Richard G. Petty, MD

A New Treatment for Toxoplasmosis

I have talked at some length about the possible link between toxoplasmosis and some forms of mental illness, but there is also another side to toxoplasmosis: the Toxoplasma gondii parasite infects nearly one-third of all humans: more than two billion people worldwide. In the United States alone, congenital toxoplasmosis occurs in an estimated 1 per 5,000 births a year and can cause severe vision loss, brain damage and even death. The human cost is incalculable, and in dollars and cents, it has been estimated that the annual cost of caring for these children may exceed $1 billion.

Toxoplasma gondii is carried by some cats and it is said that an infected cat can excrete up to 20 million oocysts over a period of two weeks, and every single oocyst is infectious. They are tenacious and can remain infectious in water for up to six months and in warm moist soil for a year of more.

Toxoplasma infects humans through three main routes:

• Consumption of undercooked, infected meat
• Ingestion of T. gondii oocysts in food, through accidental contamination from cat litter
• Finally, a newly infected pregnant woman may pass the infection to her fetus, hence the warning that pregnant women should not clean the cat box

Not only is toxoplasmosis the most common parasitic infection in the world, but also it can cause particular problems in people with compromised immune systems, for instance people with cancer, autoimmune disease, AIDS or transplant recipients.

It is even possible for people with normal immune systems to suffer major organ damage from chronic infections. Eye disease leading to loss of sight can be caused both a primary infection and as a result of infection transmitted from mother to child. Damage to other organs has recently caused deaths among otherwise healthy young people during epidemics in Surinam and French Guiana.

The parasites that cause malaria are related to Toxoplasma gondii, and a new drug that will soon enter clinical trials for the treatment of malaria also appears to be 10 times more effective than the current gold-standard treatment of toxoplasmosis, a combination of the drugs pyrimethamine and sulfadiazine.

In the March issue of PLoS Neglected Tropical Diseases, a research team based at the University of Chicago Medical Center reports that the drug, known as JPC-2056, is extremely effective against Toxoplasma gondii, both in cell culture and in mice, and apparently without the toxicity associated with the current standard treatment.

The drug works inhibiting the action of the from of the enzyme dihydrofolate reductase (DHFR) that is produced by the family of parasites that includes those that cause toxoplasmosis and malaria, and in cell culture studies, the drug appears actually to kill the parasite, rather than simply preventing its replication. This is very important: not only do most of the current medications have a good many side effects, they have little effect on Toxoplasma during certain phases of its life cycle. It can hunker down in the quiescent cystic phase and wait until the antibiotics are gone.

Rima McLeod, professor of ophthalmology and specialist in infectious diseases at the University of Chicago said,

"JPC-2056 has the potential to replace the standard treatment of pyrimethamine and sulfadiazine. Taken by mouth, is easily absorbed, bioavailable, and relatively nontoxic. In tissue culture and in mice, it was rapidly effective, markedly reducing numbers of parasites within just a few days."

JPC-2056 is not a new drug. It was developed in the late 1980s by teams led by Wilbur Milhous and Dennis Kyle of the Walter Reed Army Institute for Research and David Jacobus of Jacobus Pharmaceutical Company. The original version was quite toxic, but the researchers found ways to reduce the toxicity and developed an oral version of the drug. Clinical trials using JPC-2056 to treat malaria are scheduled to begin later this year.

Bobby Fischer R.I.P.

News services round the world have been reporting the untimely death of Bobby Fischer, a.k.a. Robert James Fischer, the American-born chess genius.

Fischer’s match with Boris Spassky in 1972 had a huge influence on me, tempting me back to competitive chess, and over the years I studied most of his games in great detail. So I was definitely a fan.

But sadly much of the coverage has focused on some of the foul things that he said in his later years. It is particularly unfortunate because most of the reports failed to mention a number of other things about him.

I never met or examined Fischer and it is dangerous to diagnose people at long range. But there were multiple reports that made it very clear that he long ago crossed the line into mental illness.

He was always single-minded and cantankerous, and some of his allegations about cheating turned out to be correct. But when he began to believe that people could pick up or manipulate his thoughts through the fillings in his teeth, it was clear that something else was going wrong with him.

Some people have tried to link genius in chess and mental illness, but the link is at best tenuous, even though more than one very strong player has succumbed to mental illness. As we have discussed, there may be a link between creativity and schizotypal personality disorder, but the thing about chess is that high-level play requires enormous sustained concentration and motivation, to say nothing of the ability to withstand intensive mental stress. Thos are all things that become difficult as mental illness progresses.

One of the best ways of evaluating a culture is the way in which it treats its weakest members. So let us remember and celebrate Fischer’s genius and recognize that his later and ever darker life was driven by a terrible mental deterioration.

“The chessboard is the world, the pieces are the phenomena of the Universe, the rules of the game are what we call the laws of Nature. The player on the other side is hidden from us.”
--Thomas Henry Huxley (English Biologist and Educator, 1825-1895)

“Chess is the touchstone of intellect.”
--Johann Wolfgang von Goethe (German Poet, Playwright and Philosopher, 1749-1832)

Schizophrenia and Evolution

Schizophrenia remains one of the cruelest illnesses ever to afflict humanity. There are more theories about it than any other problem, and we may be getting closer to understanding why it seems to occur only in humans, and at roughly the same rate throughout the world. One idea is that the genetic predisposition to schizophrenia might have evolved as a secondary consequence of selection for human cognitive traits. As humans have evolved so has the brain, and it has become more lateralized, so this might explain the association between schizophrenia and handedness.

Several genes with strong associations to schizophrenia have evolved rapidly during human evolution, according to new research in the Proceedings of the Royal Society B this week.

In support of the cognition/schizophrenia hypothesis, researchers Dr Steve Dorus from the University of Bath, who worked with Dr Bernard Crespi from Simon Fraser University in Canada and Dr Kyle Summers from East Carolina University in the United States found that these genes had been positively selected.

They analyzed the molecular evolution of the 76 genes that have the strongest genetic association with the disorder. They surveyed human polymorphisms for discrete changes in the human genome that vary between individuals, in order to try and track very recent selective events within specific human populations. They also compared genes between mammalian species to identify selection on primate lineages salient to the evolution of humans and the disorder.

Amongst the genes for which they found positive selection were three genes that have the best functional or reproducible associations with the disorder: disrupted in schizophrenia (DISC1), dystrobrevin-binding protein 1 (DTNBP1) and neuregulin 1 (NRG1).

The selective forces underlying adaptive evolution of these genes remain largely unknown, but these findings are consistent with the hypothesis that schizophrenia is a maladaptive by-product of adaptive changes during human evolution, perhaps associated with creativity and human cognition.

Mindfulness and Depression

 

Mindfulness meditation has rightly been receiving a lot of attention recently. It is quite simply a technique in which you become intentionally aware of your thoughts and actions in the present moment, non-judgmentally. Though originally a Buddhist technique, it is something that can be practiced by anyone, and there are, in fact, similar techniques that have been developed by Christian mystics and Sufis.

It has recently been discovered that some of the techniques that were developed so that a mystic or meditator could carry on without distraction, may also have value in treating clinical problems. After all, if a group of people has spent a thousand years developing tools and techniques for managing the mind, it might be a good idea to see what they have discovered!

There have recently been several excellent books on the use of mindfulness in the management of depression:
The Mindful Way Through Depression 
Relaxation, Meditation and Mindfulness
Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition

This whole field was moved forward by some research from San Francisco (NR822) that was presented at the end of May at the 2007 Annual Meeting of the American Psychiatric Association in San Diego. The researchers used Mindfulness-Based Cognitive Therapy (MBCT) in a group of 53 people with treatment resistant depression.

MBCT is based on the Mindfulness-based Stress Reduction (MBSR) eight-week program that was developed by Jon Kabat-Zinn in 1979 at the University of Massachusetts Medical Center. Research has show that MBSR can be enormously empowering for people with chronic pain, hypertension, heart disease, cancer, and gastrointestinal disorders, as well as for psychological problems such as anxiety and panic.

Mindfulness-based Cognitive Therapy grew from this work. Zindel Segal, Mark Williams and John Teasdale adapted the MBSR program so that it could be used for people who had suffered repeated episodes of depression.

The results of the study presented in San Diego showed that MBCT was effective in reducing depression when compared to treatment as usual: what we call “TAU.” What seems to happen is that MBCT gives people a set of skills for detaching from the stream of depressive thoughts and feelings. As a result the symptoms decrease. Though the study will need to be expanded and replicated, this is clearly a fertile area for research.

This work is also interesting in the light of recent research showing that mindfulness training may improve the activity of some of the subsystems of the brain dedicated to attention, as well as helping  some people with mental illness control their aggressive behavior. Mindfulness training may also help to reduce subjective reduces distress and improves positive mood states. It seems to be particularly good at reducing distracting and ruminative thoughts and behaviors.

And just for good measure, mindfulness may help some smokers quit.

“The purpose of meditation is not enlightenment, it is to pay attention even at extraordinary times, to be of the present, nothing-but-in-the-present, to bear this mindfulness of now into each event of ordinary life.”
--Peter Matthiessen (American Naturalist and Writer, 1927-)

“Meditation is not to escape from society, but to come 
back to ourselves and see what is going on. Once there is 
seeing, there must be acting. With mindfulness, we know 
what to do and what not to do to help.”
-- Thich Nhat Hanh Vietnamese Buddhist Monk, 1926-)

“Conscious means "having an awareness of one's inner and outer worlds; mentally perceptive, awake, mindful." So "conscious business" might mean, engaging in an occupation, work, or trade in a mindful, awake fashion. This implies, of course, that many people do not do so. In my experience, that is often the case. So I would definitely be in favor of conscious business; or conscious anything, for that matter.”
--Ken Wilber (American Philosopher, 1949-)

Musical Hallucinations

A paper on auditory hallucinations of music was presented this afternoon at the 2007 Annual Meeting of the American Psychiatric Association in San Diego, California.

The researcher looked at 22 people diagnosed with schizophrenia and 23 with schizoaffective disorder at Maimonides Medical Center in Brooklyn, New York. The question was whether it would be possible to use the presence of musical hallucinations to distinguish between schizophrenia and schizoaffective disorder. The conclusions from the study were that these auditory hallucinations of music were more common in people with schizoaffective disorder and that voices with a religious or superstitious content were more common in people with schizophrenia.

Though it is good to see someone examine the content of hallucinations, this was a very puzzling study.

First, there is always a lot of debate around the “schizoaffective” diagnosis. Although there are clear criteria for it in the DSM-IV, many experts believe that most people who have been labeled “schizoaffective” actually have a form of bipolar disorder. But in any case, bipolar disorder and schizophrenia probably lie on a spectrum. People’s diagnoses often change over time. Not because of disagreement or inaccuracy, but because people change over time. The term “phenomenological drift” has been used to describe this observation. What that means is that we always need to be sure of the diagnosis at the time of the study, rather than what was written in the chart in the dim and distant past.

The other point is that genuine musical hallucinations are very rare. The world literature contains under a hundred papers in European languages, and the classic paper, published by German Berrios in 1991 was an analysis of just 46 cases. Berrios is regarded by many as one of the finest phenomenologists in Europe, so it is surprising that the investigator in New York found so many cases.

It will be good to see if the author or someone else can replicate the work. The classic teaching about musical hallucinations has been that they:

• Are more common in women
• Are more common in people who have hearing problems or are deaf
• Are more likely to occur in people with neurological diseases, including Alzheimer’s disease
• If they occur in people with neurological disease, it is more likely that the damage will be in the right or non-dominant hemisphere of the brain. (In men, language tends to be in the dominant hemispheres and music in the non-dominant. The pattern is a bit more complicated in women, but they also usually sing and recognize music with the right or non-dominant hemisphere)

A recent report from Japan reported that an elderly man with musical hallucinations was helped with the cholinesterase inhibitor donepezil (Aricept), suggesting that cholinergic neurons are somehow involved in generating musical hallucinations.

Many of us have music or tunes giong round in our heads, but that is quite different from hallucinating music.

And let me repeat: hearing things is common, and does not mean that someone is mentally ill.

 

House Supporting NAMI

Regular readers will know two things about me:

1. I am a huge advocate for the mentally ill
2. Last year I had to publish two denials after some mendacious individual posted the preposterous suggestion that the character of Gregory House in the wonderful TV show, was in some way based on me. To this day I don't know where that idea came from, other than the fact that I have specialized in trying to crack diagnostic conundrums.

Take the two together, and I'd like to give credit where it's due.

I was delighted to see that the entire cast and crew got together to support the National Alliance of the Mentally Ill (NAMI).

House has a well known expression, "Everyone lies." The the show's producers and cast members, along with the slogan, will benefit the organization and its work in education, support, and advocacy for individuals and families affected by mental illness.

For a limited time, T-shirts from the show, emblazoned with the phrase "Everybody Lies," are being sold on-line.

The executive producer of house is Katie Jacobs, and she had this to say:

"Mental illness is stigmatized and misunderstood in our society, and we’re trying to do something about that. We’re very fortunate to be celebrating an extremely successful third season for HOUSE, and we’d like to give something back to a cause we feel is both worthy and overlooked."

The TV show, in the course of showing Dr. House attempting to diagnose illnesses with hallucinatory or psychotic symptoms, has helped educate the public about the medical nature of many psychiatric symptoms including mood and personality changes. These diagnoses have included herpes encephalitis, syphilis, hypercortisolism (Cushing's), Wilson's disease, hemochromatosis, and Korsakoff's syndrome (vitamin B1 deficiency).

"Everybody Lies" conveys a message about stigma, false perceptions and misinformation about mental illness. In the TV show, the phrase represents that people who are being diagnosed with ANY illness often withhold information. In a time when it seems that Hollywood has been indifferent to, or even has propagated, stigma about mental illness, it is refreshing that the producers and cast of a TV show are helping to combat that.

NAMI executive director Mike Fitzpatrick says,

"On behalf of every individual and family who live with major depression, bipolar disorder, schizophrenia and other mental illnesses, NAMI thanks the show and cast. They are making a difference in people's lives."

In addition to the sale of the T-shirts, an on-line auction is running for seven days (1 May 2007 through 7 May 2007) to sell five special autographed items. All proceeds go to NAMI.

Sage Words about Violence and Mental Illness

One of the blogs that I highlight down of the left-hand side of this one is attached to schizophrenia.com.

