Tag: psychiatry

New research links subgroups of schizophrenia to specific visualized brain anomalies

On By A.P.In Medicine, schizophreniaLeave a comment

An international team of researchers has linked specific symptoms of schizophrenia with various anatomical characteristics in the brain, according to research published in NeuroImage.

By analyzing the brain’s anatomy with magnetic resonance imaging (MRI), researchers from the University of Granada, Washington University in St. Louis, and the University of South Florida have demonstrated the existence of distinctive subgroups among patients with schizophrenia who suffer from different symptoms.

These findings could herald a significant step forward in diagnosing and treating schizophrenia.

To perform the study, the researchers conducted the MRI technique “diffusion tensor imaging” on 36 healthy participants and 47 schizophrenic participants.

The researchers found that tests on schizophrenic participants revealed various abnormalities in parts of the corpus callosum, a bundle of neural fibers that connects the left and right cerebral hemispheres and is essential for effective interhemispheric communication.

Different anomalies in the corpus callosum were associated with different symptoms in the schizophrenic participants. An anomaly in one part of the brain structure was associated with strange and disorganized behavior; another anomaly was associated with disorganized thought and speech, as well as negative symptoms such as a lack of emotion; and other anomalies were associated with hallucinations.

In 2014, this same research group proved that schizophrenia is not a single illness. The team demonstrated the existence of 8 genetically distinct disorders, each with its own symptoms. Igor Zwir, PhD, and Javier Arnedo from the University of Granada’s Department of Computer Technology and Artificial Intelligence found that different sets of genes were strongly linked with different clinical symptoms.

“The current study provides further evidence that schizophrenia is a heterogeneous group of disorders, as opposed to a single illness, as was previously thought to be case,” Dr Zwir said in a statement.

While current treatments for schizophrenia tend to be generic regardless of the symptoms exhibited by each patient, the researchers believe that in the future, analyzing how specific gene networks are linked to various brain features and specific symptoms will help develop treatments that are adapted to each patient’s individual disorder.

To conduct the analysis of the gene groups and brain scans, the researchers developed a new, complex analysis of the relationships between different types of data and recommendations regarding new data. The system is similar to that used by companies such as Netflix to determine what movies they want to broadcast.

“To conduct the research, we did not begin by studying individuals who had certain schizophrenic symptoms in order to determine whether they had the corresponding brain anomalies,” said Dr Zwir in a statement. “Instead, we first analyzed the data, and that’s how we discovered these patterns. This type of information, combined with data on the genetics of schizophrenia, will someday be of vital importance in helping doctors treat the disorders in a more precise and effective way.”

Reference
Arnedo J, Mamah D, Baranger DA, et al. Decomposition of brain diffusion imaging data uncovers latent schizophrenias with distinct patterns of white matter anisotropy. NeuroImage. 2015; doi:10.1016/j.neuroimage.2015.06.083.

http://www.psychiatryadvisor.com/schizophrenia-and-psychoses/types-subgroups-schizophrenia-linked-various-different-brain-anomalies-corpus-callosum/article/470226/?DCMP=EMC-PA_Update_rd&cpn=psych_md&hmSubId=&hmEmail=5JIkN8Id_eWz7RlW__D9F5p_RUD7HzdI0&NID=&dl=0&spMailingID=13630678&spUserID=MTQ4MTYyNjcyNzk2S0&spJobID=720090900&spReportId=NzIwMDkwOTAwS0

Research uncovers genetic cause underlying schizophrenia

On By A.P.In Neuropsychiatric Disease, schizophreniaLeave a comment

Excessive activity in complement component 4 (C4) genes linked to the development of schizophrenia may explain the excessive pruning and reduced number of synapses in the brains of patients with schizophrenia, according to a study published in Nature.

The study, co-funded by the Office of Genomics Research Coordination at the National Institute of Mental Health and the Stanley Center for Psychiatric Research at the Broad Institute in Cambridge, Massachusetts, analyzed various structurally diverse versions of the C4 gene.

Led by Steve McCarroll, PhD, of the Broad Institute of Harvard and MIT, researchers analyzed the genomes of 65 000 study participants and 700 postmortem brains, detecting a link between specific gene versions and the biological process that causes some cases of schizophrenia.

The team—including Beth Stevens, PhD; Michael Carroll, PhD; and Aswin Sekar, BBS— determined that C4 genes generate varying levels of C4A and C4B proteins; the more C4A found in a person, the higher his or her risk of developing schizophrenia. The researchers found that during critical periods of brain maturation, C4 identifies synapses for pruning. Overexpression of C4 results in higher amounts of C4A, which could cause excessive pruning during the late teens and early adulthood, “conspicuously corresponding to the age-of-onset of schizophrenia symptoms,” the researchers noted.

“It has been virtually impossible to model [schizophrenic] disorder in cells or animals,” said Dr McCarroll. “The human genome is providing a powerful new way into this disease. Understanding these genetic effects on risk is a way of prying open that black box, peering inside, and starting to see actual biological mechanisms.”

Research suggests that future schizophrenia treatments may be developed to target and suppress excessive levels of pruning, halting a process that has the potential to develop into psychotic illness.

Reference

Sekar A, Bialas AR, de Rivera H, et al. Schizophrenia risk from complex variation of complement component 4. Nature. 2016; doi: 10.1038/nature16549.

