Dr Shock MD PhD

DSM-5 troubles

Dr Shock — Thu, 20 Nov 2008 04:23:47 +0000

Both Shrink Rap and Mind Hacks report on a debate about how transparent the process for developing the upcoming DSM-V should be. This debate is published in the LA Times. Those in charge of the revision want secrecy, nobody knows why. It is suggested in the comments it could have something to do with the insurance companies?

Besides transparency of the making of the new revision of this psychiatric diagnostic bible other problems were mentioned on this blog as well as others:

Psychiatrists updating the DSM did not disclose ties with pharmaceutical drug companies
Will Internet addiction be a new diagnosis in the DSM V? Medicalize problems again. In an editorial in the American Journal of Psychiatry Internet Addiction is proposed as a new diagnosis in DSM V. Now the American Journal of Psychiatry used to be a serious peer reviewed journal although some of us doubt this feature for a while now.
More than half the 28 new members of writers of the next edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) have ties to the drug industry.
The Last Psychiatrist also has an opinion about Internet addiction in the DSM V.
Suicidal behavior as Sixth Axis in DSM VIt is suggested in an editorial of the American Journal of Psychiatry that suicidal behavior be considered a separate diagnostic category documented on a sixth axis. Ridiculous. Suicidal behavior (death and attempts) is a symptom of various psychiatric conditions. We will need a seventh axis for addiction, another item often overlooked. It is a kind of safe guard against lack of interest, lack of empathy for psychiatric patients.

There is still a long way to go. The DSM-V is due out in May 2012, and all mental illness and proposals for the classifications of new mental illness are currently under review by the DSM-V committee.

Grand Round at Dr Deb

Dr Shock — Wed, 19 Nov 2008 04:08:06 +0000

At Dr Deb the new grand round is up. She made them into playlists, their is even a patient playlist, mental health playlist and many more, so go and enjoy.

Dutch Grand Round is up: Grote Visite

Dr Shock — Wed, 19 Nov 2008 04:02:40 +0000

At De Gezondheidszorg leuker en effectiever the new Dutch Grand Round with contributions by Laika’s MedlibLog and Medblog.nl, go have a look.

Electronic Game Players No Couch Potatoes

Dr Shock — Tue, 18 Nov 2008 04:35:50 +0000

Gaming among college-aged men may provide a healthy source of socialization, relaxation, and coping.

In college-aged males:

there were no significant correlations between participants’ BMI and frequency of electronic game play
there were no significant correlations between academic performance and frequency of electronic game play
there were no significant mean differences between other variables related to social functioning (e.g., relationship status) and frequency of electronic game play, revealing no obvious trends in interpersonal functioning for those who play games more or less frequently.
other media usage was either not related to frequency of electronic game play as for magazines or was inversely related, as with the frequency of consumption of television.

This last observation suggests that individuals may be more selective with their choice of media rather than, as has been the general assumption, generally consuming multiple forms of media at equivalent rates.

In spite of their negative associations electronic game play actually facilitate positive relationships and coping skills to some extent.

These results are only applicable to college-aged males. Gegeneralizations should be limited to this group. Itis possible that they are better able to manage the frequently conflicting academic, social,
and intrapersonal demands of their developmental period.

The frequency of playing was positively correlated with being bored as well as playing when lonely and when stressed.

How was this study done?
The current study investigated relationships between frequency of electronic game play and obesity, the social/emotional context of electronic game play, and academic performance among 219 college-aged males. They electronically signed an informed consent form, completed the online survey, received a debriefing form that they could print for their records, and were offered the opportunity to request results of the study after its completion.

Results revealed that 92.7% of participants reported that they had played electronic games within the last month. Additionally, 62.1% of participants reported that they played
electronic games within the last 24 hours. Individuals who were identified as current game players (played electronic games within the last week) reported a weekly average of 9.73 hours of game play. Of those currently engaging in game play, 8.5% reported playing an average of 35 hours per week.
The reported mean age of commencement of electronic game play was 7.5 years of age.

This study has to be replicated in other samples, with experimental and longitudinal studies will be necessary to ascertain the impact of prolonged gaming on social functioning. This also has to be done in other age groups in order to elucidate the role that electronic gaming plays across the lifespan.