They have a particularly good entry for April 20th, that discusses not just the tragedy in Virginia and its possible relationship to mental illness, but also some broader social questions. Having been born and raised in the UK, and then worked there and in the United States in both medicine and psychiatry I can really relate to many of the points made in the article. It really should be disseminated as widely as possible, so I am going to do something that I usually do not, and quote the article in full:

The Loss of Life in Virginia, and How it Could Have Been Prevented

Read more... Schizophrenia, Poverty & Crime

Whenever a tragedy happens such as the recent shootings in Virginia, the question inevitably turns to why did it happen, and how could it have been prevented.

While some reports (such as here, here and here) have suggested the shooter in this tragedy - Cho Seung Hui - might have suffered from psychotic depression, schizophrenia or bipolar disorder - its impossible to know with the limited amount of evidence available, and even after all the evidence is reviewed it will never be known for sure.

From what has been reported it does, however, seem obvious that he was seriously depressed and socially withdrawn, and had some significant delusions of persecution and paranoia. Whether these symptoms add up to a serious mental illness or some type of sociopathic disorder is unknown. Some factors don't seem to point towards schizophrenia - as Cho Seung Hui did not seem to suffer from the lack of motivation (called avolition) that is so common with schizophrenia. He was able to attend college and, from the sounds of things, was attending classes regularly and finishing his assignments. Typically when a person develops schizophrenia schoolwork and personal hygiene the first thing that suffers, and an inability to complete schoolwork is common.

With regard to the question of why did it happen - it is of course impossible to know for sure. But at the same time research into mental illness and brain disorders does point to some possible answers.

The path towards mental illness (any mental illness) is a complex one with many different factors - from genetic predisposition and pregnancy factors, to early life stresses and environmental factors, to social stresses. We have more information on this in our "Preventing Schizophrenia" - but fundamentally the factors that nudge people towards mental illness are many and varied. The factors that have been conveyed about the life of Cho Seung Hui suggest that early life experiences could have been factors. Here are some of the relevant points that have been discussed in the news:

1. A Difficult Early Life - news on the family has suggested that they had a difficult (low-income) family life in Korea which prompted the move to the US when the parents had a young family. A low income life that motivates a young family to leave a country - is likely to be a high stress environment - a factor that could contribute to mental illness.

2. Social stresses of immigration to the US (many studies out of the UK have indicated that immigrants frequently face extremely difficult social challenges in new countries due to a lack of understanding of social norms (as well as racism) - which causes a great deal of social stress and significantly higher rates of mental illness.

3. Cho Seung Hui's Father worked in a Dry Cleaning company - and the family may have been exposed to higher levels of dry cleaning chemicals - which are linked to neurological damage.

Additionally, on a related topic, Dr. Michael Merzenich, the Neuroscientist at UCSF - comments in his blog on the important issues related to the general social environment that is also a factor in the extremely high levels of gun violence and deaths in America - typically 300% to 600% higher than in other developed countries:

"Our jurisprudence is based on the principle of “blame” for behaviors that should by hypothetically controlled by our “free will”. Alas, human observers and psychologists (and with increasing clarity, we brain scientists) have understood from the beginning of time that your or my “will” is not entirely “free”. The boundaries of “good judgment” are defined by a combination of the inherited factors governing our brain function, by our physical brain status (2 million head injuries/annum in the US alone!), and the brain’s own plasticity-embedded experiences. For most of us, our genetics combined with fortuitously not busting our skull in the wrong place and with our particular plastic, experientially-driven brain ‘history’ adequately protects us from serious transgression. At the same time, in our (and other) contemporary society(ies), we tolerate conditions that result in millions of young men and women being reared with an experiential history that is NOT adequate to keep THEM safe from offending. THIS IS THE PART OF THE EQUATION THAT IS UNDER OUR (SOCIETY’S) CONTROL. We’re doing a bad job with it. In fact:

1) We live in a violent society chock full of models of behavior (a violence & fear-obsessed media, violent films, gangsta rap, et alia) that are well outside any rational societal norms. The mass murder of children on school campuses is one our MANY rather spectacular modern American-violence inventions with little historical precedent.

2) We tolerate the hardening of young brains to otherwise-not-tolerable bloody, shoot-em-/slash-em-up violence as an acceptable source of intensive training “fun” in the heavily-rewarded game-play of millions of our children. All that intensive training is somehow supposed to be just fine for the child and their brain?! Those tens or hundreds of thousands of violent repetitions in rewarded behaviors just don’t matter a whit? Stuff and utter nonsense.

3) We continue, collectively, to find innumerable ways to shame children in their young lives as “failures”, “weaklings”, “misfits” or “oddballs” in school and in life.

4) We send juveniles and young adults off to crime school (prison) at an extraordinarily high (and growing) rate.

Sometimes I think that we could hardly be doing a better job of training young people to misbehave. When they do, we hold them to a universal high standard of acceptable behavior that they may actually have had little experience with, in their own path through life, in our very own society."

Lastly - there is the issue of easy access to guns in the US - which when combined with all the above factors makes for an extremely toxic mixture. Easy access to guns results in high death rates in shootings; death rates that are typically 500% to 1,000% higher in the US than in other civilized countries, as can be seen in the diagram below.

National Comparisons for Selected Countries Homicide Rates Per 100,000 Population

Source: Corrections Service Canada

As New Scientist Magazine notes "Scientific studies have demonstrated over and over that owning a gun makes it significantly more likely that you will be shot. The US has the highest rate of firearms-related homicide in the industrialized world – Americans are literally sacrificing hundreds of innocent citizens each year upon the altar of the Second Amendment."

Are any of these factors preventable? Yes - of course they are - but the actions are costly and complex. To prevent these types of tragedies takes:

1. Better education of the public about how to achieve mental health for their children,
2. Early and easy treatment for mental disorders with early testing and screening in schools,
3. Good insurance coverage so that people can actually get their mental health problems addressed. The US is the only developed country in the world that severely limits coverage of mental health problems. Better and easier access to high quality mental health treatments is a great need in the US.
4. Laws that make it possible for mentally ill people to get treatment, even though they may not understand the need.
5. A reduction in the culture of violence in the US (a movement to reduce violence in movies, on TV, and in video games). Read: In denial about on-screen violence for more information.
6. Strict gun controls that take the millions of hand guns off US streets, and that will make it more difficult for the people who become mentally ill or who have psychiatric disorders - to obtain guns. Approximately 29,000 US citizens are killed by their fellow citizens each year, by hand guns. (see Statistics, Gun Control Issues, and Safety for more information)

The answers are relatively clear - but whether we actually do anything about it is up to you.

Related Reading:

Mental Health, the Law and Predicting Violence (NPR)

America's tragedy - Its politicians are still running away from a debate about guns (The Economist)

Mayors urge Bush to tighten gun control laws

Stricter gun control after shootings at U.S. university - not going anywhere fast

Relationship of US gun culture to violence ill-understood

Violence may be a 'socially infectious disease'

Fewer cheap guns = fewer criminals with guns

 

Posted by szadmin at April 20, 2007 08:45 AM

 

Madness and Genius Revisited

I must have heard a thousand times that there’s a fine line between genius and insanity. I have talked before about the possible link between the two through schizotypal personality disorder. It is quite well known that there are two living Nobel Prize winners who have a diagnosis of schizophrenia and many more who have first-degree relatives with it.

There is some very interesting research in the current issue of the Journal of Clinical Investigation from a team of scientists at the National Institutes of Health's (NIH) National Institute of Mental Health (NIMH).

In the latest installment of a story that has been unfolding over the last three decades, they report on their findings concerning a human gene for a master switch in the brain called DARPP-32. Most people inherit a version of a gene that optimizes their brain's thinking circuitry, yet paradoxically also appears to increase risk for schizophrenia, an illness marked by impaired thinking. The main kinds of thinking involve reasoning, abstraction and creativity.

Over the last two decades, studies in animals, most notably by Nobel Laureate Paul Greengard at Rockefeller University, have established that DARPP-32 in the striatum switches streams of information coming from multiple brain chemical systems so that the cortex can process them. Both the neurotransmitter that DARPP-32 works through – dopamine - and the chromosomal site of the DARPP-32 gene have been implicated in schizophrenia.

The NIMH researchers in this new study have identified a common version of the gene and showed how it impacts the way in which two key brain regions exchange information, so affecting a range of functions from general intelligence to attention.

To understand DARPP-32's role in the human brain, they used genetic, structural and functional magnetic resonance imaging and also post-mortem studies to identify the human gene's variants and their functional consequences.

Seventy five percent of subjects had the most common version of the gene, which boosted the activity of circuits in the prefrontal cortex of the brain. This region is the major filter, controller and processor of cognitive information. When active, it increases structural and functional connections and our performance on tasks that involve thinking. It almost certainly does so by increasing gene expression. In 257 affected families, people with schizophrenia were also more likely to have this common version of the DARPP-32 gene.

DARPP-32 appears to shape and control a circuit running between the striatum and prefrontal cortex. The circuit affects key brain functions implicated in schizophrenia, such as motivation, working memory and reward-related learning.

The senior investigator is Daniel Weinberger, who had this to say,

"Our results raise the question of whether a gene variant favored by evolution, that would normally confer advantage, may translate into a disadvantage if the prefrontal cortex is impaired, as in schizophrenia. Normally, enhanced cortex connectivity with the striatum would provide increased flexibility, working memory capacity and executive control. But if other genes and environmental events conspire to render the cortex incapable of handling such information, it could backfire -- resulting in the neural equivalent of a superhighway to a dead-end."

Although several groups of researchers have looked for the possible clinical relevance of DARPP-32, they have had much success. This study shows a strong connection between the molecule and human cognition and also, perhaps, with schizophrenia.

What is also interesting about this finding is that it helps provide us with a mechanism by which environmental stress could lead to cognitive problems.

Apart from the uninformed tirades of Tom Cruise, I see a lot of opinion pieces on websites and YouTube expressing the opinion that psychiatry is baseless, ostensibly because there is no science behind it. By anyone’s standards, this is high level science utilizing a series of state-of-the-art approaches. And another piece of evidence that psychiatry is becoming more science than art, linking the mind, the brain and the environment into one harmonious whole.

Medication-induced Weight Gain

It is not really a surprise that medicines that are designed to have effects on emotion might also have other effects. After all, emotion originally evolved as an outgrowth of the sympathetic nervous system, which, as every student of biology knows, is involved in the "Four F's:"

• Fear
• Fight
• Flight
• Sexual activity

So if powerful medicines influence emotion, they will likely also influence one or more of these.

Cocaine and amphetamine lead to a loss of appetite for food, though I am told that marijuana makes people hungry. I do not, of course, know that from personal experience.

Many antipsychotics, mood stabilizers and antidepressants cause weight gain by an array of different mechanisms.

New research published by colleagues from Johns Hopkins has done a lot to clarify the role of histamine in the appetite problems that often occur with antipsychotics.

You may be interested in reading more here.

The conclusion? Histamine has a major role to play in antipsychotic-induced appetite increase.

But it is not the only factor in the weight gain, insulin resistance and diabetes problems that seem to bedevil some of these medicines.

Before the book comes out, I shall write some more about the ways in which the Atlanta Approach successfully - and uniquely - deals with all of those problems.

Hormones, Addictions and Mood

People working with mental illness have been for years now been puzzled by two observations. The first is that mood disorders and schizophrenia follow quite different trajectories in men and women. Women tend to be more vulnerable to mood disorders and if they get schizophrenia it tends to be less severe and to have fewer "negative" symptoms, such as flat, blunted or constricted affect and emotion, poverty of speech and lack of motivation until after menopause. We have looked at some of the reasons for the different rates of mood disorder, in terms of relationships and social pressures, but there must also be a biological component. The second puzzle is that women are more vulnerable to addictive drugs in the days before they ovulate.

New research published in the  Proceedings of the National Academy of Sciences may provide part of the answer to both puzzles.

Colleagues at the National Institute of Mental Health (NIMH), a component of the National Institutes of Health (NIH), have conducted a fascinating imaging study that has shown that fluctuations in levels of sex hormones during women's menstrual cycles affect the responsiveness of the reward systems in the brain.

The reward system circuits include the:

• Prefrontal cortex, which has key roles in thinking, planning and in the control of our emotions and impulses
• Amygdala, which is involved in rapid and intense emotional reactions and the formation of emotional memories
• Hippocampus, which is involved in learning, memory and navigation
• Striatum that relays signals from these areas to the cerebral cortex

It has been known for some time that neurons in the reward circuits are rich in estrogen and progesterone receptors. However, how these hormones influence reward circuit activity in humans has remained unclear.

The researchers used functional magnetic resonance (fMRI) imaging to examine brain activity of 13 women and 13 men while they performed a task that involved simulated slot machines. The women were scanned while they did the task, both before and after ovulation.

When anticipating a reward, in the pre-ovulation phase of their menstrual cycles the women showed more activity in the amygdala and frontal cortex. When women were actually winning prizes, their reward systems were more active if they were in the phase of their menstrual cycle preceding ovulation. This phase of the cycle is dominated by estrogen, compared to postovulatory phase when estrogen and progesterone are both present. When winning, the main systems that became active were in the parts of the brain involved in pleasure and reward.

The researchers also demonstrated that the reward-related brain activity was directly linked to levels of sex hormones. Activity in the amygdala and hippocampus was in directly linked to estrogen levels, regardless of where a woman was in her cycle. When women won prizes during the post-ovulatory phase of the cycle, progesterone modulated the effect of estrogen on the reward circuit.

Men showed a different activation profile from women during both anticipation and delivery of rewards. Men had more activity in the striatum during anticipation compared with women. On the other hand, women had more activity in a frontal cortex when they won prizes.

This research could have a number of important implications. The most obvious is that it confirms what many women know already: they are more likely to take addictive substances or to engage in pleasurable - but perhaps impulsive or risky - behaviors just before they ovulate.

It is not difficult to imagine why this might have developed during evolution.

“Coming to terms with the rhythms of women's lives means coming to terms with life itself, accepting the imperatives of the body rather than the imperatives of an artificial, man-made, perhaps transcendentally beautiful civilization. Emphasis on the male work-rhythm is an emphasis on infinite possibilities; emphasis on the female rhythms is an emphasis on a defined pattern, on limitation.”
--Margaret Mead (American Anthropologist and Writer, 1901-1978)

Over-Medicating America

There is an important study in this month's issue of the Annals of Family Medicine It concerns something that most health care professional in the United States have been worried about for some time: it is direct-to-consumer advertising of prescription medicines. I rarely watch much television, but out of interest I had one channel on for an hour this morning and saw six advertisements for medicines. It is not widely known that this practice is illegal in most of the rest of the world, with the exception of New Zealand.

The research suggests that this direct-to-consumer television advertising of prescription drugs may be influencing Americans to believe that they are sicker than they really are. This may in turn lead to taking more medication than they actually need.