Why do older white men have higher risk of suicide?

On By A.P.In mental health, mental illness, suicideLeave a comment

Older men of European descent (white men) have significantly higher suicide rates than any other demographic group in the United States, including older women across ethnicities and older men of African, Latino, or Indigenous decent, according to research published in Men and Masculinities.

In her latest addition to suicide research, Silvia Sara Canetto, PhD, professor in the Department of Psychology at Colorado State University, has found that older white men have higher suicide rates yet fewer burdens associated with aging. They are less likely to experience widowhood, have better physical health and fewer disabilities than older women, and have more economic resources than older women across ethnicities and ethnic minority older men.

Rather than being due to physical aging adversities, therefore, increased suicide rates among older white men in the United States may be because they are less psychologically equipped to deal with the normal challenges of aging; likely because of their privilege until late adulthood, Dr Canetto asserted.
Another important factor in white men’s vulnerability to suicide once they reach late life may be dominant cultural scripts of masculinity, aging, and suicide, Dr Canetto said. A particularly damaging cultural script may be the belief that suicide is a masculine response to “the indignities of aging.” This idea implies that suicide is justified or even glorified among men.

To illustrate these cultural scripts, Dr Canetto examined two famous suicide cases and their accompanying media coverage. The founder of Kodak, George Eastman, died of suicide at age 77. His biographer said that Eastman was “unprepared and unwilling to face the indignities of old age.”

American journalist and author Hunter S. Thompson died of suicide in 2005 at age 67, and was described by friends as having triumphed over “the indignities of aging.” Both of these suicides were covered in the press through scripts of conventional “white” masculinity, Dr Canetto stated. “The dominant story was that their suicide was a rational, courageous, powerful choice,” she said in a statement.

Canetto’s research challenges the idea that high suicide rates are inevitable among older white men. Canetto notes that older men are not the most suicide-prone group everywhere in the world; in China, for example, women at reproductive age are the demographic with the highest rate of suicide. This is additional evidence that suicide in older white men is culturally determined and thus preventable.

Dr Canetto’s research shows that cultural scripts may offer a new way of understanding and preventing suicide. The “indignities of aging” suicide script and the belief that suicide is a masculine, powerful response to aging can and should be challenged, Dr Canetto said.

Canetto SS. Suicide: Why Are Older Men So Vulnerable? Men Masc. 2015; doi:10.1177/1097184X15613832.

Exploring the Biology of Eating Disorders

On By A.P.In Neuropsychiatric DiseaseLeave a comment

With the pressure for a certain body type prevalent in the media, eating disorders are on the rise. But these diseases are not completely socially driven; researchers have uncovered important genetic and biological components as well and are now beginning to tease out the genes and pathways responsible for eating disorder predisposition and pathology.

As we enter the holiday season, shoppers will once again rush into crowded department stores searching for the perfect gift. They will be jostled and bumped, yet for the most part, remain cheerful because of the crisp air, lights, decorations, and the sound of Karen Carpenter’s contralto voice ringing out familiar carols.

While Carpenter is mainly remembered for her musical talents, unfortunately, she is also known for introducing the world to anorexia nervosa (AN), a severe life-threatening mental illness characterized by altered body image and stringent eating patterns that claimed her life just before her 33rd birthday in 1983.

Even though eating disorders (ED) carry one of the highest mortality rates of any mental illness, many researchers and clinicians still view them as socially reinforced behaviors and diagnose them based on criteria such as “inability to maintain body weight,” “undue influence of body weight or shape on self-evaluation,” and “denial of the seriousness of low body weight” (1). This way of thinking was prevalent when Michael Lutter, then an MD/PhD student at the University of Texas Southwestern Medical Center, began his psychiatry residency in an eating disorders unit. “I just remember the intense fear of eating that many patients exhibited and thought that it had to be biologically driven,” he said.

Lutter carried this impression with him when he established his own research laboratory at the University of Iowa. Although clear evidence supports the idea that EDs are biologically driven—they predominantly affect women and significantly alter energy homeostasis—a lack of well-defined animal models combined with the view that they are mainly behavioral abnormalities have hindered studies of the neurobiology of EDs. Still, Lutter is determined to find the biological roots of the disease and tease out the relationship between the psychiatric illness and metabolic disturbance using biochemistry, neuroscience, and human genetics approaches.

We’ve Only Just Begun

Like many diseases, EDs result from complex interactions between genes and environmental risk factors. They tend to run in families, but of course, for many family members, genetics and environment are similar enough that teasing apart the influences of nature and nurture is not easy. Researchers estimate that 50-80% of the predisposition for developing an ED is genetic, but preliminary genome-wide analyses and candidate gene studies failed to identify specific genes that contribute to the risk.

According to Lutter, finding ED study participants can be difficult. “People are either reluctant to participate, or they don’t see that they have a problem,” he reported. Set on finding the genetic underpinnings of EDs, his team began recruiting volunteers and found 2 families, 1 with 20 members, 10 of whom had an ED and another with 5 out of 8 members affected. Rather than doing large-scale linkage and association studies, the team decided to characterize rare single-gene mutations in these families, which led them to identify mutations in the first two genes, estrogen-related receptor α (ESRRA) and histone deacetylase 4 (HDAC4), that clearly associated with ED predisposition in 2013 (1).