Elizabeth Wack, Stacey Tantleff-Dunn (2008). Relationships between Electronic Game Play, Obesity, and Psychosocial Functioning in Young Men CyberPsychology & Behavior, 2147483647-4 DOI: 10.1089/cpb.2008.0151

Serious Adverse Events with DBS for Obsessive Compulsive Disorder

Dr Shock — Mon, 17 Nov 2008 04:35:32 +0000

In Deep Brain Stimulation for treatment resistant depression with stimulation of Broadman area 25 (Cg 25) no consistent declines in memory for either verbal or visual material were noted after onset or maintenance of DBS over baseline. This makes DBS a procedure with out apparent cognitive side effects in treatment resistant depression. In a recent publication with DBS in the Subthalamic Nucleus for treatment resistant Obsessive Compulsive Disorder (OCD) no cognitive decline was found. The ratings of neuropsychological measures were not modified by stimulation.

In 17 patients participating in this 10-month, crossover, double-blind, multicenter study assessing the efficacy and safety of stimulation of the subthalamic nucleus one patient had a parenchymal brain hemorrhage (bleeding) resulting in a permanent finger palsy. Two patients had an infection leading to removal of the pulse generator. Seven transient motor and psychiatric symptoms induced by active stimulation occurred in the first month of stimulation and resolved spontaneously or rapidly after adjustment of the setting. Ten other patients also had serious but transient side-effects.Three patients became hypomanic, three suffered from anxiety, two of depressive symptomps the others suffered from transient neurological side-effects such as dyskinesia, trouble walking, dysarthria, dysphagia and facial asymmetry.

Deep Brain Stimulation of the subthalamic nucleus significantly reduced the symptoms of severe forms of OCD.

In conclusion, findings from this 3-month crossover study suggest that stimulation of the subthalamic nucleus may lessen the severity of obsessive–compulsive symptoms and improve global functioning in patients with refractory, severe OCD. Serious adverse events occurred in 11 of the 17 patients in whom stimulators were implanted. The occurrence of severe adverse events, the small number of patients, and the short duration of the study highlight the risks of stimulation of the subthalamic nucleus and the need for larger studies with longer follow-up. In addition to assessment in a larger number of patients, a comparison with other stimulation targets and surgical procedures would be desirable, as would an evaluation of the long-term benefits of stimulation of the subthalamic nucleus in patients with OCD, notably with respect to their quality of life and their ability to function in social and work environments.

Ideal Workplace, Found It!

Dr Shock — Sun, 16 Nov 2008 04:39:25 +0000

Found another ideal workplace, nobody could direct me to my former ideal workplace. This one is a little expensive but looks very comfortable, maybe a donation? The price list and specifications were not yet available for download but will keep you informed. The workplace is called the emperor not very nerdy nor geeky.

For other Inspiring workplaces see flickr.

Thanks Bright.nl

Robot with a Human Face

Dr Shock — Sat, 15 Nov 2008 04:38:53 +0000

Scientists have created the first ‘humanoid’ robot that can mimic the facial expressions and lip movements of a human being.

‘Jules’ - a disembodied androgynous robotic head - can automatically copy the movements, which are picked up by a video camera and mapped on to the tiny electronic motors in his skin.

It can grin and grimace, furrow its brow and ’speak’ as his software translates real expressions observed through video camera ‘eyes’.

The project, called ‘Human-Robot Interaction’, was devised at the Bristol Robotics Laboratory (BRL), run by the University of the West of England and the University of Bristol. Want to know more about the technique and developments read The robot that can pull faces on Mailonline

Effect of Blogging on Well-Being: Increased Social Support and Satisfaction

Dr Shock — Fri, 14 Nov 2008 04:11:49 +0000

In comparison to non bloggers the bloggers’ levels of social integration and the tendency to count on others for assistance (reliable alliance) increased over time in as short as a period of two months. Compared to non bloggers, bloggers were more satisfied with number of face-to-face and online friends and with closeness of face-to-face friendships. These changes were not present for non bloggers. Both groups were less psychologically distressed after using MySpace for 2 months than when they first joined, but not significantly so.

Higher levels of social integration suggest that bloggers feel greater belonging to a group of likeminded people with interests and ways of thinking similar to their own.

You can express your stress factors and emotions on blogs, get it of your chest. Blogging can provide you with social support, friendship and positive interactions. Blogs can bring together likeminded and supportive communities and thus provide opportunities to relieve feelings of isolation. Blogs may allow authors to communicate subject matter difficult to express in regular social interaction by reducing social constraints that hinder discussion of distressing events in offline life.