The study was funded by the National Cancer Institute's Centers of Excellence in Cancer Communication Research and the Robert Wood Johnson Foundation, and was led by Dominick Frosch from the David Geffen School of Medicine at the University of California, Los Angeles.

The researchers evaluated the educational value of 38 direct-to-consumer television advertisements for prescription drugs and analyzed how they tried to influence viewers. The drugs in question were for treating illnesses ranging insomnia and depression to high cholesterol and high blood pressure.

Their findings suggest that the advertisements had virtually no educational value. Furthermore they failed to describe who is most at risk for which illnesses, what their symptoms might be, and whether non-medicinal alternatives such as lifestyle changes might also be viable options.

According to the figures cited, Americans watch up to 16 hours of television advertising about prescription drugs per week. The scientists watched the advertisements shown during the evening news and prime time periods. They used a coding system that takes into account a number of attributes of each ad. The attributes included the factual claims made about the illness the drug is aimed at, the method used to attract the consumer, and also what is revealed about the behavior and lifestyle of the people in the advertisement.

Although they found that over 80% of the advertisements did make some factual claims and put forward rational arguments for use of the drugs, only 25-26 per cent of them described symptoms and causes of illnesses, the associated risk factors and how common or rare they are.

The scientists also found some common strategies: many of the advertisements portrayed the drugs in terms of people losing control over their lives (58%) and then regaining it (85%) once they took the medication. 78% of the ads also portrayed the medication as engendering social approval, while 58% of them implied that the drug was a medical breakthrough.

The findings also show that nearly all advertisements (95%) used emotional appeal to influence viewers and none of them showed lifestyle and behavior change as viable alternatives, except for 19% of them that showed this as an adjunct to taking the drug. 18% of the advertisements suggested that changes to lifestyle would not be enough to deal with the illness.

The conclusion of the study is that despite the claims that television advertisements play an educational role, they contain limited information about causes and symptoms of their target illnesses, their prevalence and risk factors. They also show people that have "lost control over their social, emotional or physical lives without the medication; and they minimize the value of health promotion through lifestyle changes. The ads have limited educational value and may oversell the benefits of drugs in ways that might conflict with promoting population health."

Dr Frosch said that "We're seeing a dramatization of health problems that many people used to manage without prescription drugs," and that the "ads send the message that you need drugs to manage these problems and that without medication your life will be less enjoyable, more painful and maybe even out of control." He said that the US should consider banning direct to consumer television advertising of prescription drugs too. Something that was echoed in the accompanying editorials.

I have spent a great deal of time weighing the pros and cons of direct-to-patient advertising with health care professionals and people in the pharmaceutical industry in Europe, the United States and Australia and New Zealand. Despite all of our work to empower people, I remain unconvinced that they are ultimately in peoples' best interests.

Altruism and the Brain

There is a fascinating new study which will be out next month in the journal Nature.

Colleagues from Duke University Medical Center in Durham, North Carolina, believe that they have found a region of the brain that is associated with altruism: selfless concern for the well-being of others.

Some scientists have claimed that it is of no value because it has no survival advantage. I've never been able to agree with that extreme position. Another view is that the survival advantage comes from an ability to perceive the intention of others and therefore to anticipate their actions. I'm also not certain that this is genuine altruism, in the sense that altruism should be selfless.

45 volunteers were asked to play a computer game and also to watch the computer play the game. In some instances successful completion of the game resulted in the volunteers winning money for themselves, and in other instances it resulted in money being donated to a charity that each person had chosen at the beginning of the experiment. During these games the researchers took functional magnetic resonance imaging (fMRI) scans of the participants' brains.

According to the old fashioned - and false - theory that pleasure and pain are THE main drivers of behavior, it was assumed that altruistic acts would activate the reward systems in the brain.

They do not.

A region of the brain called the posterior superior temporal cortex (pSTC) is activated by altruism and is very sensitive to the difference between doing something for personal gain and doing it for someone else's gain. The pSTC appears to help us tune into perceiving and giving meaning to the actions of others. It is not focused on reward.

In the next stage of the research the participants were asked questions about the type and frequency of their altruistic or helping behaviors. The researchers then analyzed the responses to generate an estimate of a person's tendency to act altruistically and compared each person's level against their fMRI brain scan. The results showed that pSTC activity rose in proportion to a person's estimated level of altruism. Note that it was their estimated level rather than their actual altruistic acts.

The suggestion by the researchers is that the ability to perceive other people's actions as meaningful is critical for altruism.

I am going to be a Devil's advocate and interpret the data differently. I think it more likely that people who have a good understanding of social relationships are more likely to do things for other people. Helping other just makes sense to you. Both the tests and the imaging could be interpreted in terms of social understanding and empathy. In other words we are looking at an aspect of social cognition.

There may also be another correlation here. Some years ago we showed that in people with chronic schizophrenia there is a shift in the handedness of a particular region of the brain called the planum temporale, which lies on the top of the temporal lobe. This lead to the hypothesis that when people are hearing voices, they really are hearing something being generated in the right hemisphere of the brain. People with schizophrenia sometimes have trouble with reading other people's intentions and may attach meaning to random events. This new research mat help us understand why that can happen.

It also makes clinical sense: the best ways of helping people with mental illness who have these problems is to ensure that they are not on medicines that impair their social cognition, and to use social skills training.

“What we have done for ourselves alone dies with us; what we have done for others and the world remains and is immortal.”
--Albert Pike (American Lawyer, Masonic Author and Historian, 1809-1891)

“Spiritual energy flows in thankfulness and produces effects on the phenomenal world.”
--William James (American Psychologist and Philosopher, 1842-1910)

Toxoplasmosis and Behavior

Last August I wrote an article about some extraordinary new evidence implicating Toxoplasma gondii in some psychological and psychiatric illnesses. Latent infection with Toxoplasma gondii is amongst the most prevalent of human infections and it had been generally assumed that it is asymptomatic unless there is congenital transmission or reactivation because a person has an immune system that has become depressed or compromised. That assumption is being completely re-evaluated. 

The article generated some extremely interesting correspondence and some spirited discussions.

Here is a very insightful letter from a physician:

Dear Dr. Petty,

I thought about the concept of psychological illness caused by a virus or other organism. I was wondering what would be the mode of dispersion of such a virus. Upper respiratory tract infections, skin and gastrointestinal infections spread by cough, by touch and hand to mouth respectively. How would such a brain virus or protozoal organism promote itself? Of course it could be by the above methods but it seems that there should some way that the specific disease process is connected to a behavior that helps it to spread itself. 

Then I got to thinking; diseases have learned physical ways to disseminate themselves, I wonder if a disease could change behavior to promote it's own dissemination and survival? I imagine that if that were true, people with the flu would be sociable, people with infectious diarrhea would be sociable and hungry, people with AIDS would have increased libido. I haven't yet seen any data for this. Although I've always felt that there was one disease that did alter behavior in a way that is conducive to disseminating itself, and that is rabies. The host goes from being docile, to seeing all others as the enemy. He then attacks them, bites them and thus passes on the organism. A true mind altering virus, although it's psychology works better with animals than with people. Do you think that there are other diseases that spread purely by behavior, that cause the host to seek out the next host and not just pass the disease from one to another just due to proximity?

This was my response:

What great questions!

And believe it or not, there's quite a lot of empirical research on these very topics.

There is a whole textbook on the behavioral effects of parasites edited by Janice Moore entitled  Parasites and the Behavior of Animals. Here's an interesting one: rats and mice are hard wired to avoid cats. Millions of years of programming have ensured that Tom's very presence would send Jerry packing. Cats carry Toxoplasma gondii and if mice or rats become infected with it, usually by eating cat poop, they lose their fear of felines. So now Tom can have lunch at his leisure.

I've also talked about the way in which people with creativity and schizotypal personality disorder (i.e. carriers of genetic risk) tend to be promiscuous, while people with schizophrenia have fewer children. Both groups tend to get more sexually transmitted diseases than the general population. It would be tempting to think that toxoplasmosis can be spread that way, however there's a 32-year old study in German that showed that Toxoplasma was not transmitted by intercourse. However, cytomegalovirus, a common partner to Toxoplasma may be. And both modulate dopamine activity in the regions of the brain involved in salience.

I have done a very detailed literature search encompassing papers written in all the languages that I can read, and have not been able to find any clear evidence of behavior change induced by HIV, influenza or infectious diarrhea: what interesting and important questions to research.

We do have some more data confirming the effects of Toxoplasma infections on the behavior of rats: they become less anxious and therefore do not respond to environmental threats as quickly as uninfected rodents. An antipsychotic medication (haloperidol), a mood stabilizer (valproic acid) and two chemotherapeutic agents - pyrimethamine or Dapsone – have all been shown to prevent the development of Toxoplasma-induced behavioral change.

Another recent study from the Departments of Parasitology, Microbiology and Zoology, Charles University, the Centre of Reproductive Medicine and GynCentrum, in the Czech Republic also speaks to the significance of latent Toxoplasma infections: the presence of the parasite in the blood of pregnant women increases their chance of giving birth to boys. The increased survival of male embryos in infected women may be explained by Toxoplasmosis infections modulating and suppressing the immune system.

If Toxoplasma plays a part in the development of some psychiatric illnesses, yet a high proportion of the population carries it without any problems, one obvious question is what activates it? Environmental stress might, perhaps, cause the Toxoplasma to become reactivated and play a part in the development of specific psychiatric symptoms.

This story is continuing to develop and I am going to watch it closely. If it is confirmed, it could open up some brand new avenues for helping treat and perhaps even prevent some types of psychiatric illness.

Genetic Testing in the Treatment of Depression

By a remarkable “coincidence,” less than a week after the appearance of two items (1. 2.) questioning the value of using genetic testing to help predict response to treatment in people suffering from depression, an important report has been released today.

The report is supported by a collaboration of the Agency for Healthcare Research and Quality and the Centers for Disease Control (CDC) and Prevention’s National Office of Public Health Genomics, and it was the CDC that funded it.

It is gratifying to see that the findings of the report are identical to those published in the two articles last week. The main conclusion of the report is that there is insufficient evidence to determine if current gene-based tests intended to personalize the dose of medications in a class of drugs called selective serotonin reuptake inhibitors (SSRIs) improve patient outcomes or aid in treatment decisions in the clinical setting.

The investigators reviewed 1,200 abstracts that led to the final inclusion of 37 articles. As we learned last week, the evidence indicates the existence of tests with high sensitivity and specificity for detecting only a few of the more common known polymorphisms of the cytochromes 2D6, 2C19, 2C8, 2C9, and 1A1.

They found mixed evidence regarding the association between CYP450 genotypes and SSRI metabolism, efficacy, and tolerability in the treatment of depression, mainly from a series of heterogeneous studies in small samples.
There were no data regarding:

1. If testing for CYP450 polymorphisms in adults starting SSRI treatment for non-psychotic depression leads to improvement in outcomes versus not testing, or if testing results are useful in medical, personal, or public health decision making.
2. If CYP450 testing influences depression management decisions by patients and providers in ways that could improve or worsen outcomes.
3. If there are direct or indirect harms associated with testing for CYP450 polymorphisms or with subsequent management options.

This report confirms that there is little point in doing these genetic tests.

It also raises another point. It is now some years since some of these tests became available commercially. If they were really of value then we have to ask why there hasn’t been an avalanche of research on the topic – especially by the people marketing the tests – and why none of major psychopharmacology groups in the United States, Europe, Japan or Australia picked up on the tests. I probably know most of the people in these hospitals, universities and research centers and none has been much interested in this work.

So when someone suggests that you undergo some new test or investigation, remember to use your common sense. If there is only one person doing it - whether it’s a genetic test, a brain scan, some non-standard type of thyroid or adrenal test, or a Vega test - ask why nobody else is using it and why nobody has published any decent research on the method.

When it comes to your health use your common sense, your intuition and impartial information to be your guide and your support.

Mystical Experience

I recently wrote a little bit about mystical experiences and mentioned the most widely used “definition,” the Stace Criteria:

1. Deeply positive mood
2. Experience of Union
3. Ineffable sense
4. Enhanced sense of meaning, authenticity and reality
5. Altered space and time perception/transcendence
6. Acceptance of normally contradictory propositions

There are many ways of inducing the mystical state: -

• Meditation
• Prayer
• Control of breathing: e.g. Pranayama
• Chanting: e.g. Zoroastrian priests
• Dance and movement: for example the whirling Dervishes or Morihei Ueshiba who reportedly achieved a state of mystical union after performing kata
• Light, as happened with the mystic Jacob Boehme
• Biofeedback
• Mantra
• Drugs

Although many people deliberately seek mystical experiences, some come out of a clear blue sky: the French writer, philosopher and Marxist materialist, Simone Weil, reported how reciting a devotional-metaphysical poem by the English religious poet George Herbert (1593-1633) while highly concentrated and emotional, turned her from an agnostic into a mystic. She was not looking for it to happen: it was unsought as it was unexpected. What was interesting was that after that first time, particularly in the last year of her life, she had mystical insights several times a week. Despite – or perhaps because – she was suffering from tuberculosis and was first in a hospital and then in a sanatorium during most of that time.

Some children have had a mystical glimpse before the age of ten, more during adolescence and still more during their thirties or forties. Richard Maurice Bucke in his classic book, Cosmic Consciousness, thought that the peak time was in the early thirties, but it can still happen in people in their seventies.

Many people need a dramatic shock - some form of enforced awakening - that subjugates the ego. Only then do they come alive spiritually. This enforced awakening is effective only if it breaks down old habits, trends, and beliefs. It may come about through working with or reading a teacher like Krishnamurti or Gurdjieff, or through major life events like a life threatening illness or unexpected bereavement. There is also little doubt that people become more interested in spiritual matters and more receptive to them at key points in their lives. Sometimes the experiences may occur as part of the process of individuation described by Carl Jung.

Some years ago I wrote a speculative piece suggesting that some mystical experiences may be triggered by a neurological mechanism involving the reticular activating system of the brain. The popular idea that mysticism is somehow related to the right hemisphere of the brain is probably not accurate. With the passage of time, it begins to look as if those speculations were accurate. Though one of the points that I made at the time, is that although we might be able to find a neurological substrate for mystical experiences that provide the form of the experience, that still left us with the problem of the content of the experience and therefore of its meaning for the individual.

At the beginning, the content of the mystical experience is culture bound and tends to be a product of a person’s belief system, which is why some mystics contradict each other. The Indian spiritual teacher Swami Ramdas (1884-1963) said that joy was both evidence of spiritual fulfillment and an ingredient of spiritual practice, while Simone Weil took an exactly opposite view and substituted unhappiness and suffering for joy: each proposed that a personal experience reflected a broadly universal truth. This is has been a common error for many spiritual teachers and their followers.