“We have larger genetic studies on-going, including the collection of more families. We just happened to publish these two families first because we were able to collect enough individuals and because there is a biological connection between the two genes that we identified,” Lutter explained.

ESRRA appears to be a transcription factor upregulated by exercise and calorie restriction that plays a role in energy balance and metabolism. HDAC4, on the other hand, is a well-described histone deacteylase that has previously been implicated in locomotor activity, body weight homeostasis, and neuronal plasticity.

Using immunoprecipitation, the researchers found that ESRRA interacts with HDAC4, in both the wild type and mutant forms, and transcription assays showed that HDAC4 represses ESRRA activity. When Lutter’s team repeated the transcription assays using mutant forms of the proteins, they found that the ESRRA mutation seen in one family significantly reduced the induction of target gene transcription compared to wild type, and that the mutation in HDAC4 found in the other family increased transcriptional repression for ESRRA target genes.

“ESRRA is a well known regulator of mitochondrial function, and there is an emerging view that mitochondria in the synapse are critical for neurotransmission,” Lutter said. “We are working on identifying target pathways now.”

Bless the Beasts and the Children

Finding genes associated with EDs provides the groundwork for molecular studies, but EDs cannot be completely explained by the actions of altered transcription factors. Individuals suffering these disorders often experience intense anxiety, intrusive thoughts, hyperactivity, and poor coping strategies that lead to rigid and ritualized behaviors and severe crippling perfectionism. They are less aware of their emotions and often try to avoid emotion altogether. To study these complex behaviors, researchers need animal models.

Until recently, scientists relied on mice with access to a running wheel and restricted access to food. Under these conditions, the animals quickly increase their locomotor activity and reduce eating, frequently resulting in death. While some characteristics of EDs—excessive exercise and avoiding food—can be studied in these mice, the model doesn’t allow researchers to explore how the disease actually develops. However, Lutter’s team has now introduced a promising new model (3).

Based on their previous success with identifying the involvement of ESRRA and HDAC4 in EDs, the researchers wondered if mice lacking ESRRA might make suitable models for studies on ED development. To find out, they first performed immunohistochemistry to understand more about the potential cognitive role of ESRRA.

“ESRRA is not expressed very abundantly in areas of the brain typically implicated in the regulation of food intake, which surprised us,” Lutter said. “It is expressed in many cortical regions that have been implicated in the etiology of EDs by brain imaging like the prefrontal cortex, orbitofrontal cortex, and insula. We think that it probably affects the activity of neurons that modulate food intake instead of directly affecting a core feeding circuit.”

With these data, the team next tried providing only 60% of the normal daily calories to their mice for 10 days and looked again at ESRRA expression. Interestingly, ESRRA levels increased significantly when the mice were insufficiently fed, indicating that the protein might be involved in the response to energy balance.

Lutter now believes that upregulation of ESRRA helps organisms adapt to calorie restriction, an effect possibly not happening in those with ESRRA or HDAC4 mutations. “This makes sense for the clinical situation where most individuals will be doing fine until they are challenged by something like a diet or heavy exercise for a sporting event. Once they start losing weight, they don’t adapt their behaviors to increase calorie intake and rapidly spiral into a cycle of greater and greater weight loss.”

When Lutter’s team obtained mice lacking ESRRA, they found that these animals were 15% smaller than their wild type littermates and put forth less effort to obtain food both when fed restricted calorie diets and when they had free access to food. These phenotypes were more pronounced in female mice than male mice, likely due to the role of estrogen signaling. Loss of ESRRA increased grooming behavior, obsessive marble burying, and made mice slower to abandon an escape hole after its relocation, indicating behavioral rigidity. And the mice demonstrated impaired social functioning and reduced locomotion.

Some people with AN exercise extensively, but this isn’t seen in all cases. “I would say it is controversial whether or not hyperactivity is due to a genetic predisposition (trait), secondary to starvations (state), or simply a ritual that develops to counter the anxiety of weight related obsessions. Our data would suggest that it is not due to genetic predisposition,” Lutter explained. “But I would caution against over-interpretation of mouse behavior. The locomotor activity of mice is very different from people and it’s not clear that you can directly translate the results.”

For All We Know

Going forward, Lutter’s group plans to drill down into the behavioral phenotypes seen in their ESRRA null mice. They are currently deleting ESRRA from different neuronal cell types to pair individual neurons with the behaviors they mediate in the hope of working out the neural circuits involved in ED development and pathology.

In addition, the team has created a mouse line carrying one of the HDAC4 mutations previously identified in their genetic study. So far, this mouse “has interesting parallels to the ESRRA-null mouse line,” Lutter reported.

The team continues to recruit volunteers for larger-scale genetic studies. Eventually, they plan to perform RNA-seq to identify the targets of ESRRA and HDAC4 and look into their roles in mitochondrial biogenesis in neurons. Lutter suspects that this process is a key target of ESRRA and could shed light on the cognitive differences, such as altered body image, seen in EDs. In the end, a better understanding of the cells and pathways involved with EDs could create new treatment options, reduce suffering, and maybe even avoid the premature loss of talented individuals to the effects of these disorders.

References

1. Lutter M, Croghan AE, Cui H. Escaping the Golden Cage: Animal Models of Eating Disorders in the Post-Diagnostic and Statistical Manual Era. Biol Psychiatry. 2015 Feb 12.

