Author: Dr Justin Marley

 

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 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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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 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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