Saint Teresa of Ávila, a.k.a. St. Teresa de Jesus, the Spanish nun, mystic and author (1515-1582) was brought up in the Roman Catholic Church, and her mystical revelations fit into classical Catholic dogma. In contrast a modern Christian mystic - Holden Edward Sampson – who was brought up in the Protestant Evangelical Church, thought that his personal experiences proved that Saint Teresa’s writings were false.

These differences of opinion, even amongst the most advanced mystics, are striking but not often discussed. As an example, it amused me to see Ramana Maharshi make gentle fun of Sri Aurobindo's doctrine of spiritual planes. I love and rever the workds of both of these sages. Simone Weil staunchly promoted the spirituality of Greek culture while the French-born writer René Guénon a.k.a. Sheikh 'Abd al-Wahid Yahya thought that there was nothing much to it. As people progress, there is usually more of a confluence: mystics tend to report similar experiences, but they are often still colored by their past lives.

Many people have mystical and spiritual experiences without knowing what is happening to them: they have never studied or been taught anything about them. I have seen quite a number of people who were supposed to be suffering from a psychotic episode, but who were actually having a profound spiritual experience. I have seen many thousands of psychotic people in almost fifty countries, and it is normally not that difficult to differentiate a breakdown from a breakthrough. Though even the most experienced of people sometimes find it difficult to be 100% certain what is going on.

It is essential for health care providers and for anyone who comes into contact with an individual who is having strange experiences, not simple to label them as mentally ill, but to remain alert to the possibility that there may be something yet more profound and meaningful going on in their lives.

Though for some people medicines, psychotherapy and the rest may be very helpful, others need spiritual support and guidance as they grow through a process of spiritual growth.

Breast is Best, But…

I think that everyone knows that breastfeeding confers considerable advantages on a baby. So much so that the American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life. Though some mothers cannot manage this for a whole range of reasons, and it’s always a real shame when women are made to feel guilty if they cannot breastfeed.

Amongst some of the likely health benefits for both mother a baby:

1. Mother and child are more likely to bond
2. A reduced risk of the child developing some respiratory problems, ear infections and gastrointestinal problems
3. A reduced risk of developing allergies later in life
4. A reduced risk of obesity in adulthood
5. A reduced rate of attention deficit disorder
6. A reduced risk of developing type I diabetes
7. There may also be a reduced risk of developing osteoporosis in later life
8. The mother has a reduced level of stress and postpartum bleeding
9. Mothers who breastfeed have a slightly reduced risk of some types of cancer

To this list we can add that breastfed children are more intelligent. That is not a new discovery. It was first reported in the 1920s. A new study published in the British Medical Journal has re-examined the question. Most of the earlier studies failed to consider the mother’s intelligence, despite the well-recognized association between maternal education and breastfeeding. That association often breaks down in professional women who have to go straight back to work after giving birth, but it remains a key variable.

The researchers examined data from 3,161 mothers and 5,475 children, who were followed in a twenty-five year prospective study. Premature babies were excluded and the children’s’ intelligence was measured up to age five.

The breastfed babies had slightly higher IQs, but the effect was entirely accounted for by their mothers’ intelligence. Breastfeeding itself had little or no effect on intelligence scores. The mothers of the breast-fed children tended to be older and to be more likely to provide the growing child with a stimulating and supportive home environment.

In a separate study from the Australian Raine Study at the Telethon Institute for Child Health Research, that has tracked the growth and development of more than 2500 West Australian children over the past 16 years, it now emerges that children who were breastfed for longer than six months have significantly better mental health in childhood.

Children that were breastfed had particularly lower rates of delinquent, aggressive and anti-social behavior, and overall were less depressed, anxious or withdrawn. This makes sense: apart from the psychological impact of having a mother who is willing and able to breastfeed, breast milk is a rich source of polyunsaturated fatty acids - examples include docosahexaenoic acid and arachidonic acid - that are important for brain development and the growth of nerve cells.

There is also evidence that breastfeeding may reduce the risk of developing schizophrenia later in life, although it is difficult to be sure if it because of the breast milk itself or the kinds of mothers who breastfeed.

Hearing Voices

In 1973, there occurred a notorious episode in the history of psychiatry. A psychologist named David Rosenhan did an infamous experiment in which he had a group of eight people present themselves to twelve hospital emergency rooms claiming that they were hearing the words, “Empty, “Dull” or “Thud.”

Most were admitted and given psychiatric diagnoses. The second part of the experiment consisted of asking staff at a psychiatric hospital to detect non-existent 'fake' patients. They did rather badly. A paper about this was published in the journal Science, with the title, “On Being Sane in Insane Places.”

 
In its day, this paper was considered a damning critique of psychiatry and a plank in the ant-psychiatry movement that was in full swing at the time. In truth, it tells us only that if you lie to doctors and nurses you may deceive them. And second it is only a criticism of bad psychiatry. The idea of diagnosing schizophrenia or any other mental illness on the basis of hearing a single word is absurd. At least 40% of the population will at some time hear their name being called, particularly in times of stress or after bereavement. And very many people in the general population will occasionally hear a word being spoken. It is diagnostic of nothing.

I sincerely hope that none of the people that I’ve taught in 45 countries around the globe would EVER diagnose schizophrenia or any other mental illness simply on the basis of hearing voices, a.k.a. auditory hallucinations. As I’ve stressed time and again, the only purpose in making a diagnosis is to guide treatment and prognosis. Simply hearing voices can guide neither.

This topic came up during one of the things that I was doing to advocate for patients, because September 14th 2006 was World Hearing Voices Day, and I received some very interesting information from a UK based organization, the Hearing Voices Network. (There's also a nice article here as well.)

There is some excellent research on people who hear voices yet are not mentally ill. Many of these people do not feel the need for any treatment and not only peacefully coexist with them, but regard them as a blessing. Most of the research has been done by Professor Marius Romme and Sondra Escher from Maastricht University in the Netherlands, Richard Bentall from the University of Manchester, and Gordon Claridge at Oxford.

About 4% of the general population hears voices, and most of them are not mentally ill. It is essential for us to understand the notion of dimensional rather than categorical diagnoses. I’m mentioning it again, because it prevents us falling into the error of labeling people for no readily apparent reason. For some people their voices are supportive and comforting.

One of several studies has shown that the form and content of auditory hallucinations is much the same whether someone has been labeled with a mental illness or not. Trauma and abuse can reactivate voices, or make them threatening.

The key to the hearing voices is whether or not they are causing distress to the individual or to those around them. There are four major coping strategies typically used by people who hear voices: distraction, ignoring the voices, selective listening to them, and setting limits on their influence.

The biggest danger for people who are hearing voices and are suffering from cognitive impairment or a mental illness, is that the voices may form the basis for delusions. As people are trying to make sense of their experiences, they may develop highly creative explanations.

I once worked with someone who was not hearing voices, but feeling odd sensations coursing along her limbs. She got a textbook of Chinese medicine, and became convinced that she was feeling the flow of Qi in her body. But because she also felt the sensations in places that were nowhere near the channels and meridians, she became convinced that it was her mission to redefine not just the courses of the channels, but to re-write the whole of Chinese medicine according to the sensations in her body.

Her attempt to make sense of her experiences made her grandiose and delusional. She became unable to care for herself, eventually became very distressed and was grateful to have some treatment which eradicated the sensations, which in turn caused the delusions to evaporate.

So treat each person as an individual and forget the unhelpful and stigmatizing labels.

Psychiatric Diagnosis

Several months ago I wrote about the advantages of seeing psychiatric problems on a spectrum rather than independent categories. And that it is also essential to look at the whole person: there is currently a terrible tendency in medicine and in psychiatry to reduce people to the neurotransmitters in their brains, which is not just a very limiting way of seeing an individual, it’s just plain rude.

One of the reasons why it is essential to look at the whole person is that the agenda of a physician and of a person asking – or being sent – for help may be entirely different. A doctor may want the voices to go away, and for the person to stop being fearful about the things that the TV is saying to them. The person may want help with making sense of their experiences. If someone believes that they are feeling this way because they’ve been abandoned by God, you can pour medications into them until you are blue in the face: they will not help the core problem. Yes, of course you can re-balance their dopamine, serotonin, GABA and acetylcholine receptors. But if their core belief has to do with abandonment, your efforts are unlikely to be crowned with success.

These issues came up again when I had the privilege of speaking to a meeting of the National Alliance of the Mentally Ill in Natchez, Mississippi last week.

There were all the usual questions about advances in mental health, and on the chances for recovery. My answer to that one is always the same: the chances for recovery from any mental illness - including schizophrenia and bipolar disorder - are better than they have ever been. The largest single barrier is expectation. If doctors, psychologists and therapists assume that nothing can be done apart from controlling symptoms, then it is unlikely that people will get better. We all know what will happen if we start the day assuming that’s it’s going to be terrible.

I’d like to highlight two blogs – here and here - that were started by the same person after she had recovered from a psychotic episode. She contacted me after my earlier posts. She has an excellent website which she started after an exchange with two psychiatrists who said essentially the same thing: “If the person can be cured, then it is NOT schizophrenia. Schizophrenia is a chronic mental illness that has no cure.”

This is not true: but rather than being an indictment of psychiatry, it’s an indictment of bad psychiatry. We have a great deal of evidence that the brain is a highly plastic organ, and that many of the typical changes seen even in unmedicated people with the illness can return toward a normal pattern. This shouldn’t be a surprise: it has been known for many years that at least a third of people who carried a diagnosis of schizophrenia recover completely. To say that the recovery indicates that the original diagnosis was wrong is an extraordinary piece of circular reasoning.

The statement also implies that the writer doesn’t see a difference between healing, treatment and cure, which for me are three different interactions.

There is also another point that I made in Natchez: psychiatric diagnoses are still descriptive and are therefore largely at the level of the rest of the medicine of 100 years ago, when a person might be diagnosed with “dropsy,” “anasarca” or “icterus.” Terms now rarely used because we understand the underlying pathology. In the same way terms like schizophrenia will eventually give way to descriptions based on the biological, psychological, social and spiritual issues going on in a person.

Because the diagnoses are descriptive, getting too worried about the precise one is unlikely to be helpful. I once had a family become very angry with me. Their son had seen many specialists, who had all offered different diagnoses. After many day’s observation and exhaustive investigations, the one that I came up with did not please them. Because I wanted to treat their son as a human being with a problem that had responded to an antipsychotic and therapy, but they wanted him to have a less intimidating diagnosis. I tried in vain to explain that these were all just descriptors, and the important thing was that he was getting better with our treatment.

The reason for making a diagnosis at all is so that we can communicate, that it may guide treatment and allow us to offer some advice about prognosis. If someone has a heart attack, it is usually not too difficult to diagnose it. The reason for the diagnosis is not so that we can write it on a form or so that we can label someone, but because it can help guide us.

I certainly don’t agree with every one of points made in the articles that he’s posted, but that’s just fine. Active debate is always better than ignoring each other. Or as Winston Churchill once said, “Jaw, jaw, is better than war, war.”

On the main points in these blogs, I think that we are in complete agreement:

1. Even without drugs it is possible to induce mania and psychosis in just about anyone: sleep deprivation, arousal and sensory overload will usually do it in a few days. If someone has a family history of psychiatric problems it will likely take half as long. If they have a personal history it might take a quarter as long.
2. Recovery should be the aim for anyone with a psychiatric problem.
3. Recovery is not necessarily the same as cure.
4. Not all people diagnosed with “psychiatric problems” have them: some are having genuine spiritual experiences: I’ve seen many people going through kundalini and other types of spiritual awakening who had been given psychiatric diagnoses. I used to get some raised eyebrows when I had a string of referrals from clergy and spiritual teachers that usually read something like, “I don’t know if this person is psychotic or possessed. Please could you see them and advise me.”
5. The quest for meaning and purpose is essential to our humanity. I have seen some of the most damaged of people with large traumatic holes in their brain trying to extract meaning and purpose from what had happened to them. Psychotic, manic, depressed and cognitively impaired, but still trying to work out the meaning for them personally.

The major psychiatric illnesses can be very hard to help: I regularly see everyone else’s problems when I travel: 45 countries and 47 states at last count. But it’s very unusual to find someone for whom we can do nothing.

But I never let clinicians give up: the people who come to us for help deserve better than that.

And for people who got through the process on their own, I congratulate you. But I beg you, please don’t suggest to everyone that they can do the same thing. Many need outside help that addresses all five dimensions of their being.

A Missing Link: Serotonin, Inflammation and Psychiatric Illness

We have previously looked at the extraordinarily high rates of inflammation in psychiatric illnesses, as well as the evidence implicating disturbances in the serotonin transporter and an array of psychiatric and physical illnesses, including fibromyalgia and irritable bowel syndrome. Disturbances in serotonin homeostasis as well inflammation-promoting (pro-inflammatory) cytokines have both been implicated as causative factors in major mental illness. So the hunt has been on to see if there’s some way of uniting these two causative pathways.

There’s an exceptional important paper out this week in the journal Neuropsychopharmacology.

Investigators from the Vanderbilt University School of Medicine in Nashville, Tennessee, have established that the pro-inflammatory cytokines interleukin-1beta and tumor necrosis factor-alpha activate serotonin transporters. Using rat cells, they were able to show the precise mechanism by which these cytokines could regulate the activity of the serotonin transporter.

So why is this so important? Not only does it open up several new options for treating mental illness, but it may also explain some puzzles.

It’s recently been shown that mental illness is more common in overweight people. Large amounts of fat in the abdomen act as a kind of inflammation factory, soaking the circulation in inflammatory mediators. So here we have a link between ever expanding waistlines and the increasing rates of mental illness in the population. It’s not just stress and environmental overload; it is likely also fat causing inflammation.

Toxoplasmosis, Behavior and Mental Illness

This title may seem odd, but this item may actually turn out to have enormous implications for all of us.

A couple of years ago I read a fascinating book: Parasites and the Behavior of Animals, in which the author – Janice Moore from Colorado State University – cataloged some of the extraordinary ways in which parasites can impact the behaviors of a vast array of animals. As difficult as it is to interpret studies of parasites in humans, I kept coming back to some odd observations about an illness with which I’ve been involved for more than 30 years: schizophrenia. I kept wondering if some of the odd observations made over the years could be explained by the parasites?

What kind of odd observations?