2. Cui H, Moore J, Ashimi SS, Mason BL, Drawbridge JN, Han S, Hing B, Matthews A, McAdams CJ, Darbro BW, Pieper AA, Waller DA, Xing C, Lutter M. Eating disorder predisposition is associated with ESRRA and HDAC4 mutations. J Clin Invest. 2013 Nov;123(11):4706-13.

3. Cui H, Lu Y, Khan MZ, Anderson RM, McDaniel L, Wilson HE, Yin TC, Radley JJ, Pieper AA, Lutter M. Behavioral disturbances in estrogen-related receptor alpha-null mice. Cell Rep. 2015 Apr 21;11(3):344-50.

http://www.biotechniques.com/news/Exploring-the-Biology-of-Eating-Disorders/biotechniques-361522.html

CPAP therapy demonstrated to reduce depression in adults with obstructive sleep apnea

On By A.P.In mental health, mental illnessLeave a comment

A new study shows that depressive symptoms are extremely common in people who have obstructive sleep apnea, and these symptoms improve significantly when sleep apnea is treated with continuous positive airway pressure therapy.

Results show that nearly 73 percent of sleep apnea patients (213 of 293 patients) had clinically significant depressive symptoms at baseline, with a similar symptom prevalence between men and women. These symptoms increased progressively and independently with sleep apnea severity.

However, clinically significant depressive symptoms remained in only 4 percent of the sleep apnea patients who adhered to CPAP therapy for 3 months (9 of 228 patients). Of the 41 treatment adherent patients who reported baseline feelings of self-harm or that they would be “better dead,” none reported persisting suicidal thoughts at the 3-month follow-up.

“Effective treatment of obstructive sleep apnea resulted in substantial improvement in depressive symptoms, including suicidal ideation,” said senior author David R. Hillman, MD, clinical professor at the University of Western Australia and sleep physician at the Sir Charles Gairdner Hospital in Perth. “The findings highlight the potential for sleep apnea, a notoriously underdiagnosed condition, to be misdiagnosed as depression.”

Study results are published in the September issue of the Journal of Clinical Sleep Medicine.

The American Academy of Sleep Medicine reports that obstructive sleep apnea (OSA) is a common sleep disease afflicting at least 25 million adults in the U.S. Untreated sleep apnea increases the risk of other chronic health problems including heart disease, high blood pressure, Type 2 diabetes, stroke and depression.

The study group comprised 426 new patients referred to a hospital sleep center for evaluation of suspected sleep apnea, including 243 males and 183 females. Participants had a mean age of 52 years. Depressive symptoms were assessed using the validated Patient Health Questionnaire (PHQ-9), and the presence of obstructive sleep apnea was determined objectively using overnight, in-lab polysomnography. Of the 293 patients who were diagnosed with sleep apnea and prescribed CPAP therapy, 228 were treatment adherent, which was defined as using CPAP therapy for an average of 5 hours or more per night for 3 months.

According to the authors, the results emphasize the importance of screening people with depressive symptoms for obstructive sleep apnea. These patients should be asked about common sleep apnea symptoms including habitual snoring, witnessed breathing pauses, disrupted sleep, and excessive daytime sleepiness.

http://www.eurekalert.org/pub_releases/2015-09/aaos-ctr092215.php

Computers are now able to predict who will develop psychosis years later based on analysis of their speech patterns.

On By A.P.In Medicine, Neuropsychiatric Disease, Psychosis, schizophreniaLeave a comment

An automated speech analysis program correctly differentiated between at-risk young people who developed psychosis over a two-and-a-half year period and those who did not. In a proof-of-principle study, researchers at Columbia University Medical Center, New York State Psychiatric Institute, and the IBM T. J. Watson Research Center found that the computerized analysis provided a more accurate classification than clinical ratings. The study, “Automated Analysis of Free Speech Predicts Psychosis Onset in High-Risk Youths,” was recently published in NPJ-Schizophrenia.

About one percent of the population between the age of 14 and 27 is considered to be at clinical high risk (CHR) for psychosis. CHR individuals have symptoms such as unusual or tangential thinking, perceptual changes, and suspiciousness. About 20% will go on to experience a full-blown psychotic episode. Identifying who falls in that 20% category before psychosis occurs has been an elusive goal. Early identification could lead to intervention and support that could delay, mitigate or even prevent the onset of serious mental illness.
Speech provides a unique window into the mind, giving important clues about what people are thinking and feeling. Participants in the study took part in an open-ended, narrative interview in which they described their subjective experiences. These interviews were transcribed and then analyzed by computer for patterns of speech, including semantics (meaning) and syntax (structure).

The analysis established each patient’s semantic coherence (how well he or she stayed on topic), and syntactic structure, such as phrase length and use of determiner words that link the phrases. A clinical psychiatrist may intuitively recognize these signs of disorganized thoughts in a traditional interview, but a machine can augment what is heard by precisely measuring the variables. The participants were then followed for two and a half years.
The speech features that predicted psychosis onset included breaks in the flow of meaning from one sentence to the next, and speech that was characterized by shorter phrases with less elaboration. The speech classifier tool developed in this study to mechanically sort these specific, symptom-related features is striking for achieving 100% accuracy. The computer analysis correctly differentiated between the five individuals who later experienced a psychotic episode and the 29 who did not. These results suggest that this method may be able to identify thought disorder in its earliest, most subtle form, years before the onset of psychosis. Thought disorder is a key component of schizophrenia, but quantifying it has proved difficult.