Does Dr Shock have social support, friendship and positive interactions with his blog? He certainly does. Aqua and Herb were the first to express positive critique giving him the change to improve his writing. Jan at Medblog.nl and Laika were an example to him and of great help. To name only a few.

The conclusions of this research as written at the first lines of this post were recently published. It has some limitations that can be derived from the design.

New MySpace users (N=58) were surveyed on joining the site and again in 2 months to examine psychosocial differences between bloggers and nonbloggers over time.

The question remains if these results can be extrapolated to other blog platforms, follow-up was short. If the follow up increases advantages of blogging may become more prominent. A strong point for this research is the use of a control group (non bloggers on MySpace).

James R. Baker, Susan M. Moore (2008). Blogging as a Social Tool: A Psychosocial Examination of the Effects of Blogging CyberPsychology & Behavior, 2147483647-3 DOI: 10.1089/cpb.2008.0053

Virtual Reality Exposure Therapy for Post Traumatic Stress Disorder

Dr Shock — Thu, 13 Nov 2008 04:34:17 +0000

Civilians can be exposed to traumatic events. Most notably terrorist bombing attacks. In Israel, civilians are a frequent target of terrorist suicide bombers (e.g., attacks on civilians riding on public buses).

BusWorld is a simulation of a terrorist suicide bus-bombing attack designed to treat survivors for PTSD.

What is Post Traumatic Stress Disorder?
Patients with PTSD commonly have persistent traumatic thoughts, memories, or nightmares about the traumatic event; typically avoid thinking about the traumatic event; feel emotionally numb; and show social avoidance (e.g., avoid riding buses). Other common symptoms include recurring flashbacks, irritability, anger and rage, hypervigilance, bodily discomforts, and trouble sleeping.

In a recent publication this form of Virtual Reality Exposure Therapy was tested on 30 healthy volunteers without PTSD.

The objective of the present study was to measure the amount of anxiety elicited in nonsymptomatic adults in response to four progressively more intense levels of the BusWorld simulation toward the eventual use with people who have witnessed and survived a terrorist bus-bombing attack and developed PTSD.

What is Virtual Reality Exposure Therapy?
In Virtual Reality Exposure therapy, patients go into an immersive computer-generated environment (go back to the scene of the traumatic event) to help them gain access to their memories of the traumatic event, change unhealthy thought patterns, gradually habituate to their anxiety, and reduce the intensity of associated emotions. The therapist’s ability to manipulate the amount of anxiety experienced by the client during therapy is an important element of successful exposure therapy.

How was it done?
The therapist controls the severity of the scenario in the VRE therapy via the pressing of different function keys. The VR was programmed to have 4 levels of intensity. This way the participants and future PTSD patients can be exposed to graded exposure with 4 increasing levels of distress.

Level 1.
The participant views the quiet street scene in the absence of any action. The events are viewed
from an urban Israeli sidewalk, near a café, across the street from a bus stop
Level 2.
A bus appears and approaches the bus stop, but there is no explosion.
Level 3.
The bus arrives at the bus stop and explodes; the bus is seen to be burning, there is smoke and shattered glass on the street, but there are no accompanying sound effects.
Level 4.
This level is the same as Level 3, except with the addition of sounds of the bus exploding, people screaming and crying, as well as police sirens and reflections of flashing police-car lights (police car is not visible to participants).

In this study with healthy participants the level of distress increased with each level. This suggests that BusWorld may prove to be a valuable medium for providing graded exposure for individuals suffering from PTSD originating from suicide bus bombings.

The website of the developers of BusWorld

It has already been tried with survivors of the 9/11 attack on the World Trade Center:

a graded immersive simulation of the events of September 11, 2001, at the World Trade Center in Manhattan.

This has been studied in a controlled trial with a waiting list group. The VRE was more efficacious in reducing PTSD symptoms.

PTSD, Soldiers and War
In a recent article in British Medical Journal it is concluded that an association was found between deployment for more than a year in the past three years and mental health that might be explained by exposure to combat. In other words: Personnel who were deployed for 13 months or more in the past three years were more likely to fulfil the criteria for post-traumatic stress disorder, scored worse on the general health questionnaire, and have multiple physical symptoms. PTSD is frequent among soldiers exposed to combat.