1. Reports of mental illness have been found throughout history, yet this strange illness that we now call schizophrenia seems to have been very rare until about 1750, when it increased dramatically throughout Western Europe. I have had the privilege of working at the Bethlem Royal Hospital from which got the word “bedlam.” I know of the incredible records kept there. Something began to change in some of the types of patients being admitted at that time. I have also had the opportunity to look at some of the records at the Philip’s Hospital in Southern Germany, which has been in existence since 1533. Again the records show the sudden appearance of many cases of something that had been quite rare until then. 1750 marked the early years of the industrial revolution in Europe and the mass migration of people from the countryside to the new and very crowded cities
2. There has been recent evidence that being born and raised in a city increases your chance of developing schizophrenia.
3. There is increasing evidence that acute episodes of psychosis, mania and depression are associated with increases in circulating inflammatory mediators. There is also intriguing new data that both psychosis and depression can be improved by giving people COX2 inhibitors.
4. There has also been the strange observation that bipolar disorder may have been becoming more common in recent years, over and above our greater ability to recognize the illness.

Several years ago the well-known psychiatrist E. Fuller Torrey first suggested that a small protozoal parasite called Toxoplasma gondii might be responsible for all of these observations. Cats can carry it, which is why pregnant mothers are advised not to pet their cats during pregnancy.

The idea that such a complex disease as schizophrenia might sometimes be caused by a parasite caught the media’s attention, but in recent years the story – but not the ongoing research – died down a bit.

There was an excellent and provocative blog item by Carl Zimmer about this almost three weeks ago, but I wanted to check everything out before responding. He gave a brief review of a new paper published in the Proceedings of the Royal Society, by Kevin Lafferty from the University of California in Santa Barbara. Lafferty has attempted to correlate the varying rates of Toxoplasma in different countries with predominant personality traits and therefore – since our societies are aggregates of all our personalities, cultural characteristics.

That may all sound far-fetched, but I don’t think that it is. And I don’t think that the Proceedings would have taken a completely half-baked proposition.

I have also found a report published in the journal the Proceedings of the Biological Society. Four eminent authors, including Torrey, revisited the while issue of Toxoplasmosis and mental illness. When the parasite gets into the nervous system it can alter behavior: Rats are normally programmed to avoid cats, but once infected they are attracted to cats. Over the last few days I’ve been plowing the world literature, and I’ve learned some very interesting things that support the idea that Toxoplasma may be playing a role in several different types of psychiatric illness.

There is strong evidence that schizophrenia, bipolar disorder and major depressive disorder lie on a spectrum. The illnesses are not the same, but people often switch from one type of clinical presentation to another. The precise type if illness would be determined by the interaction of genes, physical and Intrapsychic environment. Nobody would be sufficiently naïve to try and reduce the whole of psychiatric illness to a single bug. Mental illness is a great deal more than just a physical problem, and apart from anything else, the rates of Toxoplasma infections show remarkable variations around the globe, while the rates of major mental illness are much the same everywhere.

So what have I learned?

1. There are a remarkable numbers of studies showing that many people with schizophrenia have antibodies to Toxoplasma, including people having their first attack of the illness
2. Blood donors infected with Toxoplasma have decreased levels of novelty-seeking
3. In women who become infected, there are some marked changes in personality.
4. Toxoplasma affects the dopamine systems of the brain that we know are intimately involved in mood, cognition, movement and motivation.
5. Some drugs used to treat psychosis (haloperidol) and mood disorder (valproic acid) inhibit the replication of Toxoplasma gondii. The valproic acid already does it at concentrations lower than we normally aim for when treating humans.
6. There is some intriguing work going on into the use of antibiotics to kill Toxoplasma and reverse its behavioral effects.

In the last few years, so many illnesses have turned out to have infectious origins, from peptic ulcers to arteriosclerosis and some cancers. Perhaps some mental illnesses will be next.

Last year Barry Marshall and Robin Warren were awarded the Nobel Prize in Physiology or Medicine for their pioneering work on Helicobacter. I have a strong sense that there are more prizes to come on the interaction between infectious agents, inflammation, genes, the psyche and the environment.

Perhaps the reason that some antipsychotics and mood stablizers can reverse some of the neurological damage associated with schizophrenia and bipolar disorder is becuase they are killing off the causative agents and allowing the brain to repair itself.

I shall keep you posted!

Neural Stem Cells

Stem cell research presents us with one of the most difficult moral and ethical dilemmas. Most of us have our opinions about the whole matter. But there is now a very real possibility that the scientific piece may be resolved in a different way altogether.

A recent study in the Proceedings of the National Academy of Sciences has confirmed that in adult mammals, the regions of the brain below the ventricles – the fluid-filled spaces – of the brain, harbor neural stem cells. The evidence for their existence has been building over the last five years. But this latest report is of great interest. The scientists were able to show that a soluble carbohydrate-binding protein named galectin-1 promotes the proliferation of these neural stem cells in the adult brain. These neural stem cells are highly active in the forebrains of mice.

We have yet to discover their role in adult human brains. But it would seem a safe bet that they will if anything be more active in humans, since we are endowed with incredible neural plasticity that is way beyond anything seen in most other species. And we would therefore expect to see more potential for neurogenesis in the human brain. It is valuable to place this new finding in the context of experimental work indicating that some medicines may stimulate adult neurogenesis.

“I've found that the chief difficulty for most people was to realize that they had really heard new things: that is things that they had never heard before. They kept translating what they heard into their habitual language. They had ceased to hope and believe there might be anything new.”
--Peter Demianovich Ouspensky (Russian Philosopher, 1878-1947)

Technorati tags: Stem cells Neurogenesis Adult brain

Psychotropic Medicines and Neurogenesis

One of the genuine breakthroughs of the last few years has been the understanding that the brain is not a static structure, but is instead an organ that grows, refashions and repairs itself to a remarkable degree.

You may be interested in a brief review article looking at the effects of some of the medicines that appear able to stimulate neurogenesis in the adult brain.

It is no longer far-fetched science fiction to say that we are likely soon to be able to regenerate parts of the brain and spinal cord that have been damaged by disease or trauma. And in the meantime, we have an array of stratgeies that you can adopt to keep your brain active throughout life, while dramatically reducing your risk of developing dementia.

Technorati tags: Neurogenesis Antipsychotics Antidepressants Brain repair

An Online Resource for Attention Deficit Disorder

Regular readers will know that I am very interested in attention deficit disorder, and I have written a number of articles on it. (Just click on the Category over on the left hand side).

It a common clinical problem, thought to affect 5% of American adults and an even larger number of children. Yet there is even more to it, in that attentional problems may also be able to teach us a great deal about gender differences in the brain and in psychology. To say nothing of helping us learn methods for improving everyone's abilities to concentrate, focus and pay attention, at a time when ever more objects and events are demanding our attention.

Additude magazine has as its mission statement "to provide clear, accurate, user-friendly information and advice for families and individuals affected by AD/HD." Even as a professional, I have found the quality of the magazine to be excellent, and they are certainly succeeding in their aims. They certainly do not focus on medication as anything more than one aspect of treatment.

If you are interested in ADD, I highly recommend this resource.

“Life is denied by lack of attention, whether it be to cleaning windows or trying to write a masterpiece.”
--Nadia Boulanger (French Conductor and Musician, 1887-1979)

Technorati tags: Attention Attention deficit disorder Gender differences

The Passing of the Crazy Diamond

You may have heard of the passing of Syd Barrett, one of the founding members and creative drivers of Pink Floyd. He was only 60 years old.

His extraordinary creativity is well known: his fingerprints were all over the early performances and albums, and he was a muse to a generation of performers. I remember everyone’s consternation as his behavior became progressively more erratic between 1967 and 1968. I was very young then, but we all loved the music.

Some blamed his psychological meltdown on his consumption of prodigious amounts of LSD and all manner of other trendy chemical amusement aids. But in hindsight, he was probably suffering from a psychotic illness, and he was either self-medicating, or the drugs pushed him over the edge. Without doing a full evaluation, I could not say for sure. Although it’s now a moot point, several things make me think that he had a psychotic illness:
1.    His startling type of creativity before and in the early stages of his illness.
2.    There are clues suggesting that he already had problems before become obviously unwell.
3.    The chronicity of his problems are not at all like drug-induced psychosis. I saw a man in Australia who told me that all his years of psychosis were the result of a single “bad trip” in the 1960s. Unlikely.
4.    He suffered for years from diabetes mellitus. Diabetes may be as much as twice as common in people suffering from schizophrenia and bipolar disorder, and also in their first-degree relatives. (England’s first chess grandmaster, Tony Miles, who sadly had a psychotic episode in the late 1980s, also struggled with diabetes for many years, and died at the age of only 46.)

Why does any of this matter now?

If you ever see a young person abusing drugs, be aware that it is not necessarily that he or she is being impulsive or has just fallen in with a bad crowd. It may be that they are self-medicating.

People with major mental illnesses are at increased risk of many other physical illnesses, not all of which are a result of poor lifestyle choices. If you in contact with someone struggling with mental illness, anything that you can do to help them look after their physical health is all to the good.

And finally, a favorite song of mine that was written about Syd. According to legend, by a strange coincidence he arrived at the Abbey Road studio un-announced, at very time that the song was being recorded. It was nice that he was well enough to come and listen.

Remember when you were young, you shone like the sun.
Shine on you crazy diamond.
Now there's a look in your eyes, like black holes in the sky.
Shine on you crazy diamond.
You were caught on the cross fire of childhood and stardom,
blown on the steel breeze.
Come on you target for faraway laughter, come on you stranger,
you legend, you martyr, and shine!

You reached for the secret too soon, you cried for the moon.
Shine on you crazy diamond.
Threatened by shadows at night, and exposed in the light.
Shine on you crazy diamond.
Well you wore out your welcome with random precision,
rode on the steel breeze.
Come on you raver, you seer of visions, come on you painter,
you piper, you prisoner, and shine!

Technorati tags: Syd Barrett Pink Floyd Psychotic illness Diabetes mellitus Substance abuseSelf-medication 

Systemic Psychiatry

“Once a disease has entered the body, all parts which are healthy must fight it: not one alone, but all. Because a disease might mean their common death. Nature knows this; and Nature attacks the disease with whatever help she can muster.”
--Paracelsus (a.k.a. Theophrastus Phillippus Aureolus Bombastus von Hohenheim, Swiss Physician and Alchemist, 1493-1541)

It is usually a mistake to try and look at an illness in isolation.

We are all human beings, and physical challenges affect the whole organism, as well as our mind, our relationships and our spiritual connections.

There is currently a very hot area of research that is still unknown to most people: even to most people working in psychology and psychiatry. This hot new area proposes that schizophrenia, bipolar disorder, major depressive disorder and autistic spectrum disorders, are disturbances affecting the whole body, but with prominent effects in the brain and on emotion and behavior. This may help provide one part of the explanation for why people struggling with chronic mental illness - and their relatives - suffer from an array of physical illnesses that cannot be explained by stress or poor lifestyle choices alone.

You can find a brief review with a stack of references here.

This idea of psychiatric problems being generalized systemic disturbances that have their primary effects on the brain and on behavior is important to the general themes of this blog. We are always interested in looking beyond the obvious causes, to a dynamic integrated vision of a person that includes every part and every dimension of his or her being. If we want to help people recover from illness, to triumph over adversity, and to use challenges as springboards to transcend themselves and the limits placed upon them, it is only possible if we take account of the whole person.

Perhaps we can reduce mental illnesses to disturbances in cell membranes or a few chemicals in the brain. But I do not think so. It is more accurate for us to be thinking about a perturbation or disturbance in the Informational Matrix that underlies the subtle systems of the body, that in turn support the biochemical reactions that provide the structure for the external expression of life itself.

We live in very interesting times.

“Good timber does not grow with ease. The stronger the wind the stronger the trees.”
--Willard J. Marriott (American Businessman and Founder of Marriott Hotels, 1900-1985)

Technorati tags: Schizophrenia Bipolar disorder Diabetes mellitus Phospholipid Cell membrane Systemic illness Informational matrix 

Helping to Prevent Suicide

Unless you work in psychology or psychiatry, you may not know that in the United States, there are considerably more suicides each year than there are murders.

Though there is sometimes little warning that someone might be about to harm themselves, in the majority there have been some warning signs.

The American Association of Suicidology expert consensus panel has just published a mnemonic to help professionals and the general public recognize some of the major risk factors. You can find a brief article with a link here.

Here is the whole mnemonic:
I    Ideation
S    Substance abuse

P    Purposelessness
A    Anxiety
T    Trapped
H    Hopelessness

W    Withdrawal
A    Anger
R    Recklessness
M    Mood changes

This is only a first attempt at an evidence-based summary of some of the major risk factors, and the sensitivty and specificity of the list is still quite low. But If awareness of some of these warning signs and risk factors saves even a single life, this post will have been worthwhile.

Technorati tags: Suicide Depression Self-harm

Understanding Attention Deficit Disorder as a Long-term Challenge

Regular readers will know that I am a huge advocate of natural and non-invasive methods of treatment whenever possible. But sometimes we reach an impasse, and the only option is to use pharmacological or other types of conventional intervention. But even then, it is a mistake to assume that physical treatment alone will be sufficient to help the individual and their family: it is only sensible also to address the psychological, social, subtle and spiritual dimensions of the person. And we must never lose sight of the positives: some people who have health challenges are transformed for the better, and some “illnesses” may carry gifts with them. I’ve talked about the creativity of people with bipolar disorder and schizotypy and the empathy and innovation that may accompany attention deficit disorder.

There is often a fine balance between the positives and negatives of an illness and the types of help that may be of greatest value.

I have just been involved in a common discussion at this time of year: a young person has quite bad attention deficit disorder (ADD). Since she started pharmacological treatment not only has she risen from being a failing student to getting all As and Bs, but the quality of her life has improved dramatically. Unfortunately, she has been told that she only needs to take her treatment when she feels that it is necessary to complete her schoolwork. Many healthcare providers continue to believe that ADD and ADHD are just academic problems. There is a very good new review article that discusses this misperception in some detail. Prescription patterns show that the majority of school-age children are only being treated from Monday to Friday, and from 7AM to 3PM. Why does this matter?

There is excellent and extensive research about the consequences of non-treatment, and most of it has nothing at all to do with school. If people with ADD and particularly with ADHD are left untreated, they are more likely to:
1. Develop substance abuse
2. Be involved in a serious accident
3. Engage in illegal activities
4. Contract a sexually transmitted disease
5. Have an unplanned pregnancy
6. Become separated or divorced

The article makes a point that we have often discussed with families: these consequences of non-treatment are events that primarily occur outside the school environment. So withholding medicine just when it is needed the most may be a risky business.

We are now seeing increasing evidence that successful pharmacological treatment reduces these consequences of untreated ADD/ADHD to the rates found in the general population. Simply using appropriate medications can protect people from adverse consequences of these problems both now and in the future.