For the field of schizophrenia research, and for psychiatry more broadly, this opens the possibility that new technology can aid in prognosis and diagnosis of severe mental disorders, and track treatment response. Automated speech analysis is inexpensive, portable, fast, and non-invasive. It has the potential to be a powerful tool that can complement clinical interviews and ratings.

Further research with a second, larger group of at-risk individuals is needed to see if this automated capacity to predict psychosis onset is both robust and reliable. Automated speech analysis used in conjunction with neuroimaging may also be useful in reaching a better understanding of early thought disorder, and the paths to develop treatments for it.

http://medicalxpress.com/news/2015-08-psychosis-automated-speech-analysis.html

Eye tests may predict schizophrenia

On By A.P.In Neuropsychiatric Disease, Parkinson's disease, Psychosis, schizophreniaLeave a comment

Schizophrenia is associated with structural and functional alterations of the visual system, including specific structural changes in the eye. Tracking such changes may provide new measures of risk for, and progression of the disease, according to a literature review published online in the journal Schizophrenia Research: Cognition, authored by researchers at New York Eye and Ear Infirmary of Mount Sinai and Rutgers University.

Individuals with schizophrenia have trouble with social interactions and in recognizing what is real. Past research has suggested that, in schizophrenia, abnormalities in the way the brain processes visual information contribute to these problems by making it harder to track moving objects, perceive depth, draw contrast between light and dark or different colors, organize visual elements into shapes, and recognize facial expressions. Surprisingly though, there has been very little prior work investigating whether differences in the retina or other eye structures contribute to these disturbances.

“Our analysis of many studies suggests that measuring retinal changes may help doctors in the future to adjust schizophrenia treatment for each patient,” said study co-author Richard B. Rosen, MD, Director of Ophthalmology Research, New York Eye and Ear Infirmary of Mount Sinai, and Professor of Ophthalmology, Icahn School of Medicine at Mount Sinai. “More studies are needed to drive the understanding of the contribution of retinal and other ocular pathology to disturbances seen in these patients, and our results will help guide future research.”

The link between vision problems and schizophrenia is well established, with as many as 62 percent of adult patients with schizophrenia experience visual distortions involving form, motion, or color. One past study found that poorer visual acuity at four years of age predicted a diagnosis of schizophrenia in adulthood, and another that children who later develop schizophrenia have elevated rates of strabismus, or misalignment of the eyes, compared to the general population.

Dr. Rosen and Steven M. Silverstein, PhD, Director of the Division of Schizophrenia Research at Rutgers University Behavioral Health Care, were the lead authors of the analysis, which examined the results of approximately 170 existing studies and grouped the findings into multiple categories, including changes in the retina vs. other parts of the eye, and changes related to dopamine vs. other neurotransmitters, key brain chemicals associated with the disease.

The newly published review found multiple, replicated, indicators of eye abnormalities in schizophrenia. One of these involves widening of small blood vessels in the eyes of schizophrenia patients, and in young people at high risk for the disorder, perhaps caused by chronic low oxygen supply to the brain. This could explain several key vision changes and serve as a marker of disease risk and worsening. Also important in this regard was thinning of the retinal nerve fiber layer in schizophrenia, which is known to be related to the onset of hallucinations and visual acuity problems in patients with Parkinson’s disease. In addition, abnormal electrical responses by retinal cells exposed to light (as measured by electroretinography) suggest cellular-level differences in the eyes of schizophrenia patients, and may represents a third useful measure of disease progression, according to the authors.

In addition, the review highlighted the potentially detrimental effects of dopamine receptor-blocking medications on visual function in schizophrenia (secondary to their retinal effects), and the need for further research on effects of excessive retinal glutamate on visual disturbances in the disorder.

Interestingly, the analysis found that there are no reports of people with schizophrenia who were born blind, suggesting that congenital blindness may completely or partially protect against the development of schizophrenia. Because congenitally blind people tend to have cognitive abilities in certain domains (e.g., attention) that are superior to those of healthy individuals, understanding brain re-organization after blindness may have implications for designing cognitive remediation interventions for people with schizophrenia.

“The retina develops from the same tissue as the brain,” said Dr. Rosen. “Thus retinal changes may parallel or mirror the integrity of brain structure and function. When present in children, these changes may suggest an increased risk for schizophrenia in later life. Additional research is needed to clarify these relationships, with the goals of better predicting emergence of schizophrenia, and of predicting relapse and treatment response and people diagnosed with the condition.”

Dr. Silverstein points out that, to date, vision has been understudied in schizophrenia, and studies of the retina and other ocular structures in the disorder are in their infancy. However, he added, “because it is much faster and less expensive to obtain data on retinal structure and function, compared to brain structure and function, measures of retinal and ocular structure and function may have an important role in both future research studies and the routine clinical care of people with schizophrenia.”

http://www.eurekalert.org/pub_releases/2015-08/tmsh-rcm081715.php

Psychiatry’s Identity Crisis

On By A.P.In Medicine, Psychiatry, psychologyLeave a comment

psych

By Richard A Friedman, a professor of clinical psychiatry at Weill Cornell Medical College

American psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front.

With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s.

Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective.

