects of dementia then an alternative approach could have involved looking at established diagnoses (therefore excluding delirium without dementia, mild cognitive impairment and depression without dementia) focusing on outcome measures including mortality and morbidity outcomes, detailed epidemiological data and economic analyses.  

On the other hand, the paper also helps to focus on issues that are of relevance to the topic under consideration and any disagreement (as above) can results in alternative ‘models’ which can be used for comparison and further refinement. 

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The article reviewed here is ‘Primitive Emotional Development’ by Donald Winnicott which was originally read before the British Psycho-Analytical Society in 1945. Winnicott notes in the opening that the aim of this paper is to make a ‘preliminary personal statement’. He gives us some insight into how he arrives at his ideas which in view of everything else that Winnicott has written about and the significance of his writing, I find quite fascinating

‘What happens is that I gather this and that, here and there, settle down to clinical experience, form my own theories and then, last of all, interest myself in looking to see where I stole what. Perhaps this is as good a method as any‘

I’m not sure that ’stole’ is the best word here, if he is referring (as he does earlier) to the ‘theories of others’ as many theories are built upon preceding knowledge which therefore act as a necessary foundation. Indeed it may be argued that those whose theories have preceded his would want their work to be built upon and that such a process is integral to the development of civilisation. There is maybe a sense of Winnicott’s creative drive in this statement, the need to produce new and valuable insights that are uncontestably original. 

He then discusses patients with psychosis that he has analysed during the period of the Blitz of WWII which form some of the basis for the ideas he presents in this paper. Winnicott writes that the analysis of ‘primitive emotional development’ needs to occur as an extension of the analysis of depression. He describes briefly what the therapist must be prepared for in analysing the ‘pre-depressive phase relationships’ and this includes coping ‘with the depressive position’ and the ‘persecutory ideas which appear’. He then refers to the age of 5 or 6 months as a special point in the emotional development of infants and refers to the work of his contemporaries, Anna Freud and Bowlby. The essential argument through the paper is that the infant progresses through certain stages during emotional development but these same stages may be interrupted or involved in psychosis. He writes of the ‘importance of such processes as integration, personalization and realization’ during development. 

There are some important phenomenon that he then describes in the paper – disintegration of personality, unintegration and dissociation. Regarding the disintegration of personality, he tells us that

‘failure in respect of primary integration predisposes to disintegration as a regression, or as a result of failure in other types of defence‘

He then turns to integration which he emphasises as occurring very early development while contrasting it with unintegration thus

‘An example of unintegration phenomena is provided by the very common experience of the patient who proceeds to give every detail of the week-end and feels contented at the end if everything has been said, though the analyst feels that no analytic work has been done‘

This to me sounded in part like a description of circumstantiality or perhaps overinclusiveness. While he doesn’t define dissociation I found this comment, linking dissociation and unintegration extremely interesting particularly in view of the above comment about the unintegration phenomenon

‘According to my view there grows out of unintegration a series of what are then called dissociations, which arise owing to integration being incomplete or partial‘

The remainder of the article then deals with the events following successful integration. Winnicott describes how the infant relates to the external world through reality adaptation, develops play and then focuses on thumb-sucking and related phenomenon. Interestingly he makes some remarks that precede his noted paper on transitional objects (reviewed here) and which are of relevance to that paper – these phenomenon can be thought of as the object being intermediate between the inner and outer worlds.

It had occurred to me at one point, that on reading through Winnicott’s other papers, I had not noticed the establishment of a primary hypothesis explicitly. This was supported in the present paper by Winnicott’s introduction in which he describes how he has arrived at a personal statement. This perhaps made the paper a little more difficult for me to read and I wonder if it would have been easier had he broken the paper down into a series of tightly defined hypotheses with definitions where appropriate, supported by arguments and evidence. In some senses, the paper is structured into sections and the concepts he discusses are complex and perhaps it can be argued that they are not easily described in terms of simple hypotheses. Nevertheless that would have facilitated the validation of his assertions. As it reads, the paper evoked for me a series of insights as in previous papers but these appear as approximations and relationships rather than clearly defined concepts that can be more easily analysed. Maybe if I read the paper again my view might change. I also hadn’t noticed in the previous papers of Winnicott that I had reviewed a mention of Jung, but he was here in the footnotes!

From this paper, I particularly liked the relationship between unintegration and dissociation although the former term needs sharper clarification and the latter term, while commonly used would benefit from a definition in order to ensure that it is being understood properly. Winnicott as in previous papers comes up with some interesting and complex ideas with similarly complicated relationships. 

References

In D.W.Winnicott. Primitive Emotional Development. In D.W.Winnicott. Through Paediatrics to Psycho-Analysis.  With an introduction by M.Masud R.Khan. Chapter XII. pp145-156. The International Psycho-Analytical Library. Edited by M.Masud.R.Khan. The Hogarth Press and The Institute of Psycho-analysis. 1978.

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