Virtual Reality Exposure Therapy with PTSD in soldiers

This therapy has been used with Vietnam veterans with PTSD:

a helicopter hovering over a rice paddy field, which clients viewed via a head-mounted display

This has been studied in an open trial with good efficacy for PTSD.

But can Soldiers benefit from Technology-Based Approaches to Mental Health Care

A recent study utilized a survey-based approach to examine pre- and post-deployed Soldiers’ knowledge of and attitudes toward using technology to access mental health care.

This study examined 352 U.S. Soldiers’ knowledge of and attitudes toward using technology to access mental health care. Results indicated that Soldiers were quite experienced with a wide variety of technology-based tools commonly proposed to facilitate mental health care. In addition, the majority of participants stated that they would be willing to use nearly every technology-based approach for mental health care included in the survey. Notably, 33% of Soldiers who were not willing to talk to a counselor in person were willing to utilize at least one of the technologies for mental health care.

This is especially important since soldiers often face unique barriers to care, including geographic location, deployment, complex duty environments, and fear of treatment stigma, and may not access the mental health care services they need.

Naomi Josman, Ayelet Reisberg, Patrice L. Weiss, Azucena Garcia-Palacios, Hunter G. Hoffman (2008). BusWorld: An Analog Pilot Test of a Virtual Environment Designed to Treat Posttraumatic Stress Disorder Originating from a Terrorist Suicide Bomb Attack CyberPsychology & Behavior, 2147483647-3 DOI: 10.1089/cpb.2008.0048
R. J Rona, N. T Fear, L. Hull, N. Greenberg, M. Earnshaw, M. Hotopf, S. Wessely (2007). Mental health consequences of overstretch in the UK armed forces: first phase of a cohort study BMJ, 335 (7620), 603-603 DOI: 10.1136/bmj.39274.585752.BE
Jaime A. B. Wilson, Kristin Onorati, Matt Mishkind, Mark A. Reger, Gregory A. Gahm (2008). Soldier Attitudes about Technology-Based Approaches to Mental Health Care CyberPsychology & Behavior, 2147483647-3 DOI: 10.1089/cpb.2008.0071

Vagus Nerve Stimulation, Does it Work?

Dr Shock — Wed, 12 Nov 2008 05:33:01 +0000

A recent systematic review shows that Vagus Nerve Stimulation (VNS) therapy has been reported to have antidepressant effects in open and longterm studies, but unfortunately the only blinded randomized trial was inconclusive. It is possible that much or all of the improvement reflected a placebo response or spontaneous remission.

This makes placing VNS as alternative option for treatment resistant depression hard. Other alternatives are more evidence based: 9 steps for treatment resistant depression. This doesn’t exclude vagus nerve stimulation but postpones it to last resort treatment. Particularly for those with a chronic, highly disabling course of their depression.

The Pro’s for Vagus Nerve Stimulation:

VNS solves the problem of compliance that is usually associated with regular treatments.
No systematic anaesthesia is needed as commonly practiced in ECT
No deleterious cognitive effects.
Another positive point is the absence of a deleterious effect of VNS therapy on pregnancy.As a nonpharmacologic treatment, VNS does not pass through the placenta and is safe for the pregnancy and for the infant and allows a sustained remission of depression.
VNS seems to improve sleep architecture and increase the amplitude of ultraradian sleep EEG rhythms in patients with treatment reistant depression.
The side effects reported in long-term studies are generally the same as those reported in short-term studies. They are typically mild and restricted to the time of the stimulation.

The Cons for VNS:

The high cost of the device.
The invasive nature of the treatment.
Abssence of a clear effect of VNS

The biggest problem with VNS is the fact that only one randomized controlled trial has been published. Another important observation is that it takes a while before VNS starts to work, it takes a long time (months) before a decisive evaluation of efficacy can be made.

VNS therapy would gain more credibility and become a serious option for a subgroup of depressed resistant patients. Sham vs true VNS could be tried in randomized, blinded trials, on top of treatment as usual in a large sample of patients with treatment-resistant depression. Bipolar depression and psychotic depression could also be potential targets for clinical trials with VNS.

Related Post on this blog:
Vagus Nerve Stimulation An Update

C DABAN, A MARTINEZARAN, N CRUZ, E VIETA (2008). Safety and efficacy of Vagus Nerve Stimulation in treatment-resistant depression. A systematic review Journal of Affective Disorders, 110 (1-2), 1-15 DOI: 10.1016/j.jad.2008.02.012