Even the new brain stimulatory treatments like repetitive transcranial magnetic stimulation don’t come close to the efficacy of electroconvulsive treatment, developed in the 1940s. (Deep brain stimulation is promising as a treatment for intractable depression, but it is an invasive treatment and little is known about its long-term safety or efficacy.)

At the same time, judging from research funding priorities, it seems that leaders in my field are turning their backs on psychotherapy and psychotherapy research. In 2015, 10 percent of the overall National Institute of Mental Health research funding has been allocated to clinical trials research, of which slightly more than half — a mere 5.4 percent of the whole research allotment — goes to psychotherapy clinical trials research.

As a psychiatrist and psychopharmacologist who loves neuroscience, I find this trend very disturbing. First, psychotherapy has been shown in scores of well-controlled clinical trials to be as effective as psychotropic medication for very common psychiatric illnesses like major depression and anxiety disorders; second, a majority of Americans clearly prefer psychotherapy to taking medication. For example, in a meta-analysis of 34 studies, Dr. R. Kathryn McHugh at McLean Hospital found that patients were three times more likely to want psychotherapy than psychotropic drugs.

Finally, many of our patients have histories of trauma, sexual abuse, the stress of poverty or deprivation. There is obviously no quick biological fix for these complex problems.

Still, there has been a steady decline in the number of Americans receiving psychotherapy along with a concomitant increase in the use of psychotropic medication in those who are treated in the outpatient setting. These trends are most likely driven by many factors, including cost and the limited availability that most Americans have to mental health practitioners. It is clearly cheaper and faster to give a pill than deliver psychotherapy.

The doubling down on basic neuroscience research seems to reflect the premise that if we can unravel the function of the brain, we will have a definitive understanding of the mind and the causes of major psychiatric disorders. Indeed, an editorial in May in one of the most respected journals in our field, JAMA Psychiatry, echoed this view: “The diseases that we treat are diseases of the brain,” the authors wrote.

Even if this premise were true — and many would consider it reductionist and simplistic — an undertaking as ambitious as unraveling the function of the brain would most likely take many years. Moreover, a complete understanding of neurobiology is unlikely to elucidate the complex interactions between genes and the environment that lie at the heart of many mental disorders. Anyone who thinks otherwise should remember the Decade of the Brain, which ended 15 years ago without yielding a significant clue about the underlying causes of psychiatric illnesses.

Sure, we now have astounding new techniques for studying the brain, like optogenetics, in which neurons can be controlled by light, allowing researchers to understand how neurons work alone and in networks. But no one thinks breakthrough biological treatments are just around the corner.

More fundamentally, the fact that all feelings, thoughts and behavior require brain activity to happen does not mean that the only or best way to change — or understand — them is with medicine. We know, for instance, that not all psychiatric disorders can be adequately treated with biological therapy. Personality disorders, like borderline and narcissistic personality disorders, which are common and can cause impairment and suffering comparable to that of severe depression, are generally poorly responsive to psychotropic drugs, but are very treatable with various types of psychotherapy.

There is often no substitute for the self-understanding that comes with therapy. Sure, as a psychiatrist, I can quell a patient’s anxiety, improve mood and clear psychosis with the right medication. But there is no pill — and probably never will be — for any number of painful and disruptive emotional problems we are heir to, like narcissistic rage and paralyzing ambivalence, to name just two.

This requires patients to re-experience the circumstances of their traumatic event, which is meant to desensitize them and teach them that their belief that they are in danger is no longer true.

But we know that many patients with PTSD do not respond to exposure, and many of them find the process emotionally upsetting or intolerable.

Dr. John C. Markowitz, a professor of clinical psychiatry at Columbia University, recently showed for the first time that PTSD is treatable with a psychotherapy that does not involve exposure. Dr. Markowitz and his colleagues randomly assigned a group of patients with PTSD to one of three treatments: prolonged exposure, relaxation therapy and interpersonal psychotherapy, which focuses on patients’ emotional responses to interpersonal relationships and helps them to solve problems and improve these relationships. His federally funded study, published in May’s American Journal of Psychiatry, reported that the response rate to interpersonal therapy (63 percent) was comparable to that of exposure therapy (47 percent).

PTSD is a serious public mental health problem, particularly given the rates of PTSD in our veterans returning from war. This study now gives clinicians a powerful new therapy for this difficult-to-treat disorder. Imagine how many more studies like Dr. Markowitz’s might be possible if the federal funding of psychotherapy research were not so stingy.

The brain is notoriously hard to study and won’t give up its secrets easily. In contrast, psychotherapy research can yield relatively quick and powerful results. Given the critically important value — and popularity — of therapy, psychotherapy research deserves a much larger share of research dollars than it currently receives.

Don’t get me wrong. I’m all for cutting-edge neuroscience research — and lots of it. But we are more than a brain in a jar. Just ask anyone who has benefited from psychotherapy.

The Healing Power of Caring and Hope in Psychotherapy

On By A.P.In psychiatrist, Psychiatry, psychologist, psychologyLeave a comment

By Allen Frances, MD

There are 3 consistent research findings that should make a world of difference to therapists and to the people they treat.

