Methamphetamine
We have been seeing some of the terrible consequences of methamphetamine abuse.
Where I live it is normally called and sold as "Crystal meth," and it is the worst type of drug that I have ever seen: and I’ve seen most things over a busy career during which I’ve consulted in many countries.
Apart from the personal cost, there can be few things more devastating to a family than discovering a loved one destroying their life with this highly addictive group of compounds.
I thought that you may be interested in a resource published a couple of months ago on PsychiatricResourceForum.blogs.com.
There is also another article on the same blog about some of the new principles of helping the recovery of people with chronic mental illness. But interestingly, many of the same principles apply when helping people with addictions.
These are very useful resources. Though designed for healthcare professionals, they will, I think, be of value to anyone who comes into contact with drug using people.
And that is far more of us than most people ever realize.
Mel's Madness
In the midst of all the furor about Mel Gibson and his self-admittedly foul behavior while under the influence of alcohol, an important point has been missed: when someone is drunk or brain damaged, is their behavior just disinhibition? Are they behaving this way because they’ve lost the cerebral censor that normally maintains our social demeanor? The Romans certainly thought so: in banqueting halls they would have roses carved into columns and the ceiling. The rose – the symbol of secrets – was a reminder to be discrete when alcohol might begin to lossen the tongue.
When the frontal lobes are on strike, does our “true” personality emerge? Or can alcohol, drugs and brain injury produce brand new behaviors that are not just totally out of character, but predictable by the drug or type of injury?
The answer is a mixture of the two. I know a man who is in the running for the Nobel Prize in medicine. But a couple of years ago it was all over the press when he shattered the arm of an innocent man in the middle of an alcohol-fueled frenzy. Was it the alcohol? Yes, I’m sure that it was. But the scientist has had a very long history of anger problems and of bullying younger colleagues. The alcohol was the catalyst to behavior that he normally keeps in check, but which was just waiting to come out of its cage. I’ve treated hundreds of alcohol abusing people, and the amiable ones far outnumber the violent ones. And the majority of the violent ones had also been violent when not drinking.
Some drugs and chronic alcohol abuse can produce stereotyped hallucinations and behaviors. Some alcoholic people really do see bugs and pink elephants, and there are many other examples of predictable perceptual and behavioral disturbances with drugs and with brain injuries.
Students of the healing arts learn that damage to certain regions of the brain is associated with specific behavioral and emotional consequences. This teaching goes back more than a century, and generations of students have been told that, “Damage here causes depression, and damage here causes mania, and over there a lesions will damage one type of language.” Yet for three decades we have known that much of this teaching is fictitious. I was taught brain localization by some of the finest neurologists in the world, and yet each would admit the inaccuracy of their methods. A new study from Brisbane, Australia supports that nihilism. The investigators examined 61 consecutive people admitted to a stroke unit. “Strokes” are either vascular blockage or bleeds affecting the brain.
They could find no significant relationship between the side or location of a lesion and the development of post-stroke depression. But the kinds of people that they were before the stroke had a big impact: pre-morbid neuroticism and a past history of mental disorder were important predictors of depression following stroke.
So why all the fuss about Mel? Because people are asking if deep down inside he really has been harboring some of the dark, mean spirited thoughts that he expressed to the police, and that the alcohol was the catalyst and not the creator of his diatribe.
“The intoxication of anger, like that of the grape, shows us to others, but hides us from ourselves. We injure our own cause in the opinion of the world when we too passionately defend it.”
— Charles Caleb Colton (English Clergyman and Author, c.1780-1832)
Technorati tags: Mel Gibson Alcohol abuse Pre-morbid personality Brain
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
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
Autistic Spectrum Disorders
Over the last few months I have reported on a number of advances in our understanding of autism, and I was pleased to see that Time magazine has autism as this week’s cover story.The writers at Time are really to be congratulated on having put together a first rate set of articles.
Although we often use the term autism as shorthand, we prefer to use the term Autistic Spectrum Disorders (ASD), as autism is not one illness, but rather represents many illnesses with many distinct causes. The illness can range from profound disability to mild forms that may even be advantageous. One of the mild forms that has attracted a great deal of interest on recent years is Asperger’s syndrome, in which people may be highly intelligent, but are typically clumsy and have poor social awareness. There has been speculation that a number of highly successful scientists, writers and innovators may have the disorder.