I think that we should look at ADD in the same way that we look at an illness like diabetes. In diabetes, the high blood glucose and elevated lipids are not themselves the problem. They may cause symptoms, but the real danger lies in the long-term physical consequences of high glucose and lipids. It is these that can be so devastating to the person with the illness, causing the so-called complications of diabetes, such as retinopathy, kidney and heart disease.

Similarly ADD/ADHD may cause symptoms – such as problems in school – but it is the long-term consequences that can cause such problems. Children and adolescents, and for that matter some adults with both illnesses don’t realize that these are the main reasons for treatment.

There is a common myth that adults know that they need to take their medication, and so they do. Hands up anyone who has only taken half of a course of antibiotics!!

There is very striking study of adults with ADHD who were asked to do a simulated driving test while on and off their medicines. The people in the study rated their driving performance just the same whether they were on or off their medicines. Despite the fact that when they were off their treatment they were an astounding five “standard deviations” worse in terms of driving safety and responsibility! For people not used to looking at statistics this may not seem like much, but the difference is astonishing. You would not want to share the road with an untreated person with ADD.

We know that within the first three months of treatment 50% of children and adults will have stopped their ADD/ADHD treatment and most studies agree that by 18 months, the figure is around 80%.

We need to get the message out that:

1. ADD and ADHD can create some nasty long-term problems if not adequately treated.
2. For a host of reasons, most people will stop their treatment, so plan for it, and don’t just wait for it to happen.
3. Adequate treatment consists of a lot more than giving medication and hoping for the best.
4. People need psychoeducation.
5. They need to learn coping strategies.
6. The family needs to know how to help and how to deal with the problems that someone with ADD/ADHD may be causing them.
7. And people need to know how and when to use medications and how to integrate them with non-pharmacological strategies.

Technorati tags: Attention deficit disorder Attention deficit hyperactivity disorder Substance abuse Treatment 

Healia.com

Carol Kirshner, web mistress extraordinaire, has just alerted me to a great resource for anyone looking for information on health, wellness and healing, called Healia.com.

Carol's review is excellent, and now that I've tried out the website, I really do share her enthusiasm.

One of the reasons for creating my own blog is that the internet is full of medical misinformation. I have just been writing an article that I am going to post tomorrow. My initial reactions to some of the statements that I found on line would not have been fit for you gentle reader. Suffice to say that there were comments on some websites that betrayed a complete ignorance about the workings of the human body and recommendations that can best be described as bovine excreta.

Healia.com seems to be very different. I have been putting it through its paces, and I've so far not found a single problem or contentious area, despite throwing a lot of unusually tough questions at it. I fully anticipate that it's going to become one of my major research tools, and for matters pertaining to health, it seems to be better than any other search engine that I've found.

Technorati tags: Internet search engine Health Healing Wellness

 

Attention Deficit Disorder, Allergies and Membranes

There has been a long-running debate about the relationship – if any – between allergies and attention deficit disorder (ADD).

As long ago as 1991 a paper seemed to indicate that there were higher rates of hyperactivity in the parents of children with allergies as well as increased rates of allergies in children with ADD. Recently a study from New York seemed to show higher rates of allergic rhinitis in children with ADD. The problem with all this is that we are looking at two common problems and trying to sort out a genuine connection can be tricky.

I started thinking about this problem again, after a recent report that some children had symptoms of hyperactivity, inattention, attention-deficit/hyperactivity disorder, and excessive daytime sleepiness as a result of sleep-disordered breathing. But what was remarkable was the number who improved after they had their tonsils taken out. The tonsils are one of the first lines of defense in the immune system, which is why they so often become enlarged with infections, or for that matter in any kind of immunological reaction. Now I’m not much of one to take out tonsils unless there’s a really good reason, but it is certainly an important observation for anyone who has a child with behavioral or cognitive difficulties: he or she may not be sleeping properly.

I have seen quite a number of people who had physical and psychological problems, including headaches, depression and attentional problems, who turned out to have either allergies or environmental sensitivities, and when those were addressed, the symptoms resolved. I have also seen some people who followed the notoriously difficult Feingold diet with some success, even though the research doesn’t seem to be very supportive of elimination diets. And I've seen just as many people who got no relief at all from elimination diets.

I have just done a detailed literature review on the topics of allergy and attention, and I don’t think that we have enough evidence to suggest that everybody with attention deficit needs to see an allergist. But what this highlights is that not all people with attentional problems or hyperactivity have ADD. They may have attentional problems because of sleep disturbance, depression, anxiety, obsessive compulsive disorder and a range of other problems.

There is some exciting research indicating that one of the problems in many cases of ADD is a disturbance in the normal functioning of cell membranes. If that is correct, it may be that there are disturbances in the membranes of both neurons in the brain and membranes of cells in the immune system. That link is not entirely proven. But it has received further credence by the finding that some children and adults with ADD seem to show improvements of both attention and immune function when they take omega-3 fatty acids. I have recently been hearing some encouraging reports from people who have used the Omega-3 Formula made by Omegabrite (And no, I have no link with the company!)

Technorati tags: Attention deficit disorder Allergy Atopy Hyperactivity Tonsils Cell membrane Omega-3 fatty acid 

Diagnosing Illnesses

I am pleased to say that my recent item about Categorical and Dimensional ways of looking at illnesses has provoked some spirited correspondence and questions. Far from indicating that the art of diagnosis is arbitrary and vague, it reflects clinical reality. I get a great many magazines and articles from supporters of alternative medicine, and some have so misunderstood the principles of diagnosis that they think that illnesses don't exist! One of the reasons for this flawed thinking is that we all have a bad case of physics envy. The success of Newtonian physics and Humean philosophy has seduced us into thinking that everything has a single cause, and that every item and every event has clearly defined boundaries.

We are complex and ever-evolving individuals and we are also members of of constantly changing groups, so we have to be seen not only as "objects" wth diagnostic labels, but also as people with a time and developmental dimension: you and your life challenges will change over time as you continue to develop and evolve. As the great Scottish poet Robert Burns said: “Nature's mighty law is change.”

I think that is important to let you know how this field is developing, and why it is that we cannot always come up with a cut and dried answer to the question "Well, what has he got then?"

On May 24th, I wrote a short article about the inter-relationships between schizophrenia and bipolar disorder that you may find interesting. It develops some of the points that I made in my previous article.

Technorati tags: Diagnosis Category Bipolar disorder Schizophrenia

Happiness and Resilience

For more than two decades, my main focus has been on ways to help people become more resilient to the slings and arrows of outrageous fortune. To enable people to withstand anything that's thrown at them: physically, psychologically, socially and spiritually. And not just to withstand them but to use adversity as the impetus for growth.

Adversity is a fact of life: it cannot be controlled. But we can control how we react to it.

This is such an important concept.

So many people try and make themselves stronger and stronger, yet there will always be something that can overwhelm the most powerful defenses. I knew of two martial artists in Hong Kong who claimed that they could defeat anyone. They were incredibly strong and had exquisite technique.

Which did not help them one bit when some villains shot them from behind by.

I have come across others who have spent their lives eating and exercising and still dying prematurely. What was the problem? They had not learned the arts of resilience, which include adaptability, flow and seemless integration with the Universe.

Over the next few days I am going to introduce you to some of the techniques that we have developed for enhancing psychological and physical resilience, before going on to reveal some of the secrets for strengthening the subtle fields of your body, and how to maintain dynamic relationships, not just with another person, but with your Higher Self.

One of the manifestations of resilience is happiness, so before we start, I would suggest that you try this small test that was published by the BBC by arrangement with Professor Ed Diener, from the University of Illinois who designed it.

Technorati tags: Resilience Happiness Flow Relationships

Human Evolution

For more than a century, the received wisdom has been that humans finished their physical evolution between one hundred thousand and fifty thousand years ago, and that there have been only minor changes in cognitive abilities over most of that time.

I have always found those assertions to be fundamentally flawed. Our bodies have changed beyond all recognition in the last few hundred years, as I’ve pointed out in my last book and CD series Healing Meaning and Purpose. Even more than that we have changed and are changing mentally. If we were to go back in time ten thousand or even one thousand years, we would find that people were cognitively, emotionally and morally quite different from modern humans. Not simply because of technology and the explosion of knowledge about the external universe, but because there is a dynamic relationship between our development as a species and our creations, with each feeding off the other.

It is only recently that a number of theoreticians, philosophers and psychologists have begun to look at the ways in which we are continuing to develop and what it means for all of us.

The German psychiatrist and philosopher Karl Jaspers first pointed out the great moral leap forward in what he called the Axial Period, between about 700-200B.C.E., during which the foundations of many of the world’s great religions first appeared, probably in response to the prevailing violence and unpleasantness of the time. More recently the Polish-born Swiss philosopher Jean Gebser started developing intriguing models of the transformations of human consciousness. In the United States, the psychologist Clare Graves developed a revolutionary concept of developing levels of development of the personality, that has evolved into Spiral Dynamics. (You may be interested to look at a review that I have just written about an excellent CD program detailing the latest developments in this field.)

And then there is Ken Wilber whose work in this field is remarkable, and whose creation of the Integral Institute promises great things. To these luminaries I now add Dudley Lynch a writer whose work I have only recently discovered.

Dudley recently wrote a very sensitive blog item about the efforts of a person with a mental illness trying to keep himself integrated in a sea of psychic chaos. He was kind enough to publish my brief response, which needs a little more detail.

The reasons for raising these points about continuing human development are these:

1.The manifest physical changes in people over the last few hundred years have enormous – and largely neglected - implications for clinical medicine.

2. It is likely not just peoples’ physical bodies that have changed, but also their subtle systems. I pointed out in my last book and CD series that the chakra system has developed to its current point only within the last few thousand years. This continuing development is also one of the reasons why some therapies that once only worked occasionally are now becoming more stable and predictable, and why some new forms of therapy – like the tapping therapies - are now being discovered.

3. It is because of these profound changes that new forms of therapy are now being developed. Not just using a supplement here, or a breathing exercise there, but precise combinations that help guide the healing of every aspect of an individual and his or her relationships and spiritual connections.

4. Some people who appear to have psychotic illnesses are moving into new developmental stages without having passed through the necessary intermediate stages. I have just read a first person account of an English journalist who could easily have been diagnosed with a manic illness, but was almost certainly undergoing a spiritual emergence.

5. Major emotional, cognitive, moral, conscious and spiritual shifts can be profoundly frightening to many people, and are doubtless one of the reasons for the profound feelings of social dislocation and violent reactions that we are observing throughout the world.

6. It is no surprise that new spiritual pathways are now emerging. Many will doubtless be very helpful to many of the thirty million Americans who count themselves as spiritual seekers, but have not yet found what they are looking for.

7. Taken together, these new understanding about the longitudinal development of people, relationships and whole societies are already having extraordinary effects on our ability to guide them all in more healthy and integrated pathways.

Technorati tags: Human evolution Axial period Ken Wilber Karl Jaspers Alternative medicine Complementary Medicine Integrated Medicine Chakras Subtle energy

Categorical and Dimensional Diagnoses

I recently had the great pleasure and privilege of speaking to a group of health care providers in Monteagle Tennessee, and an interesting question came up. The sick citizens of Tennessee are having a hard time now because of the problems with TennCare. This problem is not new, and is not only happening in Tennessee. There is no malice or lack of compassion involved, it is simply a matter of $$$.

And because we need to have a diagnosis in order to apply for reimbursement, the discussion soon turned to the matter of psychiatric diagnosis. It’s pretty well known that I have lectured on the subject of psychiatric diagnosis all over the world: it was actually one of the reasons that I was first invited to come to the United States. The problem is this. When we classify an illness, we can either think of it as a “category,” like strep throat or a heart attack: an illness that has clearly defined margins. Or we can think about it as a “dimension.” So instead of seeing illness as a separate entity, we think of health and illnesses as lying on a spectrum, running all the way from being healthy and well, through mild degrees of just not feeling “right,” to being severely ill. Reimbursement requires categorical diagnoses, even if they do not reflect clinical reality.

This second – dimensional - way of thinking is particularly useful when we are thinking about psychological problems. The world is full of people who are a little bit obsessive, or who get bad mood swings. But they are not bad enough to be called an “illness.” In fact, having some of these traits can be enormously beneficial: they have continued in the population because they have a survival advantage. If I need to have surgery, I sincerely hope that my surgeon will be mildly obsessive, rather than discovering a few weeks later that he had forgotten to do something he should have!

When I am teaching about schizophrenia and bipolar disorder, I discuss how they lie on a spectrum that passes through so-called schizoaffective disorder, cluster A personality disorders – schizoid, schizotypal and paranoid – to schizophrenia. (You may be interested in looking at the blog entry for May 24th here). I also make the point that I can make just about anyone psychotic. Come and live in my research center for a week, where you will not be allowed to eat or sleep; you will have to drink 30 cups of coffee a day and take up smoking. I can guarantee that most people will develop some symptoms. If you have a family history of mental illness it would not take a week, but perhaps 3-4 days. And if you have a personal history of mental illness, it could take no more than a day or two. The key is arousal. People experiencing high levels of arousal may well start to experience manic, depressive or psychotic phenomena. The types of symptoms that are experienced are determined by background, environment and genes. This sort of “reactive” psychosis is completely different from the other end of the spectrum, where, particularly in males, there are demonstrable abnormalities in the brain – shifts in laterality and progressive loss of grey matter in specific regions, with swelling in other – many of which are present before the onset of full-blown psychosis, and before exposure to medications. Though some of the older antipsychotic medicines may make the situation much worse.

In January of 2005, some of my colleagues in Edinburgh, Scotland, published an important paper after studying people at high risk of developing schizophrenia. Many of these high-risk people did not develop the illness, although some had transient and partial symptoms. We know that some family members – the carriers of the genes – may also suffer from some symptoms of the illness. This shows us how genes do not control everything: many people suffer from mild cases because their environment or personality helped protect them from developing a full-blown illness. In other words: biology is not destiny. These findings also give us important clues as to how we may be able to reduce the risk of an illness expressing itself.

Diagnoses are not always cut and dried. Medical professionals are sometimes unable to reach a definitive diagnosis, needing to wait and see how things develop. Having specialized in the diagnosis and treatment of tough cases, family members sometimes become very upset because their loved one does not have a clear diagnosis. Psychiatric diagnosis is still primarily clinical and often needs time to clarify. Although there are many demonstrable neurological disturbances in people with schizophrenia and bipolar disorder, even the most sophisticated brain scans are still not at the stage where we can make diagnoses.