1. Psychotherapy works at least as well as drugs for most mild to moderate problems and, all things being equal, should be used first

2. A good relationship is much more important in promoting good outcome than the specific psychotherapy techniques that are used

3. There is a very high placebo response rate for all sorts of milder psychiatric and medical problems

This is partly a “time effect”—people come for help at particularly bad times in their lives and are likely to improve with time even if nothing is done. But placebo response also reflects the magical power of hope and expectation. And the effect is not just psychological—the body often actually responds to placebo just as it would respond to active medication.

These 3 findings add up to one crucial conclusion—the major focus of effective therapy should be to establish a powerfully healing relationship and to inspire hope. Specific techniques help when they enhance the primary focus on the relationship; they hurt when they distract from it.

The paradox is that therapists are increasingly schooled in specific techniques to the detriment of learning how to heal. The reason is clear—it is easy to manualize technique, hard to teach great healing.

I have, therefore, asked a great healer, Fanny Marell, a Swedish social worker and licensed psychotherapist, to share some of her secrets. Ms Marell writes:

Many therapists worry so much about assessing symptoms, performing techniques, and filling out forms that they miss the wonderful vibrancy of a strong therapeutic relationship.

Thinking I can help someone just by asking about concerns, troubles, and symptoms is like thinking that I can drive a car solely by looking in the rearview mirror. Dreams, hopes, and abilities are seen out of the front window of the car and help us together to navigate the road ahead. Where are we going? Which roads will you choose and why? It surely will not be the same roads I would take. We are different—we have to find your own best direction.

If we focus only on troubles and diagnosis, we lose the advantage of capitalizing on the person’s strengths and resources. If I am to help someone overcome symptoms, change behaviors, and climb out of difficult situations, I need to emphasize also all the positives he brings to the situation. Therapy without conversations about strengths and hopes is not real therapy.

And often most important: Does the patient have a sense of humor? Laugh together! Be human. No one wants a perfect therapist. It is neither credible nor human.

Symptom checklists and diagnoses play a role but they do not give me an understanding of how this person/patient understands his world and her troubles.

And don’t drown in manuals, missing the person while applying the technique.

People come to me discouraged and overwhelmed—their hopes and dreams abandoned. Early in our time together, I ask many detailed questions about how they would like life to change. What would you do during the day? Where would you live? What would your relationship to your family be like? What would you do in your spare time? What kind of social circle would you have? By getting detailed descriptions, I get concrete goals (eg, I want to go to school, argue less with my parents, spend more time with friends).

Almost always, working with the family is useful; sometimes it is absolutely necessary. What would be a good life for your child? How would it affect you?

Sometimes our dreams are big, perhaps even too extravagant; sometimes they are small and perhaps too cautious. But dreams always become more realistic and realizable when they are expressed. Sharing a dream and making it a treatment goal helps the person make a bigger investment in the treatment, and to take more responsibility for it. He becomes the driver and the therapist may sit in the back seat.

Because my first conversation is not just about symptoms and troubles, we start off on a basis of realistic hope and avoid a negative spiral dominated only by troubles. Problems have to be faced, but from a position of strength, not despair and helplessness.

Having a rounded view of the person’s problems and strengths enriches the therapeutic contact and creates a strong alliance.

Thanks, Ms Marell, for terrific advice. Some of the best natural therapists I have known have been ruined by psychotherapy training—becoming so preoccupied learning and implementing technique that they lost the healing warmth of their personalities.

Therapy should always be an exciting adventure, an intense meeting of hearts and minds. You can’t learn to be an effective therapist by reading a manual and applying it mechanically.

I would tell therapists I supervised never to apply what we discussed to their next session with the patient, lest they would always be a week behind. Therapy should be informed by technique, but not stultified by it.

See more at: http://www.psychiatrictimes.com/blogs/couch-crisis/magical-healing-power-caring-and-hope-psychotherapy?GUID=C523B8FD-3416-4DAC-8E3C-6E28DE36C515&rememberme=1&ts=16072015#sthash.2AOArvAW.dpuf

Virtual human designed to help patients feel comfortable talking about themselves with therapists

On By A.P.In virtual humanLeave a comment

By Suzanne Allard Levingston

With her hair pulled back and her casual office attire, Ellie is a comforting presence. She’s trained to put patients at ease as she conducts mental health interviews with total confidentiality.

She draws you into conversation: “So how are you doing today?” “When was the last time you felt really happy?” She notices if you look away or fidget or pause, and she follows up with a nod of encouragement or a question: “Can you tell me more about that?”

Not bad for an interviewer who’s not human.

Ellie is a virtual human created by scientists at the University of Southern California to help patients feel comfortable talking about themselves so they’ll be honest with their doctors. She was born of two lines of findings: that anonymity can help people be more truthful and that rapport with a trained caregiver fosters deep disclosure. In some cases, research has shown, the less human involvement, the better. In a 2014 study of 239 people, participants who were told that Ellie was operating automatically as opposed to being controlled by a person nearby, said they felt less fearful about self-disclosure, better able to express sadness and more willing to disclose.

Getting a patient’s full story is crucial in medicine. Many technological tools are being used to help with this quest: virtual humans such as Ellie, electronic health records, secure e-mail, computer databases. Although these technologies often smooth the way, they sometimes create hurdles.

Honesty with doctors is a bedrock of proper care. If we hedge in answering their questions, we’re hampering their ability to help keep us well.