One of the great puzzles of these illnesses is that they appear to be becoming more common. Even when you take into account changing diagnostic criteria and a greater awareness of the illnesses, they genuinely seem to be becoming more common. It is not surprising that a whole long list of culprits has been examined, from vaccinations to radiation and food additives. But so far no credible cause for the increase has been identified.
Last December I wrote an item about mirror neurons in the prefrontal cortex and their relevance to ASD. This research was part of a large series of brain studies being conducted around the world. For many years we thought that the key regions of the brain involved in autism were in the cerebellum, a “second brain,” that lies at the back and underneath the cerebral hemispheres. This structure is involved in coordinating movement, in language, emotional processing and some social functions. But now it is becoming clear that many regions of the brain are affected. Investigators from London have just published a study indicating that some of the difficulties in relating to others that are experienced by people with ASD may be due to poor communication between brain regions. People were asked to look at pictures of faces or houses, while their brains were scanned. In healthy volunteers, paying attention to pictures of faces caused a significant increase in brain activity. However, in the people with ASD, paying attention to faces made no impact at all on the brain, explaining their lack of interest in faces. It seems that the areas of the brain concerned with decoding faces are not well connected to those parts of the brain that control attention.
Just last week, investigators from University of Texas Southwestern Medical Center in Dallas, and St. Jude Children’s Research Hospital in Memphis, published a study concerning a gene named Pten. This gene has already been linked to some rare gene disorders, and is involved in controlling the numbers and size of neurons. In mice that did not have a normally functioning gene, parts of the cerebral cortex and hippocampus did not develop normally, and the mice showed some odd deficits in their social functioning: The genetically altered mice were socially less skilled, being rather incurious about new animals coming into the cage. They also showed the same level of interest in an empty cage and in one containing another mouse, something very similar to the behavior of some children with ASD. The genetically altered mice were also less likely to build nests or look after their young. But they were more sensitive to stressful stimuli, such as loud noises or being picked up. Again, these are common features in children with ASD. The brains of the mice were also larger than those of their littermates, which is again something that has been picked up in many brain imaging studies in children with ASD. I have warned many times about trying to extrapolate from animal studies to human: Social abnormalities in a mouse may be caused by entirely different factors from human social abnormalities. But this new finding is another brick in the wall.
Professor Simon Baron-Cohen from the University of Cambridge has proposed that a central cognitive problem is ASD a result of developing extreme male tendencies to analyze and systematize rather than to empathize. His group has also just published data in the Archives of Disease of Childhood, indicating that highly analytical couples, may be more likely to produce children with ASD.
One of the things that often worries me is that desperate parents have sometimes been persuaded to try treatments that may actually do harm. Not so much from the therapy being toxic, but rather because the child may then not get the treatment that he or she needs. ASD is a prime example of a group of conditions that do best with an integrated approach: physical care, nutrition, cognitive, psychological and social skills work. And it is essential to ensure that other family members also receive help and support.
Technorati tags: autism, mirror neurons, autism spectrum disorder
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
Further Evidence for Attention Deficit Disorder
You may think it surprising that I would even raise the question about whether ADD and ADHD exist. But when I was trained in the UK, there was still a lot of skepticism about the diagnosis, and there was the constant question about whether Americans physicians, educators and psychologists were simply using a medical label for an undesirable behavior, rather than it being a separate clinical entity. There are still some people – apart from Tom Cruise(!) – who cling to the notion that ADD is not a scientifically valid illness, despite the fact that treatment can transform lives. I recently received an extraordinary article claiming that there’s no scientific basis to psychiatry. Though written by a someone with a medical degree, I found at least twelve factual errors in the article, before he moved on to tell us how to use some natural methods for treating these non-existent conditions!
I have always been strongly opposed to turning natural life events and individual styles into new illnesses, something about which I shall have more to say on another occasion. But for all the people who claim that ADD does not exist, here is a video which helps prove that it does. To me it is even more convincing, because the work was done at my alma mater in London, and the research arose out of that skepticism.
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,