If we think in terms of dimensional diagnoses that reflect clinical reality, it helps us to understand the range of symptoms that people can experience. It also speaks to the point that I have made time and again: symptoms are signs, and they are signs that can be generated in the body, in the mind, in relationships (not just because some might be stressful), and they may have subtle system or spiritual origins. Successful treatment needs us to identify the origins in an individual and to work with all the five main dimensions of the individual.

And by the way, we have succeeded in helping virtually all of our seriously mentally ill patients back to living the kind of lives that they want: jobs, relationships and so on. So this is not an academic discusssion, but instead something supremely practical

Technoratic tags:diagnosis category dimension bipolar disorder schizophrenia schizotypal personality disorder recovery spirituality

A New Atlas Promises a Breakthrough in some Brain Disorders

The very first attempts to take pictures of the living brain go back to the 1930s, but it is only in the last 20 years that MRI, SPECT and PET studies of the brain have really moved the field forward. After thousands upon thousands of imaging studies, we are beginning to approach the time when we can start harvesting the data collected over these years.

We are on the cusp of an extraordinary advance in our understanding of the brain and how it can go wrong in a large number of neurological and psychiatric illnesses. But that is only a side show: being able to identify the neurological correspondences of, say a psychiatric illness, does not mean that we reduce the illness to the firing of a group of neurons. But it does mean that we are gong to be much closer to providing suitable treatment for the neurological component aspect of the illness.

There has been a dramatic demonstration of this with the publication of a new brain map of people living with a rare but important illness called William’s syndrome.

One of the biggest puzzles for those of us who look at brain scans, is why there is so much variability in the structure of the brain. In the rest of the body, veins and arteries can turn up all over the place, but nerves tend to be in pretty much the same position in everybody. This is not the case in the brain. I’ve looked at many thousands of MRI scans of the brain, and I’ve never found any two alike. It’s one of the reasons that I’m a little doubtful about some of the claims of imagers who say that they can diagnose someone by looking at a brain scan. Most of the time there’s just too much normal variation.

All over the world, there have practitioners who have claimed to derive all sorts of information from brain images. Most experts remain a bit skeptical: hundreds of experts and hundreds of millions of dollars have only enabled us to speak in generalities. Some private practitioners even perform scans for diagnosis.

Some time ago I met a psychiatrist who had an unusual theory about the causes of mental illness. He wanted us to do two MRI scans on a patient to prove his theory. When I told him that we were not yet able to do that in individuals, he was indignant, “But you’ve published all those studies showing abnormal brain structure in schizophrenia.” I explained that all the brain imaging studies have told us quite a lot about groups of people with mental illness, but little about individuals. I do not know of any academic psychiatrists anywhere in the world who think that we can yet use PET, SPECT, fMRI or MRI scans for diagnosis of mental illness. Maybe we’re just being a bit slow. Or perhaps the brain scan diagnosers haven’t got all the pieces of the puzzle just yet. Research is expensive and takes a great deal of time. Busy clinicians are eager to exploit new investigative tools for the benefit of their patients, and usually do not publish their results in peer reviewed journals. With this new research we are going to be able to see if these individual practitioners are correct.

Not only are there many inter-individual differences, but also the current state of the person can have a big impact on some types of imaging. I was recently asked to review a paper for a scientific journal in which the authors had enthusiastically explained the way in which they could now diagnose a certain illness by doing a brain scan. Sad to say, they had not asked a couple of basic questions, like the person’s mood when they were scanned. Depression reduces the flow of blood in regions of the brain, the patients turned out to be depressed, and the results were invalidated. It was a real shame, but it is so important that patients don’t get misled by investigations that cannot help them.

So the moral of the story is this. If someone wants to do any kind of investigation for diagnostic purposes, ask them first whether there is any published evidence that the test actually works: what are the sensitivity and specificity of the findings generated by the test? And who else is doing it?

“If the brain were so simple we could understand it, we would be so simple we couldn't.” --Lyall Watson (South African Biologist and Writer, 1939-)

Technorati tags: brain structure williams syndrome bipolar disorder PET scan

New Clues to Obsessive Compulsive Disorder

In this month’s edition of the Journal of Neuroscience, a team from the University of Michigan has published a very interesting report. Every one of us has made a mistake at some stage in our lives, whether it is something trivial like dropping the groceries, or something more serious, like deleting a crucial computer file. What the researchers did was use functional MRI (fMRI) to peer inside the brain at the instant of making a mistake. While in the scanner, people were forced into making an error that carries consequences – for instance, losing money. When that happened, a particular part of the brain called the rostral anterior cingulate cortex, or rACC, became much more active when the person realized that he or she had erred and there was a penalty attached to the mistake. This part of the brain is involved in deciding what kinds of emotional responses are appropriate.

What is so interesting about this work is that in a previous study on a small group of people with obsessive compulsive disorder (OCD), the same team has shown that the rACC region of the brain became much more active in response to a no-penalty error in the brains of OCD patients, compared to people without the condition. One of the characteristics of OCD is fear and anxiety about errors or failures in certain aspects of everyday life. As a result, many begin repetitive patterns of behavior to ward off or to prevent such events.

So it looks as if people struggling with OCD have a hyperactive response to making errors, after which they begin to get more and more worried that they may have made a mistake. OCD can be a terribly incapacitating condition. We think of mild cases like Melvin Udall in As Good as it Gets, or Adrian Monk, but in reality it can cause much suffering.

I was once asked to see a seventy five year old man who had suffered from a bizarre case of OCD since the age of fourteen. He had traveled the country trying to get help, and it was an extraordinary tribute to him that despite his problem he had built a successful business and family life. He came to see me for acupuncture, but left with a prescription for a medicine that was at the time relatively new. His improvement over the next few months, as we used medication, psychological and social work and then some energetic techniques was just extraordinary.

Research like that from the University of Michigan may well bear important fruit in the future.

Technorati tags: OCD, neurobiology, anxiety, psychiatry

The Media and Mental Illness

Since time immemorial, mental illness has been used as a dramatic device, with sometimes appalling consequences. Too often people with mental illness have been depicted as dangerous villains, and for anyone working with the mentally ill, many of the portrayals of their experiences are inaccurate and inept. As a simple example, those over-wrought European movies in which one can tell that the protagonist is about to be taken away because he is seeing visions of the Virgin Mary speaking to him. Yet it is well recognized that such cross-modal hallucinations are vanishingly rare in mental illness, and are more likely to betray substance abuse, malingering or, rarely, an organic lesion of the brain.

For all the good that came of A Beautiful Mind, we are all well aware that the depictions of John Nash’s experiences made a good story, but were far from the experiences of the mentally ill. One of the first-ever sympathetic depictions of mental illness and of one person’s triumph, was the movie Out of Darkness , starring Diana Ross, on which Kimberly Littrell was the technical director.

For the last decade many of us have realized the importance of helping the media provide accurate representations of mental illness, and some of the contributors to this blog have been doing that by appearing on radio and television programs throughout the world.

A new paper discusses the research that has consistently demonstrated that news media and the entertainment industry have provided overwhelmingly dramatic and distorted images of mental illness that tend to emphasize dangerousness, criminality and unpredictability. Research also indicates that the media has in effect modeled negative reactions to the mentally ill, which have included fear, rejection and ridicule. Not so long ago, there was an infamous occasion on which Time magazine used the word “nuts” three times during their report of a tragic – and rare – case of violence perpetrated by someone struggling with mental illness. This paper makes the important point that the media can be an important ally in challenging prejudice, initiating public debate, and projecting positive, human interest stories about people who live with mental illness. It is heartening that several major syndicated television shows have recently done exactly that: presented people for whom mental illness has been a triumph over adversity.

Though not everyone will be comfortable doing this, media lobbying and press liaison can be an important role for mental health professionals. Many patients may not be able to speak out for themselves, and it provides a means of improving public education and awareness.

I would like to make a suggestion to you: one in four people live with mental disorders. Can you, personally, think of ways in which you could work with the media to improve the life chances and possibilities for recovery for them?

Resource: Fair.org has compiled a list of major media contacts just for this purpose.  Click here to be taken to the page.  Some e-mail addresses are on this page (some a little dated), but this provides you a chance to make a difference right now.

Technorati tags:  activism, media bias, mental illness, journalism

Calcium, Vitamin D, Diabetes and Schizophrenia

There are some odd puzzles in medicine. For more than 100 years it has been known that diabetes is more common in people suffering from schizophrenia, bipolar disorder and probably also depression. There has also been data indicating that some children with ADD and autism have metabolic disturbances that may underlie some of the cognitive difficulties. It has also been observed in Europe that dark skinned immigrants - whose skin coloring makes them less able to make Vitamin D - are more likely to develop diabetes. Some dark skinned immigrants are also far more likely to develop schizophrenia compared with their families that stayed in sunny tropical regions. Children – particularly boys - who are breastfed and/or have Vitamin D supplements in the first year of life are less likely to develop schizophrenia in later life. Vitamin D is not only involved in calcium absorption, but also in maintaining the integrity of cell membranes. So the link between diabetes and schizophrenia may have something to do with Vitamin D.

A new study just published in the journal Diabetes Care indicates that women with high intakes of vitamin D and calcium appear to have a lower risk of developing type 2 (maturity onset) diabetes. The study from Tufts-New England Medical Center looked at data on 83,779 women enrolled in the Nurses' Health Study. The women had no history of diabetes, cardiovascular disease or cancer when they enrolled in the study. Vitamin D and calcium intake from foods and from supplements were evaluated every 2 to 4 years. Over the 20 years of follow-up a total of 4843 new cases of diabetes were discovered. The lowest risk of diabetes was observed among women with the highest combined intakes of calcium and vitamin D compared with those with the lowest.

These are important findings, because interventions to raise both vitamin D and calcium intake and quick, cheap and easy, and may significantly reduce the risk of developing type 2 diabetes.

So how much should we take? Although we should be able to make enough of our own Vitamin D by spending even ten minutes in the sun, not everyone can do that, the sun is not without its risks, and the mechanisms for making Vitamin D become less effective as we become older. Though a balanced diet should also help provide some vitamin D and enough calcium, the data indicates that we should take in at least 1200mg of calcium each day, and 400 International Units (10 micrograms) Vitamin D each day. It is possible, though uncommon for people to take too much Vitamin D, and that can have all manner of health consequences.

Technorati tags: vitamins, diabetes, schizophrenia, calcium, Vitamin D,

Modafinil and ADD

The Washington Post has just reported that the FDA has turned an application from the Pharmaceutical Company Cephalon to have modafinil approved for use in children with ADD, because of worries about a potentially serious skin reaction called Stevens-Johnson syndrome .

This is a real shame: we need more options for treating children and adults with ADD, and although I am a huge proponent of non-pharmacological methods of treatment, the fact is that a lot of people simply do not respond to the methods that we currently have available, and some do not even respond to the medications that are available.

Modafinil had looked very promising: in December 1998 the FDA approved modafinil under the brand name Provigil for treating adults with sleepiness associated with narcolepsy. Its main mechanism of action is to inhibit the reuptake of dopamine in key regions of the brain, effectively increasing the amount of dopamine available. It has been used off-label for excessive daytime sleepiness and last year a study form the University of Pennsylvania indicated that it might help some cocaine addicts fight their cravings. It is an open secret that a great many students and academics have been using it for years to enable them to study and work longer. I remember an article from someone who was due to lecture in India, immediately after his arrival from the United States. He admitted to taking modafinil to help him get through the ordeal.

The application to use modafinil in ADD is not dead. The FDA has said that they want a 3000 patients study to assess the risk of Stevens-Johnson syndrome, and the company will discuss that with them. But it will inevitably mean delays.

Technorati tags: ADD, ADHD Modafinil

Neurogenesis 101

The great Spanish histologist and Nobel Prize winner in Physiology or Medicine, Santiago Ramón y Cajal, was probably the first modern scientist to say that neurons in the adult brain did not divide.  In other words, humans are born with a finite number of brain cells and an individual cannot develop/grow/replicate new cells over the course of their adult lives. This is an axiom that underlies some parts of the stem-cell debate.

There is emerging research that seems to refute this notion.  I have written a long article for my friends over at Psychiatric Resource Forum discussing the research indicating that humans may have the ability to produce new neurons in key regions of the brain throughout life, a process called neurogenesis.  I also discuss what this means for field of psychiatry.

The concept of neurogenesis also engenders hope for the fields of personal and spiritual development.  I will discuss these at a later date.  I just wanted to link to this article because it provides (along with the links) a good primer on neurogenesis that will be helpful as I write new posts.

Technorati tags: neurogenesis, personal growth, Self Improvement

Attention Deficit, Money and Motivation

People often say that I’m someone who’s glass is always half full. Well, that’s not quite correct: I’m a huge realist, but I don’t like the idea of pathologizing everything that happens to us. One example of this is ADD.

Though untreated clinical ADD can lead to a great deal of distress and the ever-present risk of impulsive behaviors and substance abuse, I am also eager to examine the positive aspects of having attentional problems. Many of the young people and adults with ADD are also extremely successful in settings that don’t require the academic type of concentration. I have met entrepreneurs with ADD, as well as some highly creative people and athletes. A question has been whether ADD might confer some others gifts, benefits or advantages on people.

Although a year old, we recently came across an item that is not as well-known as it should be. Studies using fMRI have indicated that some of the regions of the brain that do not normally show much activity in young people with ADD become highly activated by monetary rewards.

This is not to say that giving young people money is the way to “conquer” ADD. Instead it suggest that rather than just thinking about people with ADD as just having an attention problem, we should also think of them as people who derive pleasure from different things than the bulk of the populations. Not having to spend all their time attending to linear learning may actually lead to greater freedom of imagination, creativity and emotional expression.

People with sever attentional problems can run into a lot of problems in relationships, even losing attention during sex. But it may be that may also be that minor degrees of loss of attentional focus may also enhance some people’s ability to feel empathy.

Technorati Tags: ADHD, ADD, reward, Motivation, Creativity

Prairie Voles Again!

I do hope that we are all properly appreciative of the scientific contribution of these cute little creatures. I mentioned them in one of my Valentine’s Day posts, but you will find a picture and an accompanying story here.

Thomas Insel’s group at the National Institute of Mental Heath in Bethesda have spent years working on pair formation and partner preference in these little fur balls.

It seems that pouring dopamine into a region of their brains known as the nucleus accumbens makes male prairie voles seek out girlfriends. There are at least seven major subgroups of dopamine receptors. But in these little creatures D2 receptors are involved in approach behavior that is associated with the formation of a pair-bond, and D1 receptors maintain the bond. While forming a relationship the little vole’s brain actually changes.

I am always a bit worried about trying to read too much into these experiments, because human behavior really is a great deal more complicated. But I have a couple of thoughts:

1. Dopamine receptors are proteins, so they are products of genes that get switched on by the formation of a relationship. Might some people have a genetic reason for having difficulties in relationship formation, and how would that play with environmental factors? You may well know some people who seem cold and uninterested in relationships, and indeed, there are some personality disorders in which people have chronic difficulties in forming relationships. Yet certain types of psychological therapy can help them.

2. Some antipsychotic medications block D2 receptors. Is that a further explanation for the relationship difficulties of some people receiving these medicines?

3. I think that we should thank the Prairie Vole Kingdom for their help…..

Technorati tags: relationships, dopamine, love, science of love

Sleep and Mood

The interaction between sleep and mood is fascinating, complex and supremely practical.

I have received a couple of queries and comments. Let me start with one from a physician:

“I have a question about sleep disorders. My patients seem to suffer from this even after their depression is better.” 

This is an extremely interesting issue.

Every healthcare student has been taught about the sleep disturbances that may occur in association with mood disorders. The classic problems in depression are early morning wakening, difficulty in getting off to sleep and sometimes waking in the early hours. Some others will sleep for very long periods, and there has been speculation that this may be a form of hibernation behavior. People with abnormally elevated mood can often stay awake for days at a time. There is also the well-known problem of seasonal affective disorder, in which the long winter nights can cause depression. Fortunately the depression is often relieved by the use of a light box.

Many experts now consider that the disturbances of sleep are often the primary problem, which then cause depressed or elevated mood. This is actually not a new idea: one of the old fashioned treatments for depression was sleep deprivation and many of us who have worked all night have experienced the mildly manic symptoms of sleep deprivation. On early morning rounds at the hospital I commented that it was easy to tell if some of the residents had been working all night, even before they presented their reports. The giggling, high energy and disturbances in thought patterns were not at all what one sees when someone is tired.

It is not just the sleep deprivation, but also light. It is well known that people suffering with bipolar disorder are more likely to get manic episode in the spring and early summer, as the amount of ambient light increases. It is the converse of the seasonal affective disorder problem.

So what often happens is that antidepressant medications do indeed help with the depressed mood, but the underlying sleep problem takes much longer to correct itself. This is also one of the reasons why people who have seen their mood improve on treatment still have cognitive problems that can go on for months after the mood symptoms have been corrected. It is probably a combination of sleep deprivation and also the impact of corticosteroids that can rise in some sufferers causing transient damage to some key regions of the brain.

It would be nice if we could modulate people’s sleep/wake cycles and thereby treat the mood problems directly, but at the moment, despite the enormous advances in pharmacological treatments of sleep problems, we are still not able to do that reliably.

Technorati tags: Sleep, Mood, bipolar disorder, Depression,

Nutrition and Mental Health

Our brains are delicate organs sustained by a fine balance of fatty and amino acids, minerals and vitamins.

Virtually everyone of us has had the experience of a mood change if we become hypoglycemic, or sleepiness after eating chocolate or tryptophan-containing turkey. The scientific literature is full of reports about the impact of different foods and combinations of food on mood, alertness and cognition. Some of the links are not obvious. I was brought up with the old wives tale that children become sleepy after lunch or dinner because blood was being diverted to the intestines. Not so: sugary and fatty foods cause sleepiness by altering the secretion of insulin by the pancreas, which in turn effects the uptake of key amino acids in the brain, which in turn impact the synthesis of some neurotransmitters.

There has also been another yet more serious issue that has been turning up in the literature for decades, and that is the inter-relationships between diet, nutrition and mental illness. Epidemiological studies have found a clear relationship between the consumption of fish and the incidence and prevalence rates around the world: high fish consuming countries tend to have less depression. This relationship has held up in studies around the globe, so it is unlikely that it is simply that people living by the ocean in warm sunny countries are less likely to become depressed. These observations were part of what led Dr Andrew Stoll at Harvard to first study the impact of fish oils, containing omega-3 fatty acids, on mood. The results of the early studies were more impressive than the later ones, but the fact remains that fish oils have been helpful in a proportion of patients. The experimental work continues, in order to try and find the best and most effective mixture of fatty acids.

There is a theoretical reason why this might be: fish oils can change the characteristics of the membranes of many cells, including those in the brain, and thereby influence the firing and response of some neurotransmitters important in the maintenance of mood.

There have been recent reports from well-conducted studies of the impact on nutritional supplementation on reducing violence in prisons and that work is also continuing. The BBC has picked up on an eagerly awaited report from the Mental Health Foundation and Sustain. Called Feeding Minds this report by mental health advocates and food campaigners is ambitious and presents a good summary of the current state of the evidence, though its findings are sure to be controversial.

The report points out that changes in the composition of Western diets with the proliferation of industrialized farming and pesticide use and the depletion of some essential nutrients in the soil has coincided with a continuing increase in the incidence and prevalence rates of mental illness. It is always difficult to prove causality with research like this, since there have been many other social changes which could equally account for a rise in the rates of mental illness, to say nothing of ever-changing diagnostic criteria, that have sometimes labeled people with mental illness who would at one time have been described just as “different” or “eccentric” or “difficult.” But it is also fair to say that few people doubt the link between cigarette smoking and lung cancer, but to prove causality is bound to be difficult. This is very different from the situation with infectious diseases. Here we have had a set of four criteria which we can use to show whether or not an infectious organism is the cause of a disease. Known as Koch’s Postulates, which have guided us for 122 years and have so far been proven time and time again. These postulates have been modified over the years, yet still formed the basis of the work which lead to the 2005 Nobel Prize in Physiology or Medicine.

Sad to say, things are not so clear when looking at nutrition and mental illness. But let’s look at a few key items in the report:

1. Depression: I have mentioned this one already, and the report also emphasizes the link between depression and low consumption of fish that are high in omega-3 fatty acids

2. Schizophrenia: A link between some fatty acids and schizophrenia was first proposed by the late Dr. David Horrobin in the 1970s, and increasing epidemiological evidence has shown that sufferers have lower levels of polyunsaturated fatty acids (PUFA). There have been many studies which have attempted to modulate them to treat the disease, with some measure of success. Just this month there is a report in the British Journal of Psychiatry on the adjunctive use of PUFAs in the closely related condition of bipolar disorder.

3. Alzheimer's disease: Some studies have suggested that a high consumption of vegetables, particularly those containing folate, can protect against or slow the progression of this brain disorder.

4. Attention deficit and/or hyperactivity disorder: Research shown that some children with these disorders are low in iron and fatty acids, though it is not so clear whether treatment with these agents will help these children.

In my book Healing, Meaning and Purpose, I talk at length about the dietary and other physical changes over the last 100 years, and this report adds more. In the last 50 years, our consumption of omega-3 rich fish has fallen by two thirds, and over the same time course we have dropped our consumption of vegetables by 34%. There is something else more subtle, that I did not see in the report. In the decades after the second world war, British children were routinely given daily cod liver oil tablets rich in omega-3 fatty acids, as well as free school milk.

The report makes a point that I have before in entries here: people cannot be held totally responsible for maintaining healthy diets: some food and farming policies have lead to a situation in which people may no longer have access to healthy and nutritious foods. And that will likely cause further increases in some mental illness. And artificial supplements can rarely replace the real thing.

The evidence base associating nutrient intake and mental health is in its infancy, but it is clearly an area that needs a great deal more attention.

The recommendations in the new report are eminently sensible, and few would quibble with any of them. Before making any nutritional changes, always discuss them with your health care provider.

I would like to make a final point that I am going to amplify elsewhere:

If any health intervention is good for you, it should help more than one system of the body. So a diet that is good for mental health should also be good for the health of blood vessels, heart and skin. A diet like Nicholas Perricone’s, that aims to help skin aging, should also be good for the brain and the cardiovascular system. This is always a good way of checking to see if something is good for you and whether to adopt someone’s advice.

Technorati tags: Mentall health Nutrition Feeding Minds

Non-Pharmacological ADHD Treatments

There is a recently launched weblog, BrainWaves, being written by Zach Lynch of Neuroinsights that is becoming a “must read.” He is clearly following my policy of only writing about things that he has checked out himself. There is a terrific article on a new non-pharmacological technology for helping attention deficit disorder (ADD).

For some years I had my doubts about the diagnosis of ADD, and whether it was just a label for behaviors that some people didn’t like. But I am now convinced that it is a real problem, which if left untreated, can cause a lot of avoidable difficulties in life. Medication will not work for everyone, and the side effects can sometimes be troubling, so any new approaches are welcome. In a future entry, I shall review the research on some of the other non-pharmacological and whole-person approaches to treating ADD.

Technorati:  attention deficit, attention deficit disorder,  ADHD

Cannabis And Mental Illness

The debate about a possible relationship between smoking cannabis and developing mental illness - in particular schizophrenia - has been going on since the 1960s. For a long time it looked to many people as if "Cannabis psychosis" was a myth. But I’ve never been so sure. I have seen too many people who have smoked a lot of cannabis and then become psychotic.

The whole issue is now becoming clarified. We have known for years that cannabis can precipitate psychosis in people already suffering from mental illness, but over the last five years, a series of papers  (article 1, article 2, article 3 -there are many more) from Scandinavia have looked at young army conscripts and found an association between the number of times that they had used cannabis and their subsequent risk of developing schizophrenia. If they had smoked more than 50 times by the age of 18, their risk of developing schizophrenia was as much as six times higher. A new study from Cambridge in England has found that repeated use in children is also associated with a 2-3 fold increased risk.

I once talked about some of this data at a meeting in Northern California and had a "vigorous" debate with some indignant colleagues who claimed that cannabis was perfectly safe. Perhaps it is in well-adjusted adults, but I’m not so sure.

And this new research raises a number of important points:

1. The cannabis that is now used by young people is much stronger than that which was on offer in the 1960s and 1970s, and is sometimes also adulterated with other substances.

2. The age at which cannabis is smoked appears to be crucial: the data suggests that it is a problem if used during the vulnerable period of brain development that occurs during early and mid-adolescence.

3. Can we say that the cannabis is having a causal role in triggering mental illness? The answer is that we can no more prove it than prove that smoking causes lung cancer. In my book Healing, Meaning and Purpose I discuss the myth of "uni-causality," the idea that there is one cause for an illness. Apart from trauma, there are extremely few examples of one illness being caused by just one deranged gene, one missing nutrient or one external toxin. There will likely be genetic, social and environmental factors that will together determine whether or not cannabis could cause psychosis.

4. Could this just be self-medication? People taking cannabis to try and treat their symptoms? That is possible, though we then have to ask why we are not seeing a similar relationship with any other substances like alcohol or Ecstasy.

5. Finally, there is some recent evidence that one of the key active ingredients in cannabis, tetrahydrocannabinol (THC), can disrupt the normal development of the microtubules that guide the development of neurons in some regions of the brain.

The moral of the story? Cannabis isn’t good for you, and it can be REALLY BAD for people during the vulnerable period of brain development.

Addendum Dec. 22, 2005:  Hot off the presses!  Another article on cannabis and schizophrenia. 

Technorati tags: marijuana, mental illness

Addiction, Learning and Genes

Many of us have been mourning the death of George Best at the age of just 59. Arguably one of the most skillful players ever to kick a soccer ball, he finally succumbed to the slow suicide of alcohol abuse. Yet in the midst of all the opinion pieces that have tried to unravel the reasons for his alcohol abuse, all seem to have missed out on something very important. It has been missed because so many people have become wedded to the simple notion that there is one cause for one problem.

We have all seen so many television programs on which people have tearfully recounted the traumas that have befallen them, and we are then told that their current problems, whether of addiction, or of an inability to trust, or of serial infidelity, are all the result of having learned these behaviors, usually in childhood. So a person becomes an alcoholic because they saw their father drinking. An awful lot of therapy, and self-help is based upon that faulty premise. Why is it faulty? Because these people also share the same genes, and because, try as we might, we cannot reduce the whole of human behavior to ONLY learning, or ONLY genes. Most of the genes in the brain do not so much force you into behaving in a certain way; they instead predispose you to the way that you will handle something in your immediate environment.

So in the case of George Best, virtually all the tributes have said that the poor man become an alcoholic because he could not deal with all the fame, adulation and pressure that accompanied becoming soccer’s first real superstar. And doubtless, those were factors. But there is something else: his mother also died of complications of alcoholism, when she was 58 years old. Her drinking was attributed to watching her son succeed and then crash and burn. Possibly. But it is far more likely that it happened because they were both genetically predisposed to alcoholism.

When we try to understand a problem like this, it is essential not just to focus on the obvious cause: stress, or trauma, but also to look at the physical predisposition to reacting to the stress or trauma. Some people can be assailed by the most dreadful events, and come out smiling, while others have their lives ruined. It is also essential to look at the social context. George Best was brought from Belfast to Manchester when he was only 15 years old, and went home after two days because he was so homesick. He was persuaded to return to Manchester, and everyone tried to create a surrogate family for him, but it was obviously very difficult for him. It is also important to know that alcohol and substance abuse can cause havoc in the subtle systems of the body. That is why, when we treat people suffering form these illnesses, we encourage them to do some work, like Qigong or Yoga, to strengthen their subtle systems. Finally there is often a spiritual component to these problems. It is no coincidence that “spirits” as in alcohol and “spirit” as in spirituality, come from the same Latin root, in recognition of the ancient worship of the god Bacchus. Bill Wilson and Bob Smith recognized this link when they founded Alcoholics Anonymous in 1935. Many people who have struggled with addictions have been able to achieve sobriety once they discover and acknowledge the spiritual aspect of their lives, or in some cases that their substance abuse has been a reaction to a deep spiritual hunger.

Newsweek has an excellent article on the progress being made in our understanding of the physical components of addiction. The article highlights the complexity of the illness and the extraordinarily high relapse rates of sufferers.

There is only one quibble that I have with the article, and that is that it perpetuates the idea that substances of abuse hijack the “reward systems” of the brain. The reason why this is not quite correct is that it is a bit of a misnomer to talk about “reward systems.” These days we prefer to talk about salience systems. What does this mean? If something pleasurable happens to you, then the dopamine and GABA systems of the brain are indeed stimulated. And it appears that in substance abusers this system does not respond properly. So that they self-medicate because they have a form of sensory deprivation in these systems and that is the only way to get the dopamine levels that they need. But we now learn that dopamine also rises in the self same regions of the brain in response to threat. So what this system is doing is deciding what is salient, or important in the environment, and then focusing on and responding to it. It is these salience systems that seem to be under some genetic control, and can predispose someone to becoming a substance abuser.

Technorati tags: George Best alcoholism energy medicine