But some people resist divulging their secrets. In a 2009 national opinion survey conducted by GE, the Cleveland Clinic and Ochsner Health System, 28 percent of patients said they “sometimes lie to their health care professional or omit facts about their health.” The survey was conducted by telephone with 2,000 patients.

The Hippocratic Oath imposes a code of confidentiality on doctors: “I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know.”

Nonetheless, patients may not share sensitive, potentially stigmatizing health information on topics such as drug and alcohol abuse, mental health problems and reproductive and sexual history. Patients also might fib about less-fraught issues such as following doctor’s orders or sticking to a diet and exercise plan.

Why patients don’t tell the full truth is complicated. Some want to disclose only information that makes the doctor view them positively. Others fear being judged.

“We never say everything that we’re thinking and everything that we know to another human being, for a lot of different reasons,” says William Tierney, president and chief executive of the Regenstrief Institute, which studies how to improve health-care systems and is associated with the Indiana University School of Medicine.

In his work as an internist at an Indianapolis hospital, Tierney has encountered many situations in which patients aren’t honest. Sometimes they say they took their blood pressure medications even though it’s clear that they haven’t; they may be embarrassed because they can’t pay for the medications or may dislike the medication but don’t want to offend the doctor. Other patients ask for extra pain medicine without admitting that they illegally share or sell the drug.

Incomplete or incorrect information can cause problems. A patient who lies about taking his blood pressure medication, for example, may end up being prescribed a higher dose, which could send the patient into shock, Tierney said.

Leah Wolfe, a primary care physician who trains students, residents and faculty at the Johns Hopkins School of Medicine in Baltimore, said that doctors need to help patients understand why questions are being asked. It helps to normalize sensitive questions by explaining, for example, why all patients are asked about their sexual history.

“I’m a firm believer that 95 percent of diagnosis is history,” she said. “The physician has a lot of responsibility here in helping people understand why they’re asking the questions that they’re asking.”

Technology, which can improve health care, can also have unintended consequences in doctor-patient rapport. In a recent study of 4,700 patients in the Journal of the American Medical Informatics Association, 13 percent of patients said they had kept information from a doctor because of concerns about privacy and security, and this withholding was more likely among patients whose doctors used electronic health records than those who used paper charts.

“It was surprising that it would actually have a negative consequence for that doctor-patient interaction,” said lead author Celeste Campos-Castillo of the University of Wisconsin at Milwaukee. Campos-Castillo suggests that doctors talk to their patients about their computerized-record systems and the security measures that protect those systems.

When given a choice, some patients would use technology to withhold information from providers. Regenstrief Institute researchers gave 105 patients the option to control access to their electronic health records, broken down into who could see the record and what kind of information they chose to share. Nearly half chose to place some limits on access to their health records in a six-month study published in January in the Journal of General Internal Medicine.

While patient control can empower, it can also obstruct. Tierney, who was not involved as a provider in that study, said that if he had a patient who would not allow him full access to health information, he would help the patient find another physician because he would feel unable to provide the best and safest care possible.

“Hamstringing my ability to provide such care is unacceptable to me,” he wrote in a companion article to the study.

Technology can also help patients feel comfortable sharing private information.

A study conducted by the Veterans Health Administration found that some patients used secure e-mail messaging with their providers to address sensitive topics — such as erectile dysfunction and sexually transmitted diseases — a fact that they had not acknowledged in face-to-face interviews with the research team.

“Nobody wants to be judged,” said Jolie Haun, lead author of the 2014 study and a researcher at the Center of Innovation on Disability and Rehabilitation Research at the James A. Haley VA Hospital in Tampa. “We realized that this electronic form of communication created this somewhat removed, confidential, secure, safe space for individuals to bring up these topics with their provider, while avoiding those social issues around shame and embarrassment and discomfort in general.”

USC’s Ellie shows promise as a mental health screening tool. With a microphone, webcam and an infrared camera device that tracks a person’s body posture and movements, Ellie can process such cues as tone of voice or change in gaze and react with a nod, encouragement or question. But the technology can neither understand deeply what the person is saying nor offer therapeutic support.

“Some people make the mistake when they see Ellie — they assume she’s a therapist and that’s absolutely not the case,” says Jonathan Gratch, director for virtual human research at USC’s Institute for Creative Technologies.

The anonymity and rapport created by virtual humans factor into an unpublished USC study of screenings for post-traumatic stress disorder. Members of a National Guard unit were interviewed by a virtual human before and after a year of service in Afghanistan. Talking to the animated character elicited more reports of PTSD symptoms than completing a computerized form did.

One of the challenges for doctors is when a new patient seeks a prescription for a controlled substance. Doctors may be concerned that the drug will be used illegally, a possibility that’s hard to predict.

Here, technology is a powerful lever for honesty. Maryland, like almost all states, keeps a database of prescriptions. When her patients request narcotics, Wolfe explains that it’s her office’s practice to check all such requests against the database that monitors where and when a patient filled a prescription for a controlled substance. This technology-based information helps foster honest give-and-take.

“You’ve created a transparent environment where they are going to be motivated to tell you the truth because they don’t want to get caught in a lie,” she said. “And that totally changes the dynamics.”

It is yet to be seen how technology will evolve to help patients share or withhold their secrets. But what will not change is a doctor’s need for full, open communication with patients.

“It has to be personal,” Tierney says. “I have to get to know that patient deeply if I want to understand what’s the right decision